531469

research-article2014

HPQ0010.1177/1359105314531469Journal of Health PsychologySousa et al.

Article

Lifestyle and treatment

adherence among overweight
adolescents

Journal of Health Psychology

111
The Author(s) 2014
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DOI: 10.1177/1359105314531469
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Pedro Sousa1, Pedro Gaspar1, Helena Fonseca2,3

and Filomena Gaspar4

Abstract
This study evaluated the influence of overweight adolescents lifestyle on the adherence to weight
control, and identifies their predictors. Participants were 94 adolescents, aged 1218 years, attending a
Paediatric Obesity Clinic. Lifestyle was assessed using the Adolescent Lifestyle Profile and treatment
adherence through the Therapeutic Adherence to Weight Control Questionnaire. Adherence to
weight control was associated with various lifestyle domains. Several predictors were identified for
lifestyle and adherence to weight control among overweight adolescents. A broad array of intercorrelations and predictors were identified and should be taken into account when designing adolescent
weight control interventions.

Keywords
adherence to weight control, adolescents, lifestyle, overweight, predictors

Introduction
The prevalence of overweight and obesity
among adolescents has dramatically increased,
both in developed and developing countries
(Carmo et al., 2006; Huang et al., 2013; Machado
et al., 2011; Oude Luttikhuis et al., 2009; Padez
et al., 2005; World Health Organization (WHO),
2002, 2006).
Childhood and adolescence are critical periods for establishing a pattern of healthy behaviors and adoption of a healthier lifestyle
(Commission of the European Communities,
2005, 2007). By the age of 15 years, many adolescents show a reliable level of competence in
metacognitive understanding of decision-making,
creative problem-solving, correctness of choice,
and commitment to a course of action (Mann

et al., 1989). There is evidence that the implementation of strategies to prevent or reduce obesity prevalence may lead to significant gains in
health outcomes (Pereira and Mateus, 2003;
Steele et al., 2008). It is important to emphasize
the central role of lifestyle in the understanding
1Polytechnic

Institute of Leiria, Portugal

de Lisboa, Portugal
3Hospital de Santa Maria (HSM), Portugal
4School of Nursing of Lisbon, Portugal
2Universidade

Corresponding author:
Pedro Sousa, Escola Superior de Sade, Polytechnic
Institute of Leiria, Campus 2, Morro do Lena, 2411-901
Leiria, Portugal.
Email: pedro.sousa@ipleiria.pt

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Journal of Health Psychology

of obesity and behavior change processes

(Brown et al., 2009).
According to WHO (1986, 1988), lifestyle is
defined both as a set of mediating structures
which reflect the activities, attitudes, and social
values, and as a cluster of behavioral patterns,
depending on age, education, economic and
social factors, among others. The adoption of
unhealthy diets and weight-control behaviors
often leads to an energy imbalance (NeumarkSztainer et al., 2012; Vivier and Tompkins,
2008; Zeller and Modi, 2008). Several studies
have shown that a sedentary lifestyle may be
responsible for weight gain, especially among
younger children (Dietz, 2001; Giammattei et al.,
2003; Wrotniak et al., 2004). Padez et al. (2009)
studied the association between sleep duration,
overweight, and body fat in a sample of
Portuguese children and found that the prevalence of overweight and body fat percentage
decreased with a long-lasting sleep pattern.
Treating overweight patients implies adherence to behavioral changes and a healthier lifestyle (Elfhag and Rossner, 2005; Sousa, 2010;
Walpole et al., 2011). There is little data on
adherence rates to weight loss in interventions
targeting adolescents and on their measurement
and evaluation (Frana et al., 2013). It has been
found that the majority of obese persons do not
remain in weight-loss programs for a long time.
Among those who remain, the majority do not
lose weight and those who do, tend to return to
their previous weight after some time (Brambilla
et al., 2010). It is estimated that there is a 50%
dropout rate among obese adolescents, and that
less than 5% of those who achieve weight loss
are able to maintain the weight loss after 5 years
(Frana et al., 2013).
Nogueira and Zambon (2013) analyzed
potential reasons for nonadherence to follow-up
at a specialized outpatient clinic for obese children and adolescents. Patients reported that
poor adherence to the program was mainly due
to the programs being time consuming and
patients having to miss schools and other activities for coming to the clinic. Other reasons were
refusal to proceed with the treatment, dissatisfaction with the results, change of health

service, difficulty in scheduling follow-up

appointments, and spending too much time in
the waiting room.
The success of any intervention in this field
lies in the control of individual needs, encouragement in the adoption of a health-promoting
lifestyle, and promotion of adherence to the
weight-control treatment and behavioral change
strategies (Brown et al., 2009; Elfhag and
Rossner, 2005; Sousa, 2010; Walpole et al.,
2011). There is evidence that treatment adherence is critical for an effective weight-control
management. Therefore, focusing on adherence
can be the best investment for being successful
(Davin and Taylor, 2009; WHO, 2003).
Several aspects of health behaviors have shown
to be influenced by gender (Conner et al., 2004; Ho
et al., 2005). Previous studies also found relevant
results in this domain. There is some evidence that
social support mediates the relationship between
weight and psychopathology in adolescence
(Freitas-Rosa et al., 2013). Geographic location,
gender, and nutritional status also seem to play an
important role in body image concerns among
adolescents (Laus et al., 2013). Therefore, these
predictors should be taken into consideration in
designing an intervention.
The primary objective of this research was to
investigate the association between body mass
index (BMI) z-score, lifestyle, and adherence to
weight control among overweight adolescents.
A secondary objective was to identify potential
predictors for both lifestyle and adherence to
weight control.

Methods
Study design and participants
A cross-sectional correlational study was conducted. It was hypothesized that a higher BMI
z-score would be associated with a worse
health-promoting lifestyle and a worse adherence to weight control. It was further hypothesized that a greater health-promoting lifestyle
was associated with a better adherence to
weight control among overweight adolescents.
We further hypothesized that lifestyle and

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Sousa et al.
adherence to weight control were influenced by
demographic, anthropometric, behavioral, and
clinical variables.
Study participants were enrolled through an
ongoing longitudinal study on adolescent obesity and monitored by a quarterly survey. This
study was conducted with the data from the
baseline evaluation. Survey methods have been
described in detail elsewhere (Sousa et al.,
2013b). Participants (n = 94) were adolescents
included in a Paediatric Obesity Management
Program in Portugal, aged between 12 and 18
years, fulfilling the Centers for Disease
Controls (CDC) criteria for overweight (BMI
percentile 85th). Exclusion criteria were the
presence of severe psychopathology, inability
to communicate in writing, pregnancy, and having been proposed for bariatric surgery. The
program consisted of clinical assessment, medical, psychological, nutritional, and physical
activity counseling. Sample recruitment had the
support of the clinical staff. All eligible adolescents with appointments between 1 January and
31 December 2012 were included.

Procedures
This study was approved by the Ethical Committee
for Health (Lisbon, Portugal) in January 2012 and
founded by the Foundation for Science and funded
by the Fundao para a Cincia e a Tecnologia
(Portugal) (PTDC/DTP-PIC/0769/2012). All eligible adolescents and respective parents signed an
informed consent where the study objectives were
explained. Confidentiality and voluntary participation were assured. Those who signed the
informed consent were given a brochure with a
summary of relevant information and e-contacts
needed to enable them to fill out the data collection instruments online. The option of responding
to the initial questionnaire on paper was also provided at the clinic.

Measures
Data were collected during 2012 from different
sources: clinical files (demographic, anthropometric, behavioral, and clinical variables) and

self-report instruments (AWCQ - Adherence to

Weight Control Questionnaire, ALP - Adolescent
Lifestyle Profile). The instruments are described
in detail in the study protocol (Sousa et al.,
2013a).
Demographic variables. The demographic variables considered were age, gender, parental profession (grouped into classes 1 to 3, according
to the differentiation degree), and parental education (higher education, third cycle, second
cycle, first cycle, none).
Anthropometric variables.Anthropometric data
(BMI percentile, BMI z-score, and waist circumference percentile) were measured by
trained health professionals at the clinic. The
BMI cut-offs endorsed by the CDC (Kuczmarski et al., 2000) were used.
Behavioral variables. Behavioral variables were
weekly physical activity (h/w), screen time
(h/w), family support and weight-loss motivation (2 Likert-type questions, range 15), and
body image (sequence of seven silhouettes
that evolve progressively from thinness to
overweight).
Clinical variables.Clinical variables included
time elapsed since the first visit (in months),
age at onset of obesity, and blood pressure
percentiles.
AWCQ.This instrument was developed and
validated by Sousa et al. (2013a). This screening tool measures Treatment Adherence to
Weight Control (TAWC) and the Risk of
Non-Adherence to Weight Control (RNAWC)
in adolescents, with a five-point Likert-type
format. The TAWC (29 items) includes four
subscales: SEA (Self-Efficacy and Adherence
Behaviors), PPI (Parental/Providers Influence), FSI (Friends/Schools Influence), and
PB (Perceived Benefits). The RNAWC (7
items) presented a one-factor solution. Both
scales presented good reliability values (.908
and .770) and a five-point Likert-type format. A
high TAWC score corresponds to a greater

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Journal of Health Psychology

treatment adherence. Furthermore, a high

RNAWC score corresponds to a greater risk of
nonadherence.
ALP.This instrument was designed to measure
the frequency of health-promoting behaviors in
adolescents (early, middle, and late). The Portuguese version of ALP was validated by Sousa et
al. (2013c), from the original version of Hendricks et al. (2006). The Portuguese version is a
36-item summated behavior rating scale that
employs a four-point Likert-type response format, organized into seven factors (Health Responsibility, Physical Activity, Nutrition, Positive Life
Perspective, Interpersonal Relationship, Stress
Management, and Spiritual Health). This model
showed adequate adjustment indices: CMIN/DF
(chi-square/degree of freedom) = 1.667, CFI
(comparative fit index) = .807, GFI (goodness-offit index) = .822, RMR (root mean square residual) = .051, RMSEA (root mean square error of
approximation) = .053, PNFI (Parsimony Normed Fit Index) = .575, PCFI (Parsimony Comparative Fit Index) = .731. The scale has a high
reliability score ( = .866), subscale reliability
values between .492 and .747. A high ALP score
corresponds to a healthier lifestyle.

Data analysis
Missing data at baseline were determined
using the expectation-maximization method
(by including data from the second wave of the
ongoing longitudinal study). Descriptive statistics, including measures of frequency, central tendency, and distribution were used to
describe the sample characteristics and study
variables.
Nonparametric tests were used in inferential
statistics, due to a non-normal distribution of
the data. Spearman correlation, MannWhitney
U test, and KruskalWallis with Bonferroni
correction were used to assess the associations
between the variables and test the hypothesis.
All analyses were conducted using the SPSS
v.18 software. A p value of .05 was used to control the type I error rate.

Results
The characteristics of the sample are described
in Table 1. The mean BMI z-score was 2.065
(standard deviation (SD) = 0.377), corresponding to a mean BMI percentile of 97.362 (SD =
2.193). Parents with a higher education were a
minority (6.40% fathers; 10.00% mothers) and
most parents worked in services and sales
(25.60% fathers; 28.20% mothers). The high
percentage of unemployed parents (11.50%
fathers; 9.00% mothers) was noteworthy.
Statistically significant differences between
genders were only found for screen time (U =
157.000, p = .033), with boys spending more
time in front of screens (24.820 11.709 vs
17.625 10.454).
The overall lifestyle score was 2.604 (SD =
0.386), using a four-point scale. The analyses of
the subscales showed the highest values for
Interpersonal Relationship and Positive Life
Perspective and the lowest for Spiritual
Health, Health Responsibility, and Physical
Activity.
Regarding weight-control adherence (scale
range: 15), the overall nonadherence score
was 2.506 0.864, while for the overall treatment adherence score, the value rose to 3.730
0.576. Of note are the high levels of Perceived
Benefits and Parents/Providers Influence.

Association between BMI z-score and

health-promoting lifestyle
Spearman correlations between these two constructs were calculated. Weak and nonsignificant correlations were found between BMI
z-score and the various subscales of lifestyle (p
> .05) (Table 2).

Association between BMI z-score and

adherence to weight control
Spearman correlations between BMI z-score
and adherence to weight control were weak and
nonsignificant for the various subscales (p >
.05) (Table 2).

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Sousa et al.
Table 1. Descriptive statistics.
Variables

Boys (N = 46)

Girls (N = 48)

Total (N = 94)

Age, years

SD

SD

14.457

1.441

13.896

1.533

14.170

2.157
95.692
92.000

0.360
14.643
3.114

1.989
96.980
91.848

0.364
2.177
3.337

2.065
97.362
91.797

5.278
24.820
4.060
3.708
5.714

4.411
11.709
.982
1.151
0.854

3.596
17.625
3.789
3.632
5.371

2.410
10.454
0.976
1.116
0.877

4.497
21.622
3.943
3.674
5.524

26.214
6.097
77.694
43.861

28.536
3.451
26.819
30.286

19.878
6.969
76.171
38.114

23.603
3.554
21.942
26.680

23.084
6.496
77.000
40.250

3.266
4.450
3.415
4.230
3.724
2.676

0.866
0.481
0.844
0.775
0.578
0.955

3.197
4.494
3.542
4.241
3.736
2.344

0.807
0.683
0.777
0.975
0.581
0.741

3.230
4.473
3.480
4.236
3.730
2.506

2.228
2.598
2.862
2.940
2.924
2.915
1.828
2.599

0.578
0.611
0.423
0.642
0.524
0.580
0.646
0.375

2.319
2.240
2.710
3.200
3.255
2.982
1.801
2.610

0.594
0.705
0.540
0.571
0.520
0.505
0.640
0.400

2.274
2.417
2.785
3.072
3.091
2.949
1.815
2.604

Anthropometric variables
BMI z-score
BMI percentile
Waist circumference percentile
Behavioral variables
Weekly physical activity (h/w)
Screen time (h/w)
Family support
Weight-loss motivation
Body image silhouette
Clinical variables
Time elapsed since first visit (months)
Age at onset of obesity (years)
Systolic blood pressure percentile
Diastolic blood pressure percentile
Adherence to weight control
Self-efficacy/adherence behaviors
Parents/providers influence
Friends/school influence
Perceived benefits
TAWC total score
Risk of nonadherence
Lifestyle
Health responsibility
Physical activity
Nutrition
Positive life perspective
Interpersonal relationship
Stress management
Spiritual health
ALP total score

ALP: Adolescent Lifestyle Profile; BMI: body mass index; SD: standard deviation; TAWC: Treatment Adherence to
Weight Control.

Association between health-promoting

lifestyle and adherence to weight
control
The analysis of the correlation between lifestyle and adherence showed that adolescents
with higher rates of health responsibility, also

presented higher rates of self-efficacy and

adherence behaviors (rs = .469, p < .0001),
were more influenced by parents and health
professionals (rs = .219, p = .036) and showed
higher indices of overall treatment adherence
(rs = .387, p = < .0001). Individuals with
higher levels of physical activity showed

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Journal of Health Psychology

Table 2. Correlations between lifestyle, adherence to weight control, and BMI z-score.
r Spearman

HR

Adherence to weight control

.469**
Self-Efficacy/
adherence behaviours
.219*
Parents/providers
influence
.187
Friends/school
influence
Perceived benefits
.008
TAWC total score .387**
Risk of nonadherence .195
BMI z-score
.036

PA

PLP

IR

SM

SH
.289**

Total ALP

.528**

.299**

.378**

.109

.306**

.510**

.030

.251*

.448**

.174

.314**

.001

.146

.026

.181

.073

.259*

.065

.163

.011
.391**
.151
.040

.102
.278**
.158
.001

.169
.416**
.242*
119

.004
.136
.150
.111

.046
.362**
.124
.015

.022
.212*
.101
.054

.079
.454**
.229*
.047

.279**

ALP: Adolescent Lifestyle Profile; BMI: body mass index; HR: health responsibility; IR: interpersonal relations; N: nutrition; PA: physical activity; PLP: positive life perspective; SH: spiritual health; SM: stress management; TAWC: Treatment
Adherence to Weight Control.
*p < .05; **p < .01.

higher rates of self-efficacy/adherence behaviors (rs = .528, p < .0001) and overall treatment adherence (rs= .391, p < .0001). Better
nutrition rates appear to be associated with
higher levels of self-efficacy and adherence
behaviors (rs = .299, p = .004), higher parental
and providers influence (rs = .251, p = .016),
and higher overall treatment adherence (rs =
.278, p = .007).
Regarding the positive life-perspective subscale, a positive association was found between
self-efficacy and adherence behaviors (rs =
.378, p < .0001), parental and providers influence (rs = .448, p < .0001), and overall treatment adherence (rs = .416, p < .0001). However,
the positive life perspective showed a negative
correlation with risk of nonadherence (rs =
.242, p = .020).
Presenting better stress management appears
to contribute to higher rates of self-efficacy and
adherence behaviors (rs = .306, p = .003), parental and providers influence (rs = .314, p = .002),
as well as friends and school influence (rs =
.259, p = .013), and even higher overall treatment adherence (rs = .362, p < .0001). Moreover,
the higher the rates of spiritual health, the higher
the self-efficacy and adherence behaviors (rs =
.289, p = .005) and the overall treatment adherence (rs = .212, p = .044).

Finally, the higher the overall lifestyle score,

the higher the self-efficacy and adherence
behaviors (rs = .510, p < .0001), parental and
providers influence (rs = .279, p = .007) and
the overall treatment adherence (rs = .454, p <
.0001). On the other hand, the higher the overall
lifestyle score, the lower the risk of nonadherence (rs = .229, p = .028) (Table 2).

Lifestyle predictors
Demographic variables.Significant gender differences were found, with males showing
higher rates of physical activity (2.620 0.599
vs 2.228 0.707, p = .013) and females exhibiting higher rates of interpersonal relationships
(3.255 0.526 vs 2.933 0.526, p = .003) and
a more positive life perspective (3.200 0.571
vs 2.940 0.642, p = .050).
Behavioral variables.Adolescents with higher
rates of weekly physical activity presented higher
scores of health responsibility (rs = .307, p =
.005), better nutrition (rs = .372, p = .008), and
higher overall lifestyle score (rs = .389, p = .001).
On the other hand, higher rates of physical inactivity were associated with worse nutrition (rs =
.344, p = .002) and poorer interpersonal relationships (rs = .377, p = .014).

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Sousa et al.
Table 3. Lifestyle predictors.
Variables
Demographic variables
Age (rs)
Gender (U)
Mothers education (H)
Fathers education (H)
Mothers profession (H)
Fathers profession (H)
Anthropometric variables
BMI percentile (rs)
Waist circumference
percentile (rs)
Behavioral variables
Weekly physical activity (rs)
Screen time (rs)
Family support (rs)
Weight loss motivation (rs)
Body image silhouette (rs)
Clinical variables
Time elapsed since first visit (rs)
Age at onset of obesity (rs)

HR

PA

PLP

IR

SM

SH

Total ALP

.072
977
2.395
1.256
.417
1.766

.163
760.0*
2.665
1.533
3.424
2.841

.194
931
2.315
4.057
2.276
.831

.080
833.0*
6.519
2.928
1.932
6.327

.127
702.5**
5.996
1.848
2.459
.242

.044
993
2.562
4.070
2.356
.698

.107
1038.5
5.883
.763
1.786
2.838

.148
1037.5
3.652
.697
.603
.284

.741
.150

.715
.125

.992
.023

.275
.057

.307
.090

.889
.022

.624
.016

.665
.087

.307*
.197
.250
.198
.200

.527**
.226
.245
.278
.142

.372**
.344*
.142
.204
.027

.220
.109
.005
.155
.152

.211
.377*
.008
.019
.085

.089
.097
.185
.097
.150

.021
.185
.210
.164
.120

.389**
.241
.180
.235
.184

.023
.017

.110
.003

.359**
.143

.147
.009

.160
.104

.147
.118

.079
.041

.165
.042

ALP: Adolescent Lifestyle Profile; HR: Health Responsibility; IR: Interpersonal Relations; N: Nutrition; PA: Physical Activity; PLP: Positive
Life Perspective; SH: Spiritual Health; SM: Stress Management.
rs: Spearman correlation; U: MannWhitney U test; H: KruskalWallis test.
*p < .05; **p < .01.

Clinical variables.The longer the time elapsed

since the first visit, the higher the nutrition
score (rs = .375, p = .001) (Table 3).

Adherence to weight-control
predictors
Demographic variables.Significant differences
were found between educational levels of both
parents regarding parental influence on adherence (mother: Higher Education = 4.875
0.222 vs second cycle = 4.313 0.521, p =
.018; father: Higher Education = 4.875 0.177
vs third cycle = 4.251 0.695, p = .037). Significant differences were also found between
parental occupation regarding parental influence on adherence (Executives and intellectual
professions = 4.886 0.163 vs Inactive workers
= 4.417 0.793, p = .037).
Behavior variables.Adolescents who presented
higher rates of family support tended to develop

a lower risk of nonadherence to weight control

(rs = .430, p = .003).
Clinical variables. Higher waist percentiles were
associated with an increase in the risk of nonadherence to weight control (rs = .258, p = .050).
A weak negative correlation was found between
time elapsed since the first visit and the selfefficacy/adherence behaviors score (rs = .270,
p = .036) (Table 4).

Discussion
With its focus on weight control, this study
identified a set of lifestyle and treatment adherence predictors. It has long been understood
that lifestyle intervention is essential for successful treatment. A systematic review of
Brown et al. (2009), aiming to determine the
long-term effectiveness of lifestyle interventions in the prevention of overweight and morbidity, showed a significant positive impact on

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Table 4. Adherence to weight control predictors.

Variables
Demographic variables
Age (rs)
Gender (U)
Mothers education (H)
Fathers education (H)
Mothers profession (H)
Fathers profession (H)
Anthropometric variables
BMI z-score (rs)
BMI percentile (rs)
Waist circumference
percentile (rs)
Behavioral variables
Weekly physical activity (rs)
Screen time (rs)
Family support (rs)
Weight loss motivation (rs)
Body image silhouette (rs)
Clinical variables
Time elapsed since first
visit (rs)
Age at onset of obesity (rs)

SEA

PPI

FSI

PB

Total TAWC

RNAWC

.008
1020.500
.418
.141
1.517
2.702

.109
877.500
11.960*
10.185*
4.048
8.464*

.053
993.500
4.666
2.468
.447
.660

.165
981.000
3.071
2.190
2.177
1.406

.021
1015.000
1.505
1.545
.951
1.729

.046
838.000
1.976
9.192
4.223
3.936

.034
.034
.105

.003
.000
.095

.148
.145
.027

.212
.211
.032

.056
.054
.087

.067
.067
.258*

.223
.202
.295
.297
.079

.097
.005
.226
.034
.025

.028
.048
.080
.065
.008

.064
.101
.170
.269
.119

.162
.081
.247
.159
.040

.175
.141
.430**
.205
.032

.270*

.054

.182

.048

.207

.083

.120

.132

.155

.047

.171

.095

FSI: Friends/Schools Influence; PB: Perceived benefits; PPI: Parents/Providers Influence; RNAWC: Risk of Non-Adherence to Weight Control; SEA: Self-Efficacy & Adherence behaviours; TAWC: Treatment Adherence to Weight Control.
rs: Spearman correlation; U : MannWhitney U test; H: KruskalWallis test.
*p < .05; **p < .01.

weight, blood pressure reduction, type 2 diabetes, and metabolic syndrome risk.
The analysis of the intercorrelations between
lifestyle, adherence to weight control, and overweight revealed that BMI z-score was not the
main factor responsible for lifestyle and treatment adherence, making it necessary to find
other factors that may contribute to this variance.
Unlike previous research, it was not possible to
endorse the assumption that an effective overweight management implies patients adherence
to behavioral changes and a healthier lifestyle
(Elfhag and Rossner, 2005; Sousa, 2010).
Our results indicate that adherence to weight
control is closely related to lifestyle. There is
some indication that health responsibility, physical activity, nutrition, positive life perspective,
stress management, and spiritual health, all
contribute to several domains of adherence,

including self-efficacy/adherence behaviors,

parental/providers influence, friends/school
influence, and risk of nonadherence. These
results underscore the importance of behavioral
change and lifestyle as pillars of adherence to
weight control.
Based on our results, some lifestyle predictors were identified. The lifestyle domains
which scored lower were Physical Activity,
Health Responsibility, and Spiritual Health.
Brownell et al. (2010) had already noted that
the concept of personal health responsibility is a
fundamental concept in social and political
approaches to obesity, pointing out that the
fight against obesity should imply the promotion of personal and collective responsibility.
Furthermore, our findings suggest that adolescents with higher scores of health responsibility tend to score higher for weekly physical

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Sousa et al.
activity. In this domain, we found interesting
gender differences, with boys showing higher
rates of physical activity, while girls showed
higher interpersonal skills. Higher rates of
weekly physical activity were associated with
higher rates of health responsibility, a better
nutrition, and a higher overall lifestyle score. On
the other hand, higher rates of sedentary lifestyle
were associated with lower interpersonal skills
and nutrition quality. Earlier studies stressed the
importance of promoting physical activity
among overweight adolescents (Stankov et al.,
2012; Ullrich-French and McDonough, 2013).
However, overweight adolescents experience
several barriers to participation in physical
activity, such as physical discomfort and fatigue.
Moreover, stigmatization and peer discrimination can negatively reinforce their negative selfperception,
negatively
impacting
their
psychosocial development and increasing their
psychosocial vulnerability.
In this research, the adherence to weight
control domains that scored higher were benefit perception and recognition of parental/providers influence.
Another important result was the fact that
parents with a more differentiated profession
and higher education seemed to be able to influence more positively the adolescents adherence to weight control. These data are in line
with the WHO (2006) report, which states that
there is an association between overweight and
obesity and lower socioeconomic status, which
in turn contributes to an increase of inequalities
in health.
Findings suggest a positive association
between the waist circumference percentile
and the risk of nonadherence. Interestingly, our
findings indicate that the longer the time
elapsed since the first visit, the lower the selfefficacy for adherence. On the one hand, we
are aware that behavioral changes are complex,
demanding, and usually require long periods of
treatment/monitoring. On the other hand, and
according to the results, it seems that adolescents, as time goes by, start to believe less in
treatment success and in their ability for
change.

Results also indicate that the higher the waist

circumference percentile, the higher the risk of
nonadherence. Adherence to weight control is a
critical component for successful obesity management (Walpole et al., 2011). The problem of
nonadherence remains a challenge for both
health professionals and researchers and is
responsible for a significant number of people
not getting the maximum benefit from obesitymanagement programs, leading to poor health
outcomes, reduced quality of life, and increased
healthcare costs (Dulmen et al., 2007).
The strengths of this study include the use of
obesity-specific instruments, usually more sensitive than generic instruments, thereby reducing the noise of medical comorbidities (Zeller
and Modi, 2008).
One limitation of the study is the nonrandomized sample that prevents the generalization
of results. Moreover, the limited amplitude of
BMI percentiles did not allow a full exploration
of potential differences in psycho-social variables according to the overweight degree (Zeller
and Modi, 2008). A third limitation is the analysis of separate models for each correlation,
which may have led to misleading interpretations, as an intercorrelation among the different
variables is expected. Future research should
use a larger and randomized sample, with a
larger BMI variance, as well as use complementary techniques of multivariate analysis.

Conclusion
These results underline the importance of
behavioral change and the adoption of a healthier lifestyle as pillars for adherence to weight
control. Tailored obesity-management programs should be designed not only according to
adolescent health needs but also taking into
account the broad array of predictors that have
been identified.
Acknowledgements
We gratefully acknowledge the clinical staff of the
Paediatric Obesity Clinic for their dedication. We
also thank all the adolescents and parents for their
participation and collaboration.

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10

Journal of Health Psychology

Funding
This work was partially funded by Fundao para a
Cincia e a Tecnologia (PTDC/DTP-PIC/0769/2012)
and supported by the Polytechnic Institute of Leiria,
Portugal, and the Department of Paediatrics at
Hospital de Santa Maria, Lisbon, Portugal.

References
Brambilla P, Pozzobon G and Pietrobelli A (2010)
Physical activity as the main therapeutic tool for
metabolic syndrome in childhood. International
Journal of Obesity 35: 1628.
Brown T, Avenell A, Edmunds L, et al. (2009)
Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity
in adults. Obesity Reviews 10(6): 627638.
Brownell K, Kersh R, Ludwig D, et al. (2010)
Personal responsibility and obesity: A constructive approach to a controversial issue. Health
Affairs 29(3): 379387.
Carmo I, Santos O, Camolas J, et al. (2006)
Prevalence of obesity in Portugal. Obesity
Reviews 7(3): 233237.
Commission of the European Communities (2005)
Green Paper: Promoting Healthy Diets and
Physical Activity: A European Dimension for
the Prevention of Overweight, Obesity and
Chronic Diseases. Brussels: Commission of the
European Communities.
Commission of the European Communities (2007)
White Paper on a Strategy for Europe on
Nutrition, Overweight and Obesity Related
Health Issues. Brussels: Commission of the
European Communities.
Conner M, Johnson C and Grogan S (2004) Gender,
sexuality, body image and eating behaviours.
Journal of Health Psychology 9(4): 505515.
Davin S and Taylor N (2009) Comprehensive review
of obesity and psychological considerations
for treatment. Psychology, Health & Medicine
14(6): 716725.
Dietz W (2001) The obesity epidemic in young children. British Medical Journal 322: 313314.
Dulmen S, Sluijs E, Dijk L, et al. (2007) Patient
adherence to medical treatment: A review
of reviews. BMC Health Services Research
7(55): 13.
Elfhag K and Rossner S (2005) Who succeeds in
maintaining weight loss? A conceptual review
of factors associated with weight loss maintenance and weight regain. Obesity Reviews 6(1):
6785.

Frana S, Sahade V, Nunes M, et al. (2013)

Adherence to nutritional therapy in obese adolescents: A review. Nutricin Hospitalaria
28(4): 988998.
Freitas-Rosa M, Goncalves S and Antunes H
(2013) The relationship between weight status and psychopathology in adolescence:
The role of social support. Journal of Health
Psychology. Epub ahead of print 12 April. DOI:
10.1177/1359105313482162.
Giammattei J, Blix G, Marshak H, et al. (2003)
Television watching and soft drink consumption: Associations with obesity in 11- to 13-yearold schoolchildren. Archives of Pediatrics and
Adolescent Medicine 157(9): 882886.
Hendricks C, Murdaugh C and Pender N (2006)
The Adolescent Lifestyle Profile: Development
and psychometric characteristics. Journal of
National Black Nurses Association 17(2): 15.
Ho R, Davidson G and Ghea V (2005) Motives for
the adoption of protective health behaviours
for men and women: An evaluation of the psychosocial-appraisal health model. Journal of
Health Psychology 10(3): 373395.
Huang D, Lanza H, Wright-Volel K, et al. (2013)
Developmental trajectories of childhood obesity and risk behaviors in adolescence. Journal
of Adolescence 36: 139148.
Kuczmarski, R., Ogden, C., & Grummer-Strawn,
L. (2000). CDC growth charts: United States.
Advanced Data 314: 127.
Laus M, Miranda V, Almeida S, et al. (2013)
Geographic location, sex and nutritional status
play an important role in body image concerns
among Brazilian adolescents. Journal of Health
Psychology 18: 332338.
Machado M, Alves M and Couceiro M (2011) Sade
Infantil e Juvenil em Portugal: Indicadores
do Plano Nacional de Sade. Acta Peditrica
Portuguesa 42(5): 195204.
Mann L, Harmoni R and Power C (1989) Adolescent
decision-making: The development of competence. Journal of Adolescence 12(3): 265278.
Neumark-Sztainer D, Wall M, Story M, et al. (2012)
Dieting and unhealthy weight control behaviors during adolescence: Associations with
10-year changes in body mass index. Journal of
Adolescent Health 50(1): 8086.
Nogueira T and Zambon M (2013) Reasons for
non-adherence to obesity treatment in children
and adolescents. Revista Paulista de Pediatria
31(3): 338343.

Downloaded from hpq.sagepub.com at PONTIFICIA UNIVERSIDAD CATOLICA DE CHILE on May 21, 2015

11

Sousa et al.
Oude Luttikhuis H, Baur L, Jansen H, et al. (2009)
Interventions for treating obesity in children.
Cochrane Database of Systematic Reviews 1:
CD001872.
Padez C, Mouro I, Moreira P, et al. (2005) Prevalence
and risk factors for overweight and obesity in
Portuguese children. Acta Paediatrica 94(11):
15501557.
Padez C, Mouro I, Moreira P, et al. (2009) Long
sleep duration and childhood overweight/obesity and body fat. American Journal of Human
Biology 21: 371376.
Pereira J and Mateus C (2003) Custos indirectos
associados obesidade em Portugal. Revista
Portuguesa de Sade Pblica 3: 6580.
Sousa C (2010) O papel da mudana comportamental
no tratamento da obesidade. MSc Dissertation,
University of Porto, Porto.
Sousa P, Fonseca H and Gaspar P (2013a) Measuring
adherence to weight control in adolescents:
Development and validation of a self-report questionnaire. Atencin Primaria 45(Suppl. I): 7071.
Sousa P, Fonseca H, Gaspar P, et al. (2013b)
Internet-based intervention programme for
obese adolescents and their families (Next.
Step): Research protocol of a controlled trial.
Journal of Advanced Nursing. Epub ahead of
print 11 September. DOI: 10.1111/jan.12245.
Sousa P, Gaspar P, Fonseca H, et al. (2013c)
Health promoting behaviours in adolescence:
Psychometric properties of the Adolescent
Lifestyle Profile PT version. Atencin Primaria
45(Suppl. I): 140.
Stankov I, Olds T and Cargo M (2012) Overweight
and obese adolescents: What turns them off physical activity? International Journal of Behavioral
Nutrition and Physical Activity 9: e53.
Steele R, Nelson T and Jelalian E (2008) Pediatric
obesity: Trends and epidemiology. In: Jelalian
E and Steele R (eds) Handbook of Childhood
and Adolescent Obesity. New York: Springer,
pp. 310.

Ullrich-French S and McDonough M (2013)

Correlates of long-term participation in a physical activity-based positive youth development
program for low-income youth: Sustained
involvement and psychosocial outcomes.
Journal of Adolescence 36(2): 279288.
Vivier P and Tompkins C (2008) Health consequences of obesity in children and adolescents.
In: Jelalian E and Steele RG (eds) Handbook of
Childhood and Adolescent Obesity. New York:
Springer, pp. 1124.
Walpole B, Dettmer E, Morrongiello B, et al. (2011)
Motivational interviewing as an intervention to
increase adolescent self-efficacy and promote
weight loss: Methodology and design. BMC
Public Health 11: 459.
World Health Organization (WHO) (1986) Ottawa
Charter for Health Promotion. Geneva:
WHO.
World Health Organization (WHO) (1988) Adelaide
Recommendations on Healthy Public Policy.
Copenhagen: WHO.
World Health Organization (WHO) (2002) Diet,
Nutrition and the Prevention of Chronic
Diseases (Report of the joint WHO/FAO expert
consultation). Geneva: WHO.
World Health Organization (WHO) (2003)
Adherence to Long-Term Therapies: Evidence
for Action. Geneva: WHO.
World Health Organization (WHO) (2006) The
European Charter on Counteracting Obesity.
Istanbul: WHO.
Wrotniak B, Epstein L, Paluch R, et al. (2004) Parent
weight change as a predictor of child weight
change in family-based behavioral obesity treatment. Archives of Pediatrics and Adolescent
Medicine 158: 342347.
Zeller M and Modi A (2008) Psychosocial factors
related to obesity in children and adolescents.
In: Jelalian E and Steele R (eds) Handbook of
Childhood and Adolescent Obesity. New York:
Springer, pp. 2542.

Downloaded from hpq.sagepub.com at PONTIFICIA UNIVERSIDAD CATOLICA DE CHILE on May 21, 2015