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Adolesc Med State Art Rev. Author manuscript; available in PMC 2009 December 1.
Published in final edited form as: Adolesc Med State Art Rev. 2008 December ; 19(3): 421viii.

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Dietary approaches to healthy weight management for adolescents:

The New Moves model Dianne Neumark-Sztainer, PhD, MPH, RD, Colleen Freeh Flattum, MS, RD, Mary Story, PhD, RD, Shira Feldman, MPH, RD, and Christine A. Petrich Division of Epidemiology and Community Health, School of Public Health, University of Minnesota

Abstract
This paper describes the dietary component of New Moves, a school-based obesity prevention program for adolescent girls. New Moves is a multi-component intervention that integrates nutrition, social support and physical activity sessions within an all-girls physical education high school class. New Moves also includes individual counseling sessions using motivational interviewing techniques, follow-up group lunch meetings, and parent outreach activities. The nutrition component focuses on avoiding dieting and unhealthy weight control behaviors and adopting lifelong healthy eating behaviors, such as increasing fruit and vegetable intake, decreasing sweetened beverage intake, eating breakfast daily, and paying attention to internal signs of hunger and satiety. The high prevalence of obesity among adolescents is of public health concern given its physical and psychosocial consequences (1). While many factors contribute to the onset and maintenance of obesity, dietary behaviors play a major role. Dietary patterns that may increase risk for excessive weight gain in youth include large portion sizes (2), low fruit and vegetable intake (3), high consumption of sweetened beverages (4,5), frequent consumption of fast foods (6) and skipping breakfast (7). Furthermore, dieting behaviors commonly used by adolescents may actually be contributing to excess weight gain. Frequent dieting and the use of unhealthy weight control behaviors such as diet pill use, self-induced vomiting, use of food substitutes, skipping meals for the purpose of weight loss, and fasting have been shown to be predict weight gain and overweight status over time (8). Dietary interventions aimed at obesity prevention in adolescents need to address these behaviors, while taking into account both lifestyle and developmental issues of adolescents. Schools provide an excellent venue for reaching adolescents from diverse ethnic and low socio-economic backgrounds who may not have easy access to interventions conducted within clinical or community settings. This paper describes the dietary component of New Moves, a high school-based obesity prevention program for adolescent girls to improve eating behaviors, as well as physical activity behaviors, body image, and overall self-esteem.

Background
Studies have documented that dietary intakes of adolescents are far from ideal and are likely contributing to the tripling in the prevalence of obesity among adolescents over the past few decades (9,10). In Project EAT (Eating Among Teens), a large population-based study of eating and weight among adolescents in the metropolitan area of the Twin Cities in Minnesota, we found that less than a third of adolescents ate five or more servings of fruits and vegetables on a daily basis (10). Furthermore, fruit and vegetable intake tended to decline, as adolescents got older (11). Binge eating was reported by 17% of adolescent girls and by 8% of adolescent boys, with higher percentages among overweight adolescents (21% and 12% among overweight girls and boys, respectively) (12). Only 27% of girls and 38% of boys in middle school and high

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school ate breakfast every day (7). Furthermore, we found that dietary intake behaviors (e.g., low fruit and vegetable intake and high intakes of sweetened beverages) and eating patterns (e.g., breakfast skipping and binge eating) longitudinally predicted overweight status in adolescents over a five-year period (13). Adolescents concerned about their weight, and particularly adolescent girls, often adopt unhealthy dieting and weight control behaviors, instead of making healthy dietary lifestyle changes. For example, in Project EAT, 57% of all adolescent girls, and 76% of those who were overweight, reported using unhealthy weight control behaviors (12). Several studies have shown that dieting and unhealthy weight control behaviors are ineffective for long-term weight management in adolescents (14-17). In Project EAT, we found that adolescent girls who dieted were at nearly twice the odds for being overweight five years later as compared to non-dieters, and those using unhealthy weight control behaviors were at even greater risk, after adjusting for baseline weight status (17). In examining why dieting leads to weight gain over time, we found that dieting was associated with increased binge eating among adolescent girls and boys, which, in turn, was associated with weight gain (18). We also found that dieters were less likely to engage in behaviors found to help with long-term weight management, such as eating breakfast on a regular basis, compared to non-dieters. In addition to being counterproductive to weight management, dieting behaviors have also been found to increase risk for disordered eating behaviors (16,17) and eating disorders (19) in adolescents. Multiple factors influence dietary intake and eating patterns among adolescents, including socio-environmental factors (e.g., availability of healthy foods), personal factors (e.g., perceived benefits of healthy eating) and behavioral factors (e.g., goal-setting). In an examination of factors associated with fruit and vegetable intake among adolescents participating in Project EAT, home availability of fruits and vegetables and taste preferences emerged as the most predictive of intake (20). These findings emphasize the importance of addressing both socio-environmental and individual-level factors within interventions aimed at improving dietary intake. Factors influencing unhealthy weight control practices include weight pressures to be thin from family and friends and personal body dissatisfaction (21,22). Body dissatisfaction is probably the strongest predictor of unhealthy weight control practices and other disordered eating behaviors (23,24). Interestingly, and of relevance to obesity prevention intervention, more recent study findings suggest that body dissatisfaction predicts increased weight gain over time among overweight adolescent girls (25). Our research from Project EAT suggests that body dissatisfaction does not motivate adolescents to engage in healthier behaviors, such as eating more fruits and vegetables or being more physically active, but rather to use unhealthy weight control behaviors that are counterproductive to long-term weight management (26). Based upon current knowledge, dietary interventions aimed at preventing and reducing adolescent obesity need to address dietary intake behaviors, such as increasing fruit and vegetable intake and decreasing sweetened beverage intake. It is also essential to address eating patterns, such as starting the day with breakfast, eating reasonable portion sizes, and paying attention to ones bodys signs of hunger and satiety. Dietary interventions should also address weight control practices, with an emphasis on avoiding short-term dieting and instead engaging in healthy eating behaviors that can be integrated into ones lifestyle. In order to enhance program effectiveness, dietary interventions should focus on socio-environmental, personal, and behavioral factors that influence dietary intake, eating patterns, and weight control behaviors. Furthermore, given the multifactoral etiology of obesity, dietary interventions should be embedded within a more comprehensive approach focusing on promoting physical activity, a balanced approach to eating, (e.g., meal regularity and moderation), psychological well-being, and a supportive physical and social environment.

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In designing dietary interventions for obesity prevention in adolescents, it is also important to take lifestyle and developmental factors into account. Programs need to take adolescents time schedules and competing activities such as school, work, extracurricular activities, and family responsibilities into account, since they have relevance for program attendance and participation. Interventions need to be implemented within an accessible facility and at convenient times for adolescents. The developmental stage of adolescents also needs to be considered in the design of interventions. Adolescents have increased autonomy in decisionmaking over their food choices, but are often still reliant on their families. For example, given adolescents increased purchasing power and independence in getting around, adolescents are often targeted with advertisements for fast food restaurants. However, family meals are still important for the dietary intake of adolescents (27-29). Thus, interventions must take into account adolescents increased autonomy and developmental need for independence, while encouraging parental support for healthy eating patterns. In working with adolescents from diverse ethnic and racial backgrounds, dietary interventions also need to address cultural differences in food and eating behaviors and familial factors influencing these behaviors. Adolescent development, with its drastic physical, psychological, and social changes, also has implications for body image concerns. Media messages regarding an ideal appearance can have a harmful impact on adolescents body image, at a period in life in which they are most vulnerable and when body image is an important part of their identity and self-esteem. Thus, dietary interventions for obesity prevention need to take into account the sensitivity of body image concerns and their centrality to adolescents identity. Interventions need to ensure that messages do not inadvertently lead to increased body image concerns that will place adolescents at risk for unhealthy weight control and other disordered eating behaviors.

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New Moves: An Overview

New Moves is a school-based obesity prevention program for adolescent girls. The programs development was guided by findings from Project EAT and other studies, as discussed above, and by extensive formative assessments and pilot work (30-34). We chose to focus on girls, given troubling research findings showing high levels of body image concerns and disordered eating behaviors and low levels of physical activity among adolescent girls. Findings from our needs assessments and pilot work suggested that girls would feel more comfortable being physically active and discussing weight-related health issues in an all-girls environment. The underlying philosophy guiding the New Moves intervention is that if girls feel good about themselves and their bodies they will want to take care of their bodies through healthy eating, physical activity, and self-acceptance. Concepts and teaching strategies from both the obesity and eating disorder fields are incorporated into the intervention since adolescent girls are at risk for a range of weight-related problems. The New Moves study, a randomized-controlled, school-based trial, funded by the National Institutes of Health, is currently testing whether high school girls participating in the New Moves intervention will significantly decrease their percent body fat compared to girls in a control group (35). The study is being conducted in six intervention and six control high schools in the metropolitan area of the Twin Cities in Minnesota. A total of 190 adolescent girls, from six high schools (three intervention and three control schools) participated in the study during the 2007-2008 school year. An additional six schools will participate in the program during the upcoming 2008-2009 school year. Inactive high schools girls who are overweight or at risk for becoming overweight due to sedentary lifestyles were targeted for inclusion in this study. The New Moves intervention targets socio-environmental factors (e.g., peer support), personal factors (e.g., body image), and behavioral factors (e.g., goal setting) in order to bring about changes in eating and physical activity behaviors (Figure 1). Specific behavioral objectives addressed in the program are shown in Figure 2. New Moves includes an intensive intervention

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phase, in which girls participate in daily activities as part of an all-girls physical education class. The class includes physical education (Be Fit), nutrition (Be Fueled), and social support/ self-empowerment (Be Fabulous) components. Four classes a week are devoted to physical activity and one class per week to either nutrition or social support. After the physical education class ends, the intervention includes a maintenance phase, with weekly meetings occurring over lunch at school. Individual counseling sessions are offered throughout both phases. A minimal parent outreach component is also included, which spans across both the physical education class and maintenance phase. The intervention components are shown in Figure 3. Given that the focus of this paper is on the New Moves dietary intervention, each of the intervention components focusing primarily on dietary behaviors are discussed in more detail below.

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Be Fueled nutrition sessions

Be Fueled classes take a non-dieting approach towards healthy eating and weight management. The focus is on making sustainable behavior changes, such as paying attention to energy balance and portion size, drinking water instead of sweetened beverages, starting each day with a healthy breakfast, eating more fruits and vegetables, making healthy snack choices, having a well-balanced lunch, and making healthier choices at fast food restaurants. Girls receive a teen-magazine styled workbook (GirlPages) with information and activities related to these behaviors. Interactive lessons focus on challenges teens face in adopting healthy behaviors, and specific ideas for implementing behavior change. Taste-testing a variety of healthy foods is incorporated into the sessions.

Individual Sessions with a New Moves Coach

Based upon our pilot work (31), we determined that a group class setting to deliver the New Moves intervention and behavior goals was not adequate for addressing the individual needs of the girls. Therefore, opportunities are provided for each participant to meet with a New Moves personal coach, (i.e., dietitian or health educator) for up to seven individual sessions. Meetings last for about 20 minutes and are conducted at school, typically during a free period or before/after school. During these sessions, motivational interviewing techniques are used extensively. Motivational interviewing is a client-centered, collaborative and directive approach to assist individuals in working through their ambivalence about behavior change and enhance intrinsic motivation (36). Personal coaches establish a non-confrontational and supportive climate in which the girls feel comfortable expressing their thoughts and feelings around behavior change. The coach is present primarily to identify barriers and boost motivation,thereby supporting each girls autonomy and ability to make healthy lifestyle decisions. Each individual session follows a general interview format that includes open-ended questions designed to explore various issues related to the girls individual dietary behaviors and goals. The individualized, motivational interviewing format provides girls an opportunity to discuss dietary habits and goals with a counselor and complements the other New Moves group activities.

Lunch Bunches
New Moves participants are invited to a weekly lunch get-together (lunch bunch) once the physical education class ends, during the maintenance phase of New Moves. These booster sessions are held during the lunch period at school. A healthy lunch is provided with sandwiches, salads, or culturally diverse foods (e.g., Ethiopian, Asian, or Mexican). Water or low-calorie beverages are served, as are side dishes such as fruit, vegetables, and low-fat snacks. Thus, the lunch bunches provide participants an environment in which girls can practice New Moves dietary goals of eating more fruits and vegetables, drinking water, and eating

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reasonable portion sizes. Each lunch bunch session includes discussion of a topic relevant to the New Moves behavioral objectives such as eating healthy over the holidays, making healthy choices at school, emotional eating, positive body image, stress management, staying fit with a busy schedule, and ways to be active while watching television. The sessions are designed to generate discussion on ways to identify and overcome common barriers for teenagers in making healthy choices. While most of the sessions focus on activities specific to the New Moves objectives, some sessions address more general social and community building activities in a less formal manner. The lunch bunches provide an opportunity for girls to eat a healthy lunch, receive social support, and connect with their New Moves classmates after the class is over.

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Parent outreach
A parent outreach component is also included in the New Moves intervention given the importance of parental support for healthy eating, physical activity, and a positive body image in adolescents. However, budgetary constraints, potential sustainability within school systems, and issues related to adolescent autonomy were also taken into account in developing the parental component. The result was a minimal parent intervention primarily aimed at fostering parental knowledge about New Moves and support for the programs philosophy. Throughout the intervention, parents of participating girls are sent six postcards with information about topics discussed in class. Additionally, New Moves staff members are available to meet with parents at parent-teacher conferences in the fall. A Saturday spa retreat is held in the early spring at a community center for New Moves girls and their parent, older sister, or other guardian. Girls and parents participate in activities such as making bath salts, receiving chair massages, and yoga. They are served a healthy lunch during which they hear a presentation about New Moves. They leave with a spa bag and a book about parenting teens to have a healthy weight and a positive body image (37). This retreat provides an informal atmosphere to get feedback about the class from both parents and teens.

Conclusions
Prior to completing the evaluation of the New Moves intervention, conclusions cannot be drawn as to whether or not the dietary approach being utilized will be effective in helping the girls make behavioral changes. Our early impressions are that the girls, teachers, and parents are very satisfied with the New Moves approach. However, we are also well aware of the difficulties inherent to behavioral change and weight management. If proven successful, it is our hope that the New Moves model will be incorporated within high schools. It appears that group education (e.g., Be Fueled), personal attention (e.g., individual sessions with a New Moves coach), availability of healthy food options (e.g., lunch bunches), and family involvement, are important components of a dietary intervention for healthy weight management among adolescents.

Acknowledgements
This study was supported by Grant R01 DK063107 (D. Neumark-Sztainer, principal investigator) from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health.

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Figure 1. New Moves theoretical model of change based on Social Cognitive Theory

PA = physical activity

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Figure 2. New Moves Behavioral Objectives

*Dietary objectives are bolded

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Figure 3. Intervention schedule during the initial and maintenance phase of the study
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