program components and science supporting each component

Back in Whack for Teens [BiW4Teens] is an evidence-based, multicomponent pediatric weight management program. There four program components, each of which has been substantiated by research to be an essential part of an effective pediatric weight management program.  BiW4Teens utilizes evidence-based interventions to implement each program component. 

The nutrition component of the BiW4Teens program is comprised of two parts – an individualized nutrition plan that promotes an energy deficit and nutrition education that is tailored to the nutrition plan. This combination increases effectiveness of the nutrition education and improves compliance with the nutrition plan.   Research has validated that this type of nutritional intervention is an effective and essential component of a successful multicomponent weight management program for children 1, 29.
 

A. The Individualized Nutrition Plan:

1. Utilizes current dietary guidelines and  reference standards 1, 17, 37;
2. Provides a balanced diet with a variety of healthy food choices 4, 20;
3. Provides a diet tailored to the teen’s specific age and gender using caloric intake guidelines to meet the energy needs of a sedentary teen 19, 33, 37;
4. Provides an energy deficit 1, 4,25 when the teen complies with the program’s recommended physical activity prescription;
5. Is written in a format that lists number of servings and serving size descriptions 1, 4;
6. Provides a list of healthy “whole” foods for each food group 25;
7. Recommends that all grains be whole grains 3, 17, 25, 37. Most whole grains have a low glycemic load. Low glycemic load foods promote weight loss 1, 9, 18;
8. Supports eating habits that promote a healthy weight as follows:

• Encourages an adequate intake of fruits and vegetables 1, 4, 25, 37;
• Encourages an adequate intake of dairy and foods with calcium 1, 4, 37;
• Limits or excludes the intake of sugary beverages and large quantities of fruit juice 1, 4, 6, 12, 15, 19, 30;
• Decreases energy dense foods in the diet 1, 3, 4; and
• Limits the intake of high fat foods 1, 4, 30. NIH recommends that obese teens limit fat intake to 30% of their total daily caloric intake 25.

 B. Nutrition Education which teaches parents and teens the following key points about how nutrition supports health while it explains the nutrition plan:

1. Food groups, kinds of macronutrients in each food group, and why the body needs all kinds of macronutrients 20;
2. Healthy “whole” foods in each food group 17, 34;
3. Appropriate serving sizes 1, 4, 17, 31;
4. Important information on food label;
5. Identify whole foods and understand that most whole foods provide slow-release energy (low glycemic load) and fiber, which are positively associated with attainment of and maintenance of a healthy weight 2, 9;
6. Identify refined foods and understand they typically provide quick-release energy (high glycemic load), are deficient in fiber, minerals, vitamins, and promote weight gain 17;
7. The nutrition plan is to be used as a guide for healthy eating – the teen should not be expected to rigidly adhere to the nutrition plan 16; and
8. The nutrition plan not only helps get a teen’s energy balance back in whack, but it also supports normal growth and development, healthy brain development and function, good emotional health, and decreases the risk of developing chronic diseases like heart disease, diabetes and cancer 25, 37. 

Research studies have revealed many important findings about physical activity and youth. Teens who participate in at least one hour of physical activity on a daily basis have lower BMI’s, get better grades in school and make healthier food choices 1, 4, 15, 20, 30, 38. Teens who participated in a lifestyle type physical activity (i.e. walking and biking) maintained greater weight loss for two years when compared to teens who took aerobics and calisthenics classes 2, 3.
 

Screen time (television, video games, and computer) increases sedentary activity which increases risk of obesity. Numerous studies have confirmed that obesity is directly related to the number of hours spent watching television.  Television time is also associated with increased consumption of energy-dense foods 1, 3, 4, 15, 30.
 

BiW4Teens physical activity interventions aim to increase physical activity to one hour or more per day, decrease sedentary activities, and limit screen time to 2 hours a day as follows:

1. Teach teens and parents about types of physical activity that have a positive effect on the body’s energy balance and support a healthy weight 2:   a. Lifestyle activities; b. Aerobic activity; and c. Muscle strengthening activities;
2. Teach teens and parents about the benefits of physical activity and help teens identify benefits that they would like to achieve 2;
3. Help teens develop their own personal activity pyramid filled with activities they enjoy and new activities they would like to try 15, 20;
4. Help teens develop a BiW 360 Plan. This is a plan that gradually increases the amount of physical activity time each week, until they are getting 360 minutes (6 hours) of aerobic activity per week 17, 31;
5. Help teens identify alternative activities to replace screen time 1, 5, 15;     
6. Educate parents that positive reinforcement of physical activity increases spontaneous physical activity in teens 30.

The behavioral change component of the  BiW4Teens program utilizes program themes, tools, and skills that have all been confirmed by research studies to positively influence, support, and facilitate behavioral change. Goal setting, self-monitoring, stimulus control, problem solving, cognitive restructuring, positive reinforcement and rewards, contracting, social support, focus on improving health instead of weight loss, and individualizing the child’s weight management program have all been found to facilitate behavioral change in children’s weight management programs 1, 4, 15, 17.
 

A.  BiW4Teens utilizes the following program themes to facilitate and support behavioral change 25:

1 - Habit change starts in the brain and the brain is the boss of the body. This theme helps participants understand why it is important to use habit change skills and tools 13.

2 - Body appreciation is taught and reinforced throughout the program. Many overweight teens struggle with poor body image 31. Poor body image can be a roadblock to behavioral change 34. The following messages support body appreciation:                                                               

a. We have amazing bodies that allow us to do everything we do 17, 31;    

b. It is hard to take care of something you don’t like or appreciate 4, 17;     

c. Excess weight is referred to as extra stored energy. Occasionally it is necessary to use the words excess weight or unhealthy weight. The term obesity is never used during the course of this weight management program; and                                                                                 d. The focus of the program is to improve and support health 34. Teens are taught that as their body uses up some of their stored energy, they may lose weight 4. 

3 - Habit change is a journey. Habit change is compared to hiking up a tall mountain. Teens and parents are taught that there are going to be days when the path is smooth and other days when the path is rough. A teen may fall and even slip backwards during this journey. The important thing is that they get up and keep moving forward 13. Everyone succeeds on this journey as long as they keep moving forward 13. Fear of failure is a common intrinsic roadblock to behavioral change 31. This program theme helps diminish fear of failure 13

4 - Teens are taught what it feels like to have a body in peak health. Achieving peak health is the main benefit of the program 17. Teens are asked to identify one thing that they would really like to be able to do better, when they reach peak health. This activity helps teens identify a personal intrinsic jackpot reward which serves as a motivational focal point 13, 15. This helps motivate teens to keep working the program as they strive to reach their peak health and obtain their identified jackpot reward 13.  

5 - Success feels good and serves as an intrinsic motivation. Participants are encouraged to celebrate all identified successes 13.

6 - BiW4Teens has a positive focus.   The brain is attracted to positive things 13. Participants are encouraged to focus on the positive in themselves, their goals, and their accomplishments. A positive focus serves as an intrinsic motivational factor 5, 13, 17.

7 - The program utilizes self-discovery exercises throughout the program as a means to stimulate ownership in the learning process and in the program 17.

B.  BiW4Teens follows rules for goal setting which increase a teen’s success with goal achievement.

1 - The SMART model is used for setting goals 5, 13:                                             

Specific - goals explain details of the what, why, and how;                     

Measurable - goals are concrete so they can be observed and measured;                                                                                                               Attainable - goals are within the teen’s capabilities;                                 

Realistic - goals reasonably fit into the family’s schedule and budget;  

Time bound - goals have an end point or target date.

2 - Parents and teens identify unhealthy habits and then make a master list of healthy habits (goals) that could replace the teen’s unhealthy habits and help the teen achieve a healthier weight. Teens choose 2 to 3 goals from this master list to get started on.  This strategy has two benefits:                                                                                                                      

a. Teens may have as many as fifteen unhealthy habits that they need to exchange for healthy habits. This would be overwhelming to try to change that many unhealthy habits all at once. Starting out with a few achievable goals increases the teen’s success 5, 13, 15, 31, 17, 34;               

b. Autonomy is a basic human need. Teens who choose their own goals have increased autonomy and self-sufficiency, and have increased ownership of their goals 13, 15.

3 - Goals are written with positive outcomes 5. When the focus of a goal is on achieving something positive, the goal is more enjoyable to work, and naturally motivating and energizing 13.

4 - Goals are written so the teen can experience daily success with each goal they are working on. Quantity of success has more of a positive impact than intensity of success 13. It is a basic human need to feel effective or competent at what we do 13.  Achieving success fulfills this need to feel competent

5 - Teens are encouraged to connect pleasure to health goals whenever possible. The brain is attracted to pleasure and avoids pain, which includes real pain, imagined pain or perceived discomfort 13. Teens are encouraged to put something they enjoy with health goals that they don’t enjoy (i.e. listen to their favorite music when exercising).
 

C.  BiW4Teens utilizes two self-monitoring tools. It is well documented that teens who self-monitor their health goals experience much more success in accomplishing their goals 17, 31 and the results last longer, frequently into adulthood. 

1 - The BiW Habit Tracker is a six-month chart. Each page of the chart provides two weeks of goals monitoring. It takes 21 days for brain and body to start getting comfortable with a new habit 2, 14. At the end of      three weeks, teens choose a new, additional healthy habit goal to start working on. The BiW Habit Tracker facilitates behavioral change in a couple of different ways:                                                                                        

a. Clearly written goals stimulate the self-control center of the brain (prefrontal cortex) and increase self-control 2;                                               

b. A habit tracker keeps goals visible and in the forefront of the teen’s conscious mind 2;                                                                                                    

c. A habit tracer provides immediate feedback and makes the teen’s accomplishment(s) visible, as they mark daily success with their goals 13. When teens experience a sense of accomplishment, it is a motivator and it increases the teen’s sense of well-being 13.

2 - The nutrition plan worksheets are used to evaluate daily compliance with the nutrition plan 4, 5.  The worksheets contain the correct number of servings for each food group listed on the teen’s nutrition plan. Nutrition plan worksheets are great brain training tools to help the brain learn to eat to meet the teen's nutritional and caloric needs. 

D.  BiW4Teens utilizes several behavioral change tools to support newly adopted habits:

1 - Teens are encouraged to find or buy a special bracelet. The bracelet serves as a reminder to “Make Healthy Choices.". The bracelet acts as a visual stimulus control tool 31. In other words, it helps to increase the desire to eat healthy foods and decreases the desire to eat unhealthy foods 5, 15.  

2 - Teens are encouraged to journal about their journey to peak health. They are encouraged to write about changes they are making, good and bad parts of their journey, things they like and dislike, and how they feel about the different changes they are making. Journaling supports habit change 5, 13, 31.  Journaling has a positive effect on judgment and emotion centers in the brain 2.  Journaling increases self-awareness. Self-awareness increases success with long-term behavioral change 22.

3 - The program contains Parent-Youth Contract.  Parents and teens put verbal agreements, concerning how the teen and parent will work  cooperatively together to accomplish the teen’s health goals, in writing on this contract (i.e. teen agrees to eat a vegetable or fruit with each meal and the parent agrees to make sure there are always vegetables and fruits available in the house).  A Parent-Youth Contract increases accountability, cooperation, and helps diminish conflict between parents and teens during a potentially stressful time 5, 15.

E.  BiW4Teens  utilizes two types of cognitive restructuring skills to facilitate behavioral change in teens 5, 15, 22:

1 - Mighty Messages – are short, clear, positive statements about habits a teen is attempting to adopt. Mighty messages are a type of positive self-talk. Positive self-talk has been shown to effectively support new habits 2, 5. Teens and parents are taught how to practice mighty messages. Teens choose their mighty messages to practice and are given space in the workbook to write their messages. Teens are encouraged to write there mighty messages on sticky notes  and  place them in strategic locations where they will see them every day. These positive messages are to be repeated every day. The sticky notes with mighty messages written on them, serves two purposes:                            

a. They act as a visual stimulus control tool 31 by helping to keep positive messages in the teen’s conscious mind;                                           

b. The positive “mighty” messages have an energizing and motivating effect on the teen 13. 

2 - Mini Movies – are positive daydreams that teens create about their new healthy habits. They see themselves enjoying their new habits, and feeling great as they successfully adopt their new health habits. When teens create positive images about their new healthy habits, it attracts teens to the new habits and diminishes ambivalence toward these habits 2.   Mini movies effectively facilitate behavioral change 13.

F.  BiW4Teens teaches parents how to use positive reinforcement and rewards to support their teen’s efforts to adopt healthier habits. Teens are typically more motivated by extrinsic rewards than they are by intrinsic rewards 5.   Positive reinforcement and rewards can serve as a very effective means by which to motivate teens to follow a health plan 17.  Teens who complete all 27 program session can receive a reward (a program completion gift) from Positive Patterns for Life company.
 

G.  BiW4Teens teaches parents and teens how to use three different skills to prevent program derailment:

1 - Craving Prevention and Management - parents and teens are taught how to identify and modify social and environmental cues that trigger undesirable eating 2, 5, 15, 31.  When unhealthy food is removed from a teen's diet, most teens experience food cravings. Because of this, craving management plans increase program compliance and program success 15, 31.

2 - Problem Solving - parents and teens are taught how to identify and dissect problems, list possible solutions to correct the problem, choose the best solution, and put the best solution into action 5, 13.   Problem solving training has been found to significantly increase pediatric weight management program success 15, 17.

3 - Manage Program Roadblocks – parents and teens are taught how to identify and avoid potential roadblocks or devise a plan to minimize unavoidable program roadblocks 5.   Roadblock management training has been found to increase pediatric weight management program success 15, 17.

Teens who have parental support experience higher rates of success. The parent training component provides information to parents about:

• How parenting skills affect teen’s feeding behavior; and
• How parental role modeling of nutrition and lifestyle habits can have a positive or negative effect on teen’s feeding behavior and food choices.
• Treatment of obesity in teens is greatly diminished in the absence of parental participation 1, 4.  Research studies indicate that including     parents as agents of change in the treatment of their teen's obesity is     associated with both short- and long-term (more than one year)     improvements in the teen’s BMI  11.  BiW4Teens parent training includes the following four topics concerning parenting and family involvement:

1. Parents learn about parenting skills that support behavior change in teens 1, 2, 4, 13, 15, 16, 31, 34:

• Positive supportive parenting;
• Praising teens for their effort facilitates persistence;
• Provide cognitive stimulation for teens concerning nutrition and physical activity (i.e. discuss how healthy food builds strong bodies);
• Allowing teens to self-regulate intake of healthy foods at meals;
• Family cohesiveness and expressiveness;
• Avoiding harsh food restrictions concerning healthy food choices; and 
• Democratic parenting style. 

2. Parents are taught about the importance of modeling healthy eating habits and that teens experience positive changes in weight status and adiposity when parents model healthy eating and physical activity habits 1, 2, 4, 11, 15, 20, 34.

3. Parents learn about parenting patterns that should be avoided. These patterns promote the development of an unhealthy weight in teens 1, 4, 16, 31:

• Excessive parental control or total lack of control over teen’s dietary intake;
• Lack of parental support or over-possessiveness;
• Rigid and inflexible or lax parenting;
• Excessive parental concern about teen’s weight status;
• Using food to modify behavior (i.e. using food to reward or punish a teen); and
• Meeting emotional needs of teens with food.

4. BiW4Teens includes many nutrition activities which encourage the involvement of the whole family. There is also information about how to get the whole family moving more together. Parents are informed about the benefits of getting the whole family involved in adopting healthier habits:

• Family involvement in nutrition and exercise programs increases the success of pediatric weight management programs 1, 13, 15, 20, 25, 34.
• Positive family relationships support behavior change 13.  
• Social support from a family facilitates behavioral change 13, 15.

Studies confirm that obesity is largely determined by environmental factors directly related to human behavior 1, 4, 15, 17. Unhealthy nutrition and lifestyle habits are the biggest contributing environmental factors to the development of childhood obesity. Research studies have shown that the following nutrition and lifestyle habits of children are positively associated with childhood obesity: 

1 - Drinking sugary beverages on a regular basis (i.e. soda pop, sports drinks, fountain drinks, etc.) 1, 4, 6, 12, 15, 19, 30  

• People can consume a large number of calories in a short amount of time when they drink sugary drinks.   

• Sugary drinks are a form quick-release energy. Quick-release energy has a negative affect on energy balance. Quick-release energy dumps a large load of energy quickly into the body and body can’t use all this energy so it tends to store some of the quick-release energy.   

• The body responds quickly to quick-release energy and puts it into storage. This causes a person’s energy level to jump up quick and drop low quick.  This creates symptoms of hunger within 1 to 2 hours after the ingestion of a sugary beverage.   

• When energy levels drop low, the body will crave more quick release-energy to elevate symptoms of hunger.    

• Sugar in candy and deserts affect the body’s energy balance the same way. 

• White flour products (white bread, saltine crackers, pasta) and white rice affect the body’s energy balance the same way. 

• Drinking large quantities of fruit juice 1, 3, 4, 30 [i.e. as little as 12 ounces of fruit juice per day has been linked to higher BMIs in children 15]    

• A small amount of fruit juice (4 ounces) equals a whole piece of fruit. It can take 10 minutes to eat a piece of fruit and 3o seconds to drink 4 ounces of juice.  It is easy to get too many extra calories is a short time from drinking too much fruit juice.      

• Fruit juice has been stripped of all of the fiber from fruit and most of the vitamins and minerals. Because of this, fruit juices have a negative effect on energy balance when drank by its self between meals. It is always better to eat a piece of fruit instead of drink fruit juice.      

2 - Dietary intake of fat that exceeds 35% of the daily caloric intake  1, 4, 17, 30   • Fat is an important macronutrient. Fat makes up 60% of the solid mass of our brain, plus all our nerves are insulated by fat. We need it so we can absorb fat soluble vitamins. We need fat in our diet to have healthy skin.       

• However, we only need a small amount of fat each day.      

• Fat is dense energy. Two teaspoons of oil or butter has the same amount of calories as a slice of bread of a half of cup of corn.     

• Dietary fat stores easier as fat when there is excess fat in the diet. Dietary fat is broken down into triglycerides. Triglycerides are energy ready to be stored or broken down into fuel for that day. If the body has plenty of energy available for the day, triglycerides get put into storage. Dietary fat is the only food we eat that when it is digested it turns directly into triglycerides and is ready for storage. (The rest of the food we eat is broken down into glucose or amino acids).      

3 - Excluding vegetables and fruits from the diet  1, 3, 4    

• Inadequate consumption of fruits and vegetables is positively correlated with a higher BMI. 

• Adequate intake of fruits and vegetables supports healthy weight and promotes a lower/normal BMI (healthy weight). This habit helps sustain a healthy weight into adulthood.   

• The fiber in the fruits and vegetables helps satisfy a teen’s hunger while taking in fewer calories. Plus teens stay satisfied for a longer period of time after eating fiber rich foods.      

• Fiber has a positive effect on energy balance in the body.     

• Fruits and vegetables are full of vitamins and minerals that support health and are important to maintaining energy balance within the body.    

4 -Inadequate daily intake of dairy and calcium  1, 4    

• Adequate intake of calcium helps support energy balance within the body.   

• Teens who DO NOT drink milk or eat dairy products, have higher amounts of stored energy (body fat).     

• Teens who get adequate intake of dairy products have less stored energy (body fat).      

5 - Skipping breakfast  1, 4, 30     

• There are three ways that skipping breakfast negatively affects energy balance. When a person sleeping, the metabolic rate (internal furnace) slows down (burns slower). It stays slow burning until a person eats breakfast or lunch.      

• In addition to this, when a person’s metabolic rate is slow burning, a person moves slower and moves less and burns up fewer calories.      

• People who skip breakfast often load up on calories later in day (see number 7 to hear about how this is bad for energy balance).          

6 - Consuming half or more of the daily caloric intake in the evening  30    

• When half or more of the daily caloric intake is in the evenings, a body does not have time to burn these food calories off, so it goes into temporary storage (primarily the liver).      

• When temporary storage gets full, then extra calories get put into permanent storage (fat cells).      

• It is very important to spread food (caloric) intake out throughout the day. This helps keep the internal furnace burning hot and helps balance energy levels throughout the day.       

7 - Total daily caloric intake that exceeds daily caloric expenditures  1 

• This is a habit that can cause daily caloric intake to exceed daily energy expenditures.      

8- Eating supersized portions and increased portion sizes   1, 3, 4    

• This is a habit that can cause daily caloric intake to exceed daily energy expenditures.      

9 - Eating energy-dense foods  1, 3 

• This is a habit that can cause daily caloric intake to exceed daily energy expenditures.     

• Candy, cookies, and pastries are quick-release energy foods and have a negative affect on the body’s energy balance like sugary drinks do     

10 - Is a fast eater 15, 30    

• Fast eaters consume greater number of calories than slow eaters. They over fill their stomach more often than slow eaters. It takes 20 minutes for the message to get from stomach to brain and back to stomach that it is full.     

11 - Eats when bored  15, 30     

• This is a habit that can cause daily caloric intake to exceed daily energy expenditures.      

12 - Eats alone 15, 30     

• People who eat alone typically eat extra calories they didn’t need 

• This is a habit that can cause daily caloric intake to exceed daily energy expenditures.     

13 -  Eats in front of television 15, 30    

• People who eat in front of the TV don’t pay close attention to how much they are eating and tend to over eat      

1 4- Sneaks or hides food 15, 30    

• This behavior is connected with over eating and can cause daily caloric intake to exceed daily energy expenditures.      

15 - Frequently consuming meals outside the home and eating at fast food restaurants  1, 3, 4    

• Evidence suggests that teens who eat home cooked meals with their families are less likely to be overweight; eat more healthy foods; have less delinquency;  greater academic achievement; improved psychological well-being;  and positive family interactions.     

• Fast food tend to be low in vitamins, minerals, fiber (all good for energy balance) and high in fat, calories and salt (which has a negative effect on energy balance).      

16 - Lack of physical activity and low levels of physical fitness  1, 3, 4, 30    

• Teens who are not physical activity and who have low levels of physical fitness have higher BMIs than teens who get at least 60 minutes of exercise per day.     

• Lack of physical activity and low levels of physical fitness are important contributing factors in both the development of and in the maintenance of high BMIs.       

• Recommendation for physical activity for teens with high BMIs is a  minimum of 60 minutes of aerobic activity (makes you breath harder and faster and makes you sweat) most every day.     

17 - Participating in more than two hours of screen time per day (i.e. television, video games, and computer)  1, 4, 15, 30    

• Numerous studies have confirmed that high BMIs are directly related to the number of hours spent watching television or playing video games.      

• One study found that time spent viewing TV at the age of 9 can predict how high a teenager’s BMI will be 8 years later – greater body dimensions, increased energy stores, less time spent participating in sports, less active during activities of daily living.       

• TV watching significantly lowers metabolic rate – even lower than when a person is sleeping.   

• Television time is also associated with increased consumption of high calorie, unhealthy foods.     

18 - Has a television or computer in bedroom  15, 30     

• Children/teens who have TVs or gaming systems in their bedrooms have higher BMIs than teens who don’t have TVs and gaming systems in their bedrooms.       

19 - Erratic sleep schedule or goes to bed late or gets less than 8-9 hours of sleep per night  30    

• European study found a relationship between high BMIs and short sleep duration in teens.  

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