Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach
Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach
Abstract and Keywords
New Moves was developed as a school-based obesity prevention intervention for adolescent girls. The program underwent extensive pilot-testing with funding from the American Heart Association. It is being evaluated in a group-randomized controlled trial with six intervention and six comparison schools; the study is being funded by the National Institutes of Health. The intervention targets inactive adolescent girls at risk for obesity and other weight-related problems. New Moves addresses risk factors of relevance to a broad spectrum of weight-related problems. This chapter describes the New Moves intervention, with particular attention given to a few key messages and intervention strategies that have relevance not only to obesity, but also to other weight-related problems. It begins with an overview of the New Moves program. This section is followed by more detailed descriptions of the New Moves physical education component, which was designed to help girls feel comfortable being physically active regardless of their shape, size, or skills; the non-dieting approach to healthier eating; and strategies used to help the girls to view their bodies more positively. The chapter concludes by considering the importance of integrating programs such as New Moves into existing institutions, and developing programs that address a broad spectrum of weight-related problems for different types of populations.
New Moves was developed as a school-based obesity prevention intervention for adolescent girls. The programme underwent extensive pilot-testing with funding from the American Heart Association (Neumark-Sztainer et al., 2003). It is further being evaluated in a group-randomized controlled trial with six intervention and six comparison schools; the study is being funded by the National Institutes of Health (Neumark-Sztainer et al., Grant ROIDK063107). The intervention targets inactive adolescent girls who are at risk for obesity and other weight-related problems. New Moves addresses risk factors of relevance to a broad spectrum of weight-related problems. This chapter includes a description of the New Moves intervention, with particular attention given to describing a few key messages and intervention strategies that have relevance not only to obesity, but also to other weight-related problems. First, an overview of the New Moves programme is provided. This section is followed by more detailed descriptions of: 1) the New Moves physical education component, which was designed to help girls feel comfortable being physically active regardless of their shape, size, or skills; 2) the non-dieting approach to healthier eating; and 3) strategies used to help the girls to view their bodies more positively. We conclude by considering the importance of integrating programmes such as New Moves into existing institutions and developing programmes that address a broad spectrum of weight-related problems for different types of populations.
Obesity among adolescents is a significant public health problem, given its high prevalence (Ogden et al., 2006) and potential physical consequences (Daniels, 2006). Obesity may also be associated with harmful psychosocial and behavioural consequences, in part due to the difficulties of living within a society that values thinness (Puhl & Latner, 2007).
Because of particularly strong social pressures on girls to be thin, overweight adolescent girls are at high risk for body dissatisfaction and unhealthy weight control behaviours. For example, in Project EAT (Eating Among Teens), a large population-based study on adolescents’ eating behaviours and weight issues, 66% of overweight adolescent girls indicated low levels of body satisfaction and 76% reported the use of unhealthy weight control behaviours in the past year (Neumark-Sztainer et al., 2002). Research further shows that adolescent girls who have high levels of body dissatisfaction and engage in unhealthy weight control behaviours are at increased risk for both obesity and eating disorders over time (Neumark-Sztainer et al., 2007; Stice, 2002; Stice, 2001; The McKnight (p.270) Investigators, 2003; van den Berg & Neumark-Sztainer, 2007). For example, in Project EAT, girls who reported the use of unhealthy weight control behaviours were at nearly three times the odds for being overweight 5 years later, as compared to girls not engaging in weight control behaviours, in analyses adjusted for baseline weight status (odds ratio = 2.7; p = 0.004) (Neumark-Sztainer et al., 2006b). These findings suggest that obesity prevention interventions for adolescent girls need to help girls feel better about their bodies, avoid unhealthy weight control behaviours, and find appropriate, and more helpful, alternative behaviours for preventing overweight.
Girls with high levels of body dissatisfaction, or low levels of confidence in their physical activity skills, may be less likely to engage in physical activity (Allison et al., 1999; Neumark-Sztainer et al., 2006a; Sallis et al., 1999), which may be due to their discomfort in being physically active within public settings. Adolescent girls show a steep decline in physical activity during adolescence (Caspersen et al., 2000; Kimm et al., 2000; Trost et al., 2002); therefore, obesity prevention interventions need to find ways to help girls be physically active. In designing interventions with a physical activity component, it may be important to address body image concerns and provide environments in which all girls, regardless of their physical activity skill level, feel comfortable being physically active.
In developing interventions aimed at the prevention or reduction of obesity, it can be useful to think in terms of a broad spectrum of weight-related problems, which includes unhealthy weight control behaviours, body dissatisfaction, inadequate physical activity, and irregular eating patterns such as binge eating, in addition to obesity (See Fig. 24.1).
Although this type of spectrum has potential relevance for all groups, regardless of age, gender, or cultural background, it has particular relevance for adolescent girls, who are the focus of this chapter, given the pressures they experience to conform to a thin ideal. It is important to think broadly about risk and protective factors for the spectrum of weight-related problems in adolescent girls and address factors such as societal pressures to be thin, alternatives to dieting, healthful ways of dealing with stress, and obstacles to living a physically active lifestyle.
The underlying philosophy of the New Moves programme is to provide a setting that strives to help girls feel good about themselves so that they will want to nurture their bodies through physical activity and healthful eating on a long-term basis. New Moves is guided by Social Cognitive Theory (Bandura, 1986; Baranowski et al., 2002) and targets socio-environmental factors (e.g., peer support), personal factors (e.g., body image), and behavioural factors (e.g., goal setting) in order to bring about changes in eating behaviours and physical activity (Fig. 24.2).
New Moves aims to: 1) bring about positive change in physical activity and eating behaviours to improve weight status and overall health; 2) help girls function in a thin oriented society and feel good about themselves; and 3) help girls avoid unhealthy weight control behaviours. The New Moves intervention has eight behavioural objectives for girls: 1) be physically active at least 1 hour each day; 2) limit television/video watching to no more than 1 hour a day; 3) increase
The New Moves intervention includes different integrated components to address relevant socio-environmental, personal, and behavioural factors in order to help the girls achieve these eight behavioural objectives (Neumark-Sztainer et al., 2008). New Moves includes an intensive intervention phase, in which girls participate in daily activities as part of their physical education class, and a maintenance phase, which includes weekly meetings over lunch at school. Individual sessions, which incorporate motivational interviewing techniques (Flattum et al., 2009; Resnicow et al., 2006; Rollnick & Miller, 1995) are offered throughout both phases. A minimal parent outreach component is also included, which spans across both the intervention and maintenance phases.
The New Moves programme takes place in an all-girls physical education class, which counts towards the girls’ high school physical education requirement. The class includes physical education, nutrition, and social support components. Physical education teachers lead the physical education Section 4 days a week over one semester. During the study period, in which the New Moves programme was being evaluated, physical education teachers participated in a full-day teacher training, led by New Moves intervention staff that focused on understanding the profile of a New Moves girl, providing a variety of lifestyle physical activities suitable for girls of different shapes, sizes, and skill levels, reinforcing the girls’ efforts via positive feedback, and creating a fun and safe environment.
One class session per week is devoted to either nutrition or social support sessions. The nutrition component takes a non-dieting approach towards improving dietary intake and eating patterns. Building a positive self-image and self-empowerment are the main goals of the social support sessions. Classroom time during nutrition and social support sessions includes group discussion and activities on how teenagers can fuel their bodies through healthy eating as well as issues that affect teenagers’ lives such as how to create time for things they want to do and how to deal with stressors and pressures that young women face today. During the study period, these sessions were taught in a classroom setting by New Moves staff. However, following the study period, schools that have adopted the programme have chosen different methods for teaching these sessions, including having them taught by the physical education teacher, a school health care provider, or a university nutrition student.
Concepts and teaching strategies from both the obesity and eating disorder fields are incorporated into the intervention given adolescent girls’ risk for a range of weight-related problems. Intervention messages are addressed in the participant workbook, Girl Pages, and throughout the programme components. The Girl Pages contains information on each week’s topic plus additional information such as recipe cards, cut-out fit cards with various exercises, and resources for being physically active in the community. Each week’s lesson in the Girl Pages is divided into three sections, Be Fit (physical activity), Be Fab (social support and self-empowerment), and Be Fueled (nutrition). The Girl Pages workbook is designed in a teenage magazine style. Active and experiential learning form the basis for programme activities. All intervention materials are available at www.newmovesonline.com.
Enhancing physical activity: Be Fit
New Moves aims to help girls feel comfortable being physically active and meet the Healthy People 2010 goal for moderate to vigorous physical activity of at least 1 hour a day (U.S. Department of Health and Human Services PHS, 2000). The physical activity component section of New Moves, Be Fit, is focused on increasing physical activity in a fun, supportive environment and working towards leading a more active lifestyle outside of class.
(p.273) Be Fit is taught by a physical education teacher trained in the New Moves philosophy. Teachers are encouraged to increase girls’ participation in class by selecting activities that are fun, accessible, and non-competitive. Rather than reviewing the rules, practising the skills, and eventually playing the game, Be Fit classes begin with the basic aspects of an activity, e.g. hitting a volleyball back and forth over the net, and skills and rules are introduced to the class as the girls become more skilled and comfortable with the activity. Teachers are encouraged to give frequent positive feedback to the girls and facilitate a supportive class environment. Rather than skill mastery, the focus of Be Fit is to engage girls in moderate to vigorous physical activity throughout the class period.
The New Moves approach to physical activity encourages exposure to a variety of lifetime activities that are enjoyable and affirming to young women. Be Fit follows a weekly schedule that repeats throughout the class rather than the traditional use of units. Games, strength training, circuit training, and various dance and fitness modalities are included in Be Fit classes. Activities such as walking, aerobics, and dance are accessible to girls of various body shapes and sizes as well as fitness and skill level, and are used frequently in Be Fit classes.
An important part of Be Fit is the use of guest instructors from the community who come to class and lead an activity including fitness, dance, and martial arts professionals. There are a wide variety of physical activities that many girls enjoy trying such as middle-eastern dance, fitness hula hooping, hip-hop dance, yoga, and self-defence. Guest instructors are chosen based on the activity they teach and their ability to be a role model for inactive girls. Instructors are selected to provide examples of a range of fit bodies, including larger instructors who are able to model that physical activity is possible for various shapes and sizes. Additionally, guest instructors provide exposure to activities that are available in the community, such as aerobics classes at a local gym or a dance class at a studio.
Be Fit provides high school girls an opportunity to build skill and confidence for physical activity in a positive environment. These goals are further supported by the other components of the class, including several Be Fab sessions where girls are encouraged to set goals for physical activity and the individual counseling sessions. Be Fit also builds on the supportive environment that is encouraged in the classroom through community standards for behaviour and has a no tolerance policy for teasing about weight or appearance. Girls are encouraged to support and encourage one another to be physically active, both in and outside of the class. The various elements of the New Moves approach all aim to increase physical activity in inactive girls.
A non-dieting approach to healthful eating: Be Fueled
The New Moves nutrition component aims to help girls integrate healthy eating into their daily lives. A couple of unique aspects of the New Moves Be Fueled nutrition component are the anti-dieting stance and the emphasis on intuitive eating. The messages provide simple concepts, e.g. 1) dieting is not effective in losing or maintaining weight; and 2) listening to one’s body may be a more effective means of managing one’s weight. Instead of encouraging dieting and being overly restrictive, Be Fueled focuses on healthy, sustainable behaviour changes that promote a healthy relationship with food. Teaching the concept of energy balance and listening to internal hunger and fullness cues allows for discussion around healthy eating without much emphasis on calories, and more specifically avoiding calorie counting and restriction as a way to lose or maintain weight.
Be Fueled lessons focus on the New Moves goals of: 1) eating more fruits and vegetables; 2) eating breakfast everyday; 3) drinking more water; 4) avoiding unhealthy weight control behaviours, and 5) paying attention to portion sizes and your body’s signs of hunger and fullness. Messages provided in each lesson are more about finding balance between eating and physical activity and less about restricting food intake, and apply to all teenagers, not just those who are overweight. (p.274) Discussions often focus not only on how to make healthy choices in different situations (e.g. at the mall food court), but also talking about the fact that healthy eating means enjoying your food. The ultimate goal is for participants to realize that they can trust their bodies to tell them what they need to be healthy, and that they have a choice in how they fuel their bodies.
The concepts of avoiding dieting and listening to one’s body are key components of the Be Fueled lessons. The first lesson reviews the diet cycle, which shows participants what often happens when people go on diets, i.e. restrict, feel overly hungry, give in to cravings, and feel guilty, and how this is likely to be counter-productive in terms of weight loss, weight maintenance, and overall health. In addition to discouraging dieting and meal skipping, New Moves encourages girls to listen to their bodies, including cues of hunger and fullness. To accomplish this goal the hunger/fullness scale is used (Fig. 24.3) (modified from Kratina et al., 2003). Identifying hunger and fullness cues is often a new concept for many of the girls; however, girls reacted positively to this concept and discussed strategies for paying attention to these cues. Binge eating has been reported by overweight adolescent girls (Berkowitz et al., 1993; Johnson et al., 2002), and the use of the hunger and fullness scale is one tool to help girls work on decreasing binge eating episodes. Additionally, the hunger and fullness scale provides a tool that may help girls make changes in eating behaviours without being told ‘don’t eat that’ or ‘you don’t need it’, which New Moves girls were likely to hear.
Be Fueled stays away from a highly prescriptive model of telling girls what to eat, but does encourage healthy eating habits (i.e., increasing fruits and vegetables, eating breakfast, healthy snacking, etc.). Although it is important for girls to learn to understand their body and know when they are hungry and full, it is also important for them to be aware of the best ways to fuel their body. Thus, girls learn how to listen to internal signs of hunger and satiety, and receive the healthy eating/energy balance message in order to prevent both obesity and disordered eating.
Helping girls feel good about themselves and their bodies: Be Fab
The social support component of New Moves, Be Fab, focuses on increasing self-esteem, improving body image, and creating internal and external support for healthy choices. Topics covered include stress management, goal setting, media literacy, and body image. Increasing physical activity is also incorporated into Be Fab through activities with pedometers and time management. Be Fab lessons are designed to create a positive environment for girls to discuss barriers and challenges in making healthy choices and feeling good about themselves.
Adolescent girls are bombarded by media messages that infer that thin and flawless is the definition of beautiful. Therefore, one of the Be Fab lessons aims to educate girls about media messages and the narrow standards of beauty they are exposed to on a constant basis. Girls discuss common manipulations used in advertising and magazines such as airbrushing, computer editing, and lighting and make-up tricks, and are encouraged to critically examine the way media defines beauty. The lesson also focuses on girls’ collective power as consumers and discusses how they are in control of what forms of media they choose to view. An important part of this lesson is empowering girls to see that they can, and do, have a say in how beauty is portrayed in the media.
In a separate lesson, girls also learn about the concept of beauty as discussed in the poem ‘Phenomenal Woman’ by Maya Angelou (Angelou, 1978). Girls are encouraged to think of the importance of inner beauty and the role self-confidence plays in feeling beautiful. When asked for examples of beautiful women in their own lives, many girls mention mothers, aunts, grandmas, and sisters and rarely mention physical characteristics as reasons why they think these women are beautiful. This discussion helps girls realize that beauty comes in various forms and that being beautiful is about more than just outside appearances.
For many girls, it is not just the media that can impact their perceptions about their bodies, but also how they feel in comparison to their peers. Another Be Fab lesson spends time talking about the energy and time that goes into comparing oneself to others around them. Most girls relate well to the idea of the comparison trap, i.e., ‘I wish I had her arms’, and can come up with at least one example of this in their own life. The lesson brings up the negative consequences of constantly comparing parts of their bodies to others and girls brainstorm ideas of how to break the cycle of the comparison trap both within themselves and amongst their friends. Instead of girls focusing on the things they don’t like about themselves, New Moves encourages girls to focus on what they do like about themselves. For some girls, thinking about themselves in a positive manner is a challenge and may feel uncomfortable at first. To help girls begin to see the positive qualities they possess, this particular lesson ends with an activity in which classmates write compliments to each other. These compliments are meant to go beyond the superficial and help girls focus on the positive attributes each girl brings to the class. This lesson is a favourite among girls, and they enjoy not only receiving compliments but giving heartfelt compliments to their friends as well.
Be Fab helps create a positive environment where girls feel safe sharing their insecurities and struggles around healthy choices and positive body image. Combined with the other sections of New Moves, Be Fab lessons can provide a framework and opportunities to practise real-life skills for increasing self-esteem, body image, and encouraging healthy behaviours for life.
In developing obesity prevention programmes, it is crucial to take the contextual factors of the target population into account. For adolescent girls, obesity prevention programmes need to (p.276) address the high social pressures on girls to be thin, the high prevalence of body dissatisfaction, and the use of unhealthy weight control behaviours among girls, particularly overweight girls (Neumark-Sztainer et al., 2002). Additional factors that need to be addressed include the socioeconomic status of participants, racial and ethnic backgrounds, and familial dynamics and support. New Moves was designed to address the needs of adolescent girls who face strong social pressures to be thin and come from diverse socioeconomic and racial backgrounds. The New Moves model is only one approach to addressing a broad spectrum of weight-related problems. Initial findings suggest that the girls truly enjoyed the programme and greatly appreciated its approach. Future analyses will indicate to what level the programme was successful in helping the girls change their attitudes, behaviours, and weight-related outcomes. Future work is also needed to explore how best to integrate programmes such as New Moves into school settings on an ongoing basis. Finally, work is needed in developing approaches for other populations such as adolescent boys, children, and adults, which take into account a broad spectrum of weight-related problems.
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