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EMPIRICAL STUDIES

Obesity treatment*more than food and exercise: a qualitative study exploring obese adolescents’ and their parents’ views on the former’s obesity

ANDERS LINDELOF, MD1, CLAUS VINTHER NIELSEN, Associate Professor2, &

BIRTHE D. PEDERSEN, Associate Professor3

1Department of Clinical Social Medicine, Institute of Public Health, Faculty of Health Sciences, University of Aarhus,

Aarhus C, Denmark, 2Department of Clinical Social Medicine, Institute of Public Health, Faculty of Health Sciences,

University of Aarhus, Aarhus C, Denmark, and 3Research Unit of Nursing, Institute of Clinical Research, Faculty of

Health Sciences, University of Southern Denmark, Odense C, Denmark

Abstract The aim of this study was to explore obese adolescents’ and their parents’ views on the former’s obesity; especially to gain knowledge about barriers and motivational factors that influence obese adolescents’ ability to lose weight. This is a qualitative study involving field observation and semi-structured interviews with obese adolescents and their parents. The analysis takes a phenomenological�hermeneutic approach. Fifteen obese adolescents aged 13�16 years and their parents/ grandparents participated in this study (one father, seven mothers, five sets of parents and two sets of grandparents). The results showed that obese adolescents’ are aware that they have unhealthy eating habits and they wish they were able to attain to a healthier diet. Although in poor physical shape, obese adolescents perceive their daily level of exercise as moderate. Obese adolescents blame themselves for being obese and blame their parents for an unhealthy diet, and for being unsupportive regarding exercise. Parents blame their obese child of lacking will power to change eating and exercise habits. As a consequence, the homely atmosphere is often characterised by quarrels and negative feelings. The conclusion is that despite obese adolescents’ intention of reducing weight, underlying issues interfere with this goal. This is particularly related to quarrels with parents, self-blame and misguided understanding of eating and exercising habits. These matters need to be addressed when treating obesity among adolescents.

Key words: Adolescents, blame, phenomenological�hermeneutic study, obesity, views on obesity

(Accepted: 14 February 2010; Published: 16 March 2010)

Introduction

This paper deals with matters influencing the

behaviour of the obese teenage population. The

article is based on a qualitative study exploring

obese adolescents’ and their parents’ views regarding

the former’s obesity. Specific attention was given to

the obstacles and capabilities obese adolescents

face while trying to reduce weight by behavioural

modification.

Obesity continues to rise globally. For the first

time in a century, future generations in the UK are

likely to die at a younger age than their parents due

to obesity (House of Commons, 2003�2004). Child- hood and adolescent obesity is a serious issue with

many consequences for health and social well being

and it is widely agreed that obesity in these age

groups has to be reduced. However, it is especially

important to reduce adolescent obesity since the

condition most likely persists into adulthood (Dietz,

2004; Wardle, Brodersen, Cole, Jarvis & Boniface,

2006). Furthermore, due to adolescence’ increasing

autonomy as well as greater awareness of body

image, friendship and self-esteem (Coleman &

Hendry, 2000), they might be more easily encour-

aged to change behaviour compared to other age

groups.

Obesity treatment has a depressing history.

Although weight loss can be achieved in the

short run, the long-term effect is often insignificant

(page number not for citation purpose)

Correspondence: A. Lindelof, Department of Clinical Social Medicine, Institute of Public Health, Faculty of Health Sciences, University of Aarhus, PP.

Oerumsgade 11, 8000 Aarhus, Denmark. Tel: �45 8949 1242. Fax: �45 8949 1217. E-mail: [email protected]

Int J Qualitative Stud Health Well-being

#2010 A. Lindelof et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium,

provided the original work is properly cited.

1

Citation: Int J Qualitative Stud Health Well-being 2010, 5: 5073 - DOI: 10.3402/qhw.v5i2.5073

(Byrne, Cooper & Fairburn, 2003; Summerbell

et al., 2005). Traditionally obesity treatment focuses

on altering the obese individual’s diet and exercising

habits by behavioural intervention that tries to

increase the obese person’s knowledge about a

healthy diet and the importance of exerci-

sing (Doak, Visscher, Renders, & Seidell, 2006;

Summerbell et al., 2005). This strategy assumes

that greater knowledge of factors leading to obesity

generates a change of behaviour which finally leads

to weight loss. According to numerous authors this

strategy fails to acknowledge the individual needs

of the obese person (Müller & Danielzik, 2007;

Murtagh, Dixey, & Rudolf, 2006; Thompson &

Thomas, 2000). This argument is supported by

anthropological and sociological theories on daily

life (Bourdieu, 1990; Holy & Stuchlik, 1983) which

emphasise that behaviour cannot be successfully

modified without paying attention to the context

surrounding the specific behaviour. Put simply, in

order to influence a person’s behaviour in everyday

life one must attend to the reasons that stimulate and

guide such behaviour.

The reasons that stimulate behaviour could be

conceptualised by exploring the person’s views on

the particular behaviour. Obese people’s views

regarding their obesity are not fully understood.

However, important aspects have been pointed out.

Etelson, Brand, Patrick, & Shirali (2003) and

Eckstein et al. (2006) found that many parents fail

to recognise their child’s obesity. He, Irwin, Sangster

Bouck, Tucker, & Pollett (2005) found that some

parents do not recognise their child’s screen viewing

as a cause of obesity. It is also shown that although

the risk factors leading to obesity (Deforche, De

Bourdeaudhuij, Tanghe, Hills, & De Bode, 2004;

Murphy, Youatt, Hoerr, Sawyer, & Andrews, 1995;

Thakur N & D’Amico, 1999) are known, some

families give other explanations like unhealthy genes

or social problems to explain their child’s obesity

(Jackson, McDonald, Mannix, Faga, & Firtko,

2005; Lindelof, 2006). Although these studies are

small in size and need to be confirmed in the future,

they indicate a discrepancy between (a) the obese

population’s views on and reasons for their obesity

and (b) the more rational perspectives on obesity

formulated by the health authorities and operatio-

nalised in the traditional intervention strategies. It

seems likely that such discrepancy affects the effi-

ciency of the intervention strategies. For example,

and related to the above findings, in order to support

the obese child to reduce weight, its parents first of

all have to perceive the child as obese. This is a

perception many parents do not have according to

two sets of research teams (Eckstein et al., 2006;

Etelson et al., 2003). And further, if a reduction in

sedentary activities, such as screen viewing, is

beneficial in order to lose weight, the obese person

and his/her relatives need to acknowledge the

association between screen viewing and obesity*an association He et al. (2005) failed to prove in their

study.

Aim

The aim of this study was to qualitatively explore

obese adolescents’ and their parents’ views on the

former’s obesity. Especially to gain knowledge about

barriers and motivational factors that influence

adolescents’ ability to lose weight.

Theoretical framework

We hypothesise that insights into obese individual’s

views are essential if a lasting change of behaviour is

to be encouraged. In short, the obese person cannot

adopt a healthier lifestyle if his/her views contradict

this behaviour. Our theoretical standpoint is inspired

by the French sociologist Pierre Bourdieu’s (1930� 2002) theories of practice, in particular his notion of

habitus (Bourdieu, 1990). Among others, Bourdieu

develops habitus to understand why there are

behavioural similarities within different social

classes, e.g., ballet and white wine are enjoyed by

the upper class while the lower class watch soccer

and drinks beer. Bourdieu argues that behaviour is

mediated by habitus, which at a pre-conscious level

organises the individual’s behaviour in certain pat-

terns reflecting the habitus. Habitus is formed in the

individual’s past by material, cultural and social

conditions, and experiences. However, childhood

and youth are of central importance to the formation

of habitus. Thus, habitus cannot be grasped as it

constantly changes as time goes and new experiences

are integrated. In Bourdieu’s theory, habitus there-

fore takes the past and directs it into the future as

specific way of acting in everyday life.

Related to obesity and the implementation of

healthier eating and exercising habits, the under-

standing of habitus indicates that it is not sufficient

to educate the obese about the nutritionally correct

way of eating and the importance of exercising. If the

obese individual is to adopt a healthier living, he/she

needs to have a habitus that can generate healthy

behaviours. Thus, obesity intervention also needs to

focus on underlying factors that might interfere with

the implementation of healthier habits.

Material and methods

‘‘Views’’ as an outcome are hard to quantify and

largely unknown at the beginning of an investigation

A. Lindelof et al.

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Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073

which makes a qualitative approach, involving field

observations and different kinds of interviews sui-

table (Fitzpatrick & Boulton, 1996). In a scientific

frame, the study takes a phenomenological�herme- neutic approach and is inspired by the French

philosopher Paul Ricoeur’s (1913�2005) theory of interpretation (Lindseth & Norberg 2004; Pedersen

1999; Ricoeur, 1976) and used in several qualitative

explorations.

Setting

Participants were enrolled on a three-week summer

camp which aimed to reduce adolescents’ obesity by

behavioural modification. In full, 28 obese adoles-

cents attended the camp. All camp participants

perceived themselves as obese and participated

voluntarily in order to lose weight. The camp took

place in Denmark in the summer of 2006 at a

‘‘Julemaerkehjem’’ which is a Danish institution,

which normally provides socially troubled and

mostly overweight and obese children a 10 weeks’

stay free of charge. Besides a nutritious healthy diet,

the camp programme featured a daily, compulsory

morning run (1.2 km) and different physical activ-

ities like canoeing, dancing, fitness, athletics and

boxing.

Sampling

Two months prior to the start of the camp, all 28

camp participants and their parents/relatives at-

tended an information meeting about the camp. In

addition to camp information, the present study was

introduced and all camp participants were invited to

join. Besides the teenager being obese and attending

the summer camp, inclusion criteria in the study

were that he/she and his/her parents were willing to

be interviewed. The exclusion criteria were lack of

motivation or other obstacles to attend the camp. In

all, 15 adolescents (eight girls and seven boys) and

their parents: one father, nine mothers, three sets of

parents and two sets of grandparents chose to

participate in the study (Table I). The camp

participants not wanting to participate in the study

did not have to give an explanation to do so. The two

sets of grandparents had custody of the child and

functioned as parents. In both cases the child did not

know its biological father and the mother had proven

incapable of taking proper care of the child when an

infant. The poor parental skills of the mother had led

the grandparents to intervene and be in charge of the

child’s upbringing. The two children raised by their

grandparents did not in any significant way differ

from the other participants and there will be no

further distinction between grandparents and par-

ents, with the latter term being used.

The degree of obesity of the adolescents that

participated in the study varied. They were asked

to describe how many kilograms they were above

their self-perceived ideal weight: two noted 10 kg or

less, three noted 10�20 kg, six noted 20�30 kg and four wanted to lose more than 30 kg. The obese

adolescents who participated in the study were

enrolled in lower secondary schools (8th or 9th

grade). The parents had different educational levels:

one had an academic degree, eight had a level of

education corresponding to being a teacher at a

primary school, social educator, etc. The rest did not

have any education besides compulsory schooling.

When asked at the interview, nine of the 15 parents/

couples perceived themselves as overweight or obese.

All but three parents were employed. The three

unemployed received welfare payments. All partici-

pants lived in the greater municipal area of Copen-

hagen, Denmark.

Data collection

Field observation (Spradley, 1980) and semi-struc-

tured interviews (Kvale, 1996) were used to collect

data. Field observation was conducted at the camp

during all three weeks. During this period the

researcher lived at the ‘‘Julemaerkehjem’’ and parti-

cipated in the daily activities scheduled for the

adolescents. Besides gathering information by ob-

servations and informal conservations, he also es-

tablished trusting relationships with the obese

adolescents. In order to get to know the parents,

the researcher socialised with them at weekends

Table I. List of participations.

Adolescents Parents/ grandparents

Gender

Age (year)

at camp start

Weight (kg)

at camp start

Weight loss (kg)

at the camp

Mother (M) Father (F)

Grandparents (GP)

� 14 95 5 M, F � 14 112 7 GP � 15 123 6 M � 15 95 3 M � 15 118 4 M, F � 15 95 6 M � 16 87 4 M � 14 73 3 M, F � 14 92 5 M, F � 14 80 3 GP � 15 103 4 M � 15 83 4 F � 15 95 5 M � 16 86 4 M, F � 16 91 6 M

Obesity treatment*more than food and exercise

Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073 3 (page number not for citation purpose)

when they visited their children at the camp. Field

notes (Emerson, Fretz, & Shaw, 1995) were written

regularly.

On the basis of interaction with the participants, a

semi-structured interview guide was constructed

during the first two weeks of the camp (Table II).

The guide used when interviewing adolescents

covered subjects, such as daily life living as an obese,

matters related to food and exercise, relation to

parents and friends, and so on. When interviewing

the parents, the guide covered similar subjects

related to their child’s obesity, although more atten-

tion was paid to the child’s motivation to engage in

healthy habits. The same interviewer conducted all

the interviews and he adopted a consistent approach

in attitude and to questions. The guide served as the

researcher’s checklist, meaning that he looked

through it when interviewing to make sure the topics

in the guide was covered in the interview. Thus, the

participants did not receive the exact same questions

but all were asked about the same topics, e.g., if the

participant was freely talking, only a few questions

within the topics were necessary, while more ques-

tions were asked if the interviewee needed more

guidance on a given subject. Questions were always

asked openly and non-judgementally, and adjusted

to the specific interview.

Interviews with the adolescents were conducted

during the last week of the camp. To stimulate both a

broader dialogue and to reduce any sense of dis-

comfort, the adolescents were encouraged to be

interviewed in small, self-chosen groups. One group

of three, and six groups of two adolescents were

formed. To establish these groups, the adolescents

were asked to find their closest friend at the camp.

The fact that the groups consisted of close friends

made sensitive topics easier to discuss compared to a

normal in-depth single interview. Besides supporting

each other on sensitive topics, the friends could

discuss topics with each other and thereby supple-

ment and encourage each other. At the group

interviews the researcher made the interviewees

answer the same question before they were encour-

aged to discuss within the group. The researcher

then commented, added follow up questions and

juxtaposed previous answers in these discussions.

The parents were interviewed in their private

homes when their children were not in the house/

room. The interviews with the parents were always

preceded by informal conversation. This, and the

fact that the researcher had shown interest in

socialising with them at the camp made the parents

less tense and more eager to discuss matters of

importance during the interview.

The average length of the interviews for both

adolescents and parents was 72 minutes. Interviews

were audio-taped and transcribed word by word by

the same researcher who conducted the interviews.

Data analysis

Transcripts and field notes from observations were

used equally in the analysis and both types of

information are referred to as ‘‘data’’. Although field

observations compared to interviews could be inter-

preted as of lesser importance in the analyses, such

data is of great value as it in many ways serve as the

basis for the questions asked in the interview. For

example, based on the field observations, the re-

searcher could ask about a given observed behaviour

or relate a participant’s answer to an observed

behaviour. Thus, besides having value of it own field

observations were integrated in the interviews. The

analysis of the data is inspired by Ricoeur and

consists of three levels, i.e., naive reading, structural

analysis, and critical interpretation and discussion

(Angel, Kirkevold, & Pedersen, 2009; Pedersen,

1999; Ricoeur, 1976).

Naive reading. According to Ricoeur, naive reading is

a process where the interpreter reads all the written

data several times while taking a phenomenological

approach, i.e., the researcher remains non-judge-

mental and open-minded in order to grasp the

meaning of the data as a whole. The naive reading

is regarded as the first conjecture of the analysis and

it has to be validated or invalidated by the subse-

quent structural analysis.

Structural analysis. The intention of the structural

analysis is to clarify the dialectics between naive

reading on the one hand and interpretation of what

Table II. Themes of the interview guide.

Topics of interests, adolescents and parents � Obesity anamnesis; when and why, possible episodes

related to the obesity. � Attitudes to food; amount and type of food intake,

food bought in secret. � Attitudes to exercise; type and time spent on

exercise. � Previous attempts to lose weight; why, how, moti-

vation to do so. Related to the adolescents

� Parents’ and friends involvement in the handling of the obesity.

� Hopes for the future regarding the obesity. Related to the parents

� The obese child’s motivation to lose weight. � Parents’ support; what do they do, could they do

more/something else.

Note: This is not to be seen as questions but as themes the

interviewer covered while interviewing.

A. Lindelof et al.

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Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073

the data is about on the other. This part of the

analysis will move from units of meaning to units of

significance and generates themes and subthemes

related to the overall aim of the investigation.

Critical interpretation and discussion. The themes and

subthemes identified by the structural analysis are

interpreted and discussed in the critical interpreta-

tion and discussion. This level of the analysis is

related to the overall treatment of obesity with

special attention on how to increase the efficiency

of the behaviour modification approach. To validate

the analysis, the themes and subthemes are reflected

against the background of the naive understanding,

exploring whether the themes validate or invalidate

the naive understanding; if the structural analysis

invalidates the naive understanding, the whole text is

read again and a new understanding is formulated

and checked by a new structural analysis. In

Ricoeur’s terminology this process reflects a dialectic

process between explanation and comprehension,

also known as the hermeneutic spiral.

Ethics

All applicable institutional and governmental regula-

tions concerning the ethical use of human volunteers

were followed during this research. All participants

were informed orally and in writing about the study,

including the purpose of the study, the methods used

(i.e., interviews, observations with fieldnotes). All

participants were told that they could withdraw from

the study with out any notice or consequences.

Anonymity was guaranteed by ensuring strict con-

fidentiality of any material related to the study. The

Central Danish Committee on Biomedical Research

Ethics had no objections against the study (nr:

123/2007). Data gathering were always done in a

polite and tactful manner and in respect to the

individual being interviewed/observed. To limit par-

ticipants’ potential discomfort after an interview, the

researcher finished an interview with friendly and

everyday small talk.

Results

Naive reading

A thorough naive reading of the data (transcripts and

field notes) elicited several interesting impressions

related to the adolescent’s obesity. The analysis

revealed that habits relating to food and exercise

were of particular interest. Furthermore, the analysis

showed the both adolescents and parents were

occupied by thoughts of responsibility; i.e., the

adolescents blamed themselves for being obese

and the parents blamed their child for not being

motivated and determined to lose weight. These

thoughts influenced the adolescents’ ability to re-

duce weight through behavioural modifications.

Structural analysis

The structural analysis first presents themes and

subthemes related to the adolescents and then to the

parents. Tables III and IV show the movement in the

analysis with adolescents and parents, respectively.

Table III presents the structural analysis based on

interviews and field observations with adolescents.

Although the substance of the statements differed

between the obese adolescents and their parents, the

overall themes were similar. Table IV presents the

structural analysis based on interviews and field

observations with the parents.

The themes and subthemes identified in the

structural analysis and shown in Tables III and IV

are elaborated in the following sections.

Attitudes towards diet

Compared to the diet at the camp the adolescents

ate larger quantities of food and unhealthier food in

everyday life. They defined unhealthy food as food

high in sugar, fat and white flour. The adolescents

were fully aware that their diet was unhealthy and

they wished they were able to alter this behaviour. ‘‘I

wish I didn’t do it [eat unhealthy food] but I just

forget everything about losing weight when I’m

buying it’’. To explain their unhealthy eating habits

they (a) accused their parents for buying and serving

unhealthy food, and (b) blamed themselves for

consuming fast food, snacks, soft drink, etc., when

not at home/with their parents on a daily basis. The

food consumed when alone was primarily done

when sad, hungry or with peers in social gatherings.

The adolescents tried to hide their intake of un-

healthy products from their parents, as they believed

their parents would be upset if they knew the

quantity of unhealthy food they consumed. ‘‘She

[mother] would be furious if she knew how much

food I buy so I don’t tell her anything’’.

The parents disagreed with their children’s com-

plaints about unhealthy food at home and believed

they served healthy food and had done this for the

past years. ‘‘All our homely food is adjusted to her

being obese. But we cannot fully control what she

does by herself.’’ The parents primarily focused on a

diet low in fat and sugar, and rarely on size and

numbers of portions. The parents were aware that

their child ate unhealthy food when not with them

and believed this was a major reason for the child’s

obesity. ‘‘He has to want to lose weight . . . I think he

Obesity treatment*more than food and exercise

Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073 5 (page number not for citation purpose)

forgets about it when I am not there to tell him’’.

Compared to the adolescents’ statements, the par-

ents underestimated the quantity of unhealthy food

the adolescents consumed on their own. The parents

were convinced that they had done and still did

everything they could to reduce their child’s un-

desirable eating habits.

Attitudes towards exercise

Field observations revealed that the adolescents were

in poor physical shape. They were only capable of

engaging in intensive physical activity, like running,

for few minutes. None could complete the morning

run (1.2 km). In spite of their poor physical skills,

they perceived their daily level of exercise as moder-

ate although not sufficient to lose weight. This

perception was based on the fact that they were or

had been members of a gym or sports club and had a

weekly lesson (90 minutes) of sports in school. ‘‘I do

some sport, not much though. But you know, I have it

in school and I also go to the gym once in a while’’.

When asked about their membership to the sports or

gym club, the adolescents explained that they often

changed activity, either because they felt they lacked

the appropriate skills or because other club members

bullied them. The majority of the adolescents disliked

these activities and attended to lose weight and satisfy

their parents’ wishes. ‘‘ . . . in the last three years I have tried perhaps six different clubs but I didn’t like

them’’. The adolescents did not relate non-club-

based exercise like walking, playing, bike riding, etc.,

with ‘‘proper exercise’’ and weight reduction. In

order to reduce weight, they wanted to be more

active but believed they lacked motivation ‘‘to pull

themselves together’’ and start exercising regularly.

Table III. Adolescents. Findings of the structural analysis with units of significance, themes and subthemes and examples of meaningful

units shown as quotations derived from the text in the naive reading.

Units of meaning*what they say (quotations) Units of significance*what

it speaks Themes and subthemes

‘‘They [parents] know that I sometimes buy unhealthy food, but not that I do it three or four times a day’’. ‘‘She [mother] would be furious if she knew how much food I buy so I don’t tell her anything. You know, I wish I did not eat it but I just cannot stop doing so’’. ‘‘I wish I didn’t do it but I just forget everything about losing weight when I’m buying it’’. ‘‘Once I stopped eating unhealthy food for nearly one week. I was really proud of myself. But it kind of stopped after that week’’.

Large amounts of unhealthy food intake. Ashamed of eating in such a way and hide it from parents. Wish current eating habits were healthier.

Attitudes towards diet � Unhealthy food habits. � Ashamed of this behaviour

and want to change it.

‘‘I often think at night that tomorrow I am going to go for a run. And I really mean it . . . but then something else comes up and I don’t’’. ‘‘I have nearly always been a member of a sports club . . . in the last three years I have tried perhaps six different clubs but I didn’t like them. Now I’m using the gym’’. ‘‘I go to the gym . . . Well, I have only been there a few times this year. I am going to use it more, I am sure’’. ‘‘I don’t think I get enough exercise but I have physical education in school and sometimes I go to the gym’’.

Exaggerate the daily level of exercise*perceive it as moderate. Wish current exercising habits were healthier. Associate exercise with formalised sport or the gym.

Attitudes towards exercise � Discrepancy between the

actual level of exercise and the perception of it.

� Want to increase level of exercise.

� Exercise is perceived as formal and club-based.

‘‘If I am gaining weight it is because I have been lazy and not been pulling myself together’’. ‘‘My parents have tried to help me although not very well I think. But I am 15 now and I should be able to control myself.’’ ‘‘Once I lost three kilos and I was much happier and also a little bit proud. But then some problems came up and I did not have energy to do the right things. So it is my own fault, I guess I am weak.’’ ‘‘When you are slim everything is much easier. No one looks at you, your clothes fit’’.

Feel guilty for being obese and accuse themselves for not being capable of reducing weight. Believe life at normal weight is better.

Responsibility and obesity � Blame themselves for being

obese. � Associate a slim life as more

enjoyable.

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Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073

All parents characterised their child as lazy and a

person who did not enjoy exercise. ‘‘She [child] just

watches TV or is at the computer. She has always

been so lazy’’. In spite of this they agreed with their

obese child and believed he/she had a moderate level

of daily exercise. Like the adolescents, the parents

based this assumption on the fact that the child had

been or was a member of a sport club/gym and

attended a weekly session of sport in school. The

parents believed they fully supported their obese

child to increase physical activity. This was primarily

done by verbal encouragement and rarely by joint

family trips involving physical activity. ‘‘I daily tell

him [child] to go for a run. But I cannot join him

because of my knees’’. When asked about their last

family trip involving physical activity (walking, bike

rides, etc.), none of the families had done so within

the last year. The parents viewed their family as an

active family who enjoyed walking, bike rides, etc.

One parent had been riding a bike for the last week.

Neither the adolescents nor the parents considered

exercise as important as food when trying to

reduce weight. In addition, the parents were less

enthusiastic when trying to increase physical activity/

reduce sedentary activities compared to their efforts

in influencing their child’s eating habits.

Responsibility and obesity

The obese adolescents believed their lives would be

more enjoyable if they were slim; with more self-

confidence, more friends and an easier daily life.

Therefore, their desire for weight loss was signifi-

cant. ‘‘When you are slim everything is much

easier’’. They were fully aware that their eating and

exercising habits were unhealthy and counteracted a

weight reduction. They held themselves responsible

for not being capable of changing their habits and

believed they were incompetent in taking care of

themselves. ‘‘It is my own fault. I’m lazy and eat too

much’’. The adolescents did not blame their parents

for their obesity but they wished for better parental

support. In particular, they wanted the food served

at home to be healthier and the parents being better

at encouraging them to exercise. Lastly, they thought

the parents were too focused on them being obese

Table IV. Parents. Findings of the structural analysis with units of significance, themes and subthemes and examples of meaningful units

shown as quotations derived from the text in the naive reading.

Units of meaning*what they say (quotations) Units of significance*what it

speaks Themes and subthemes

‘‘All our homely food is adjusted to her [child] being obese. But we cannot fully control what she does by herself. We keep telling her not to but she just continues. We have really done everything we could’’. ‘‘We have done everything at home. We do not have butter, white bread . . . If she [child] is not motivated . . . I mean, we cannot lose weight for her’’. ‘‘I know he [child] buys candy and soft drinks. I tell him not to, but he does not seem to care. He has to want to lose weight I think.’’

Believe the food served at home is healthy. Blame the child for unhealthy dieting when by themselves.

Attitudes towards diet � Believe the home is an

environment where healthy food is prioritised.

� Blame the child for unhealthy eating habits.

‘‘It happened after he [child] entered puberty. He has become really lazy. He doesn’t even want to vacuum clean because it is too much exercise’’. ‘‘To be honest I don’t think she [child] likes to exercise but she does get some. Now she’s a member of the gym and last summer she played soccer at the club’’. ‘‘He [child] cycles sometimes but I think it is because I tell him to do so. He is a member of the gym. But he does not use it’’.

Perceive the child as lazy and living a sedentary life. Believe the child has a moderate level of daily, physical exercise. Associate exercise with formalised activities like the sports club or the gym.

Attitudes towards exercise � Blame the child for being

lazy. � Perceive the child as having a

moderate level of exercise. � Consider exercise as sport or

work out

‘‘He [child] is 15 years old now and should be old enough to make the right decisions.’’ ‘‘You know, I have done everything I could. It is up to her [child] now; she needs to be motivated. She really needs to want to lose weight.’’ ‘‘I think she [child] will mature and start taking some responsibility to her life. I am pretty sure she will grow up in that sense.’’

Believe the child is fully supported to engage in a healthier life-style. Perceive the child as lacking motivation and will power to lose weight.

Responsibility and obesity � Believe the child needs to

make a bigger effort to reduce his/her weight.

� Cannot support more than already doing.

Obesity treatment*more than food and exercise

Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073 7 (page number not for citation purpose)

and they lacked a non-accusing dialogue about their

weight. They believed they would be more motivated

and eager to engage in a healthier lifestyle if

the home atmosphere was pleasant and not char-

acterised by quarrels and accusations of being lazy

and lacking motivation to lose weight. ‘‘She [mother]

constantly tells me what not to do and blames me for

what I am doing . . . It really upset me’’. The parents on the other hand perceived them-

selves as fully supporting their child in losing weight.

Although they knew the child had difficulties in

changing behaviour and reduce weight, the parents

perceived their child as immature and in lack of

motivation and willpower. ‘‘It is up to her [child]

now; she needs to be motivated’’. Therefore, they

criticised their child for not engaging in a healthier

behaviour. The parents believed the child would be

more motivated and successful in reducing weight

when he/she matured through adolescence into

adulthood.

Critical interpretation and discussion

The title of this article indicates that obesity treat-

ment to be successful needs to focus on more than

exercise and a healthy diet. In line with Bourdieu’s

notion of habitus, attention must be paid to the

underlying mechanism that generates the unfortu-

nate behaviour leading to obesity. In short, people

do not change behaviour because they are told that

another behaviour is better. They change behaviour,

we believe, because they are motivated and have the

premises for establishing the new behaviour. In other

words, if obese individuals are to adopt a healthier

lifestyle, they need to have a habitus that can

stimulate and generate these healthier habits. The

following pinpoints areas of interest that might, if

targeted, influence obese individual’ habitus and

thereby increase the efficiency of intervention stra-

tegies aiming at reducing teenage obesity.

The study revealed a discrepancy between obese

adolescents’ and their parents’ perception of the

health of the food served at home: the former

believed the food could be healthier while the latter

disagreed with this. The study did not measure the

correctness of this, but it seems likely that reality

differs from parents’ perception since people gen-

erally tend to underestimate the amount of un-

healthy food they eat (Maurer et al., 2006).

Besides this, many parents in the study were

themselves obese which might indicate that the

family diet could be healthier. The apparent imbal-

ance between reality and parents’ perception of it is

problematic since it cannot be expected that parents

will change their diet as long as they erroneously

perceive it as healthy. Therefore, parents need

support to realise that the food consumed at home

is not as healthy as they consider it to be. As others

have pointed out (Glanz, Brug, & Assama, 1997),

this is the first and most basic step towards a

healthier diet. The change towards a healthier family

diet is important in regard of the amount of

unhealthy food the adolescent are exposed to.

However, in line with Bourdieu’s concept of habitus,

an unhealthy family diet is also important to alter as

the eating habits learned as a child/adolescent will be

brought into adulthood. Similar argument regarding

pre-school children’s consumption of fruit and

vegetables is made elsewhere (Cooke et al., 2004).

Another topic that needs attention is the under-

standing of what characterises healthy dieting. This

study showed that a healthy diet is associated with

meals low in fat, sugar and white flour, and not with

portion size. Therefore, it is rare for parents to

discuss with their obese child quantities of food

consumed. This is problematic since portion sizes

have increased during the recent years with a parallel

increase in energy intake (Ledikwe, Ello-Martin, &

Rolls, 2005). Dietary guidelines and public cam-

paigns therefore need to include portion sizes as a

central element as advocated elsewhere (Matthiessen,

Fagt, Biltoft-Jensen, Beck, & Ovesen, 2003).

Besides the food served at home, obese adoles-

cents consume large quantities of unhealthy food

when alone, feeling sad, bored, hungry or with peers.

As mentioned, they are aware that these actions

increase their weight and they are ashamed of having

such needs. In relation to future intervention strate-

gies, an important message is that besides dietary

guidelines it is equally important to implement basic

behavioural skills in order to help the obese popula-

tion to make healthier choices in everyday life. One

example could be that the obese person learns

different coping strategies in order to handle peer

pressure or avoid emotional eating. This assumption

is supported by recent studies (Forman et al., 2007;

Goosens, Braet, Vlierberghe, & Mels, 2008).

Ekelund et al. (2002) have shown that obese

adolescents are less physically active compared to a

non-obese control group. Our study did not measure

the daily level of activity but based on the fact that all

the adolescents were in poor physical condition,

Ekelund et al.’s finding might characterise the

adolescents participating in this study. In spite of

their poor physical capabilities, adolescents and their

parents believe they live a moderate active life,

although aware that in order to reduce weight they

need to increase their level of exercise. The dis-

crepancy between the actual daily level of exercise

and the perception of it is problematic: a person who

believes he/she enjoys a moderate active life might

not be as motivated to increase physical activity,

A. Lindelof et al.

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Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073

compared to the person who perceives him/herself as

living a fully sedentary life. Therefore, in order to

stimulate obese adolescents to increase their level of

physical activity, they and their parents need to

understand that the actual level is low and not

moderate. Another issue related to exercise that

needs to be considered when treating obesity is

that both adolescents and their parents associate

exercise with membership in the local gym or sport

club. Even though obese adolescents dislike these

activities, they are members of such clubs. However,

they often change activity which means that they do

not get familiar with the activity but end up with

feeling of not being good at sports and exercising.

Our suggestion is that instead of promoting club-

based activities, non-formal exercise such as cycling,

walking, social activities involving fun and playful-

ness should be encouraged. Participating in such

activities is not dependent on skills and compared to

activities in the local sports club will not lead to a

sense of failure. Therefore, these non-club-based

activities have better chances of success, as pointed

out elsewhere (Poirier & Despres, 2001). In addi-

tion, long-term compliance might be higher if they

engage in activities they like instead of club-based

exercise they dislike.

Food and exercise were discussed by both groups

of informants. These topics were often related to

blame and responsibility. Many parents of obese

adolescents believe they fully support their child in

losing weight and they are convinced that the reason

why their child does not reduce weight is because he/

she lacks motivation to do so. Parents therefore

blame their teenage child for being obese. Obese

adolescents agree with this and blame themselves for

not being able to live a healthier life. When trying to

do so, for example, going on a diet and/or joining a

new sports club/gym, they lose motivation after a few

weeks and return to their old habits. This reinforces

their self-perception as a person who is lazy, lacks

basic human skills and has a weak character. There-

fore, the unsuccessful lifestyle changes led the

adolescents to internalise society’s perception of

obese people as weak and incapable of taking care

of themselves as shown in numerous studies (Latner

& Stunkard, 2003; Puhl & Brownell, 2001). We

presume this makes weight loss even harder. A

similar consideration related to chest pain has been

made by Richards and colleagues (Richards, Reid, &

Watt, 2003). In order to stimulate adolescents to

reduce weight, our suggestion is that obesity treat-

ment needs to focus on areas such as victim blaming.

One example could be that realistic goals are set and

both parents and adolescents are aware that failure

to achieve these goals is not synonymous with poor

skills. At the same time it is important to encourage

the family to keep a pleasant homely atmosphere, as

this is more motivating than quarrels, accusations

and the like when trying to change behaviour.

This paper deals with matters that influence the

behaviour of the obese teenage population. Insight

into such areas is important because behaviour, as

social scientists like Pierre Bourdieu have theorised,

does not exist in a vacuum but is generated by

underlying factors. Therefore, to stimulate a perma-

nent change of behaviour it is these underlying

factors that need to be influenced and not the

behaviour itself. In other words and related to the

treatment of obesity, the effect of solemnly addres-

sing the inappropriate consumption of certain pro-

ducts or living a sedentary life is limited because the

obese person does not alter the motives for living an

unhealthy life. In our discussion we have paid

attention to obese adolescents’ and their families’

unfavourable views regarding their habits of diet and

exercise. Furthermore, we have addressed matters

related to blame and responsibility within the family.

In line with the concept of habitus, our argument is

that obesity treatment needs to encourage obese

individuals and their relatives to reflect on these

unfavourable views as it is these views that in many

ways generate the unfortunate behaviour leading to

obesity.

For example, in spite of obese adolescents’ wish

for more parental support in losing weight, their

parents believed they fully support their child to live

a healthier life. Such discrepancy is problematic: as

long as parents perceive their support as sufficient

they will not comply with their child’s wish of being

more supportive. Therefore, and in this case, we

argue that treatment strategies profitably could (1)

support the parents to reflect on their way of

perceiving their support and (2) make room for an

alternative way of support which meets the adoles-

cents’ needs. If these two goals are achieved a better

understanding between the obese child and its

parents could be established which is necessary to

improve the obese adolescents’ overall conditions.

We believe such treatment approach is necessary to

stimulate the individual towards more favourable

behaviours.

Limitations

To ensure the quality of this study, data were

collected by conducting both fieldwork and different

types of interviews (group and individual). The

limitation of the study lies within the recruitment

strategy. First of all, since all young participants

recruited in the study participated voluntarily at the

camp, they perceived themselves as obese and in

need of help to lose weight. Such awareness might

Obesity treatment*more than food and exercise

Citation: Int J Qualitative Stud Health Well-being 2010; 5: 5073 - DOI: 10.3402/qhw.v5i2.5073 9 (page number not for citation purpose)

differ from the obese population in general, since

many parents perceive their child as slim although

they are in fact obese (He & Evans, 2007). Secondly,

since the young participants at the camp were

exposed to behavioural interventions and counsel-

ling that aimed to reduce obesity, they might be

more aware of such factors compared to an obese

person who has not recently been exposed to such

advice. The researcher sought to minimise this by

both the personal acquaintance between the re-

searcher and the adolescents at the camp and the

group interviews where the adolescents discussed

their daily lives with a like-minded person. An

example: a camp participant recently exposed to

the ‘‘correct’’ healthy way of living might unknow-

ingly overstate the amount of daily exercise he/she

performs. But because of the confidentiality between

the researcher and the person being interviewed, the

researcher could easily sense if the responses seemed

unrealistic and if so continue asking until a more

truthful answer is given. At the same time the group

discussions during the interviews validated the

reports given, since the adolescents experienced

that their obese friends had roughly the same

problems as themselves. This reduced the fear of

telling about their actual level of exercise. Therefore,

we do not expect that this study’s recruitment

strategy and subsequent data collection compromise

the results. On the contrary we believe that fieldwork

involving observation and a personal relationship

with the participants is essential when gaining in-

sights into personal matters, such as views and

behaviour.

Conclusions

Obese adolescents wish to reduce weight but have

trouble doing so. In particular, they need coping

strategies to avoid the intake of unhealthy food when

alone or with peers. They also need a healthier

homely diet. Regarding exercise, obese adolescent

have to accept that they do not like formalised sport

and instead engage in non-formalised activities such

as cycling and walking. Another topic that interferes

with their wish of weight reduction is constant

quarrels with their parents about their weight and

weight loss. These daily fights do not motivate the

obese teenager to engage in a healthy living but

instead fills the adolescent with self blame and a bad

mood. As indicated in our title of this paper, we

therefore believe that obesity treatment will have

better chances of success if attention is given to

matters influencing the daily habits of the obese

population.

Conflict of interest and funding

The authors have not received any funding or

benefits from industry to conduct this study.

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