Journal of Adolescent Health 44 (2009) 206–213
Review Article
Preventing Obesity and Eating Disorders in Adolescents: What Can
Health Care Providers Do?
Dianne Neumark-Sztainer, Ph.D., M.P.H., R.D.*
Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
Manuscript received August 13, 2008; manuscript accepted November 4, 2008
Abstract
This article describes five research-based recommendations for health care providers to help prevent
both obesity and eating disorders among adolescents that they see within clinical, school, or other
settings. The recommendations are based primarily upon findings from Project EAT, a large, population-based study of eating and weight-related issues in adolescents. Recommendations include the
following: 1) discourage unhealthy dieting; instead encourage and support the use of eating and physical activity behaviors that can be maintained on an ongoing basis; 2) promote a positive body image;
3) encourage more frequent, and more enjoyable, family meals; 4) Encourage families to talk less
about weight and do more at home to facilitate healthy eating and physical activity; and 5) assume
that overweight teens have experienced weight mistreatment and address this issue with teens and their
families. These recommendations stress the importance of helping adolescents and their families focus
less on weight and more on sustained behavioral change. Ó 2009 Society for Adolescent Medicine. All
rights reserved.
Keywords:
Obesity; Eating disorders; Prevention
The high prevalence of obesity and its potential physical
and psychosocial consequences make it a high priority for
addressing with adolescents [1,2]. However, efforts to
prevent or treat obesity need to also take into account the
high prevalence and negative sequel of body dissatisfaction,
disordered eating behaviors such as unhealthy weight control
and binge eating behaviors, and clinical eating disorders [3–
7]. This paper, based on a plenary presentation at the 2008
Society for Adolescent Medicine annual meeting, provides
five research-based recommendations for health care
providers to help prevent both obesity and eating disorders
among the adolescents that they see within clinical, school,
or other settings.
Each of the five recommendations made here are based
upon findings from the Project EAT (Eating Among Teens)
I and II studies, which are briefly described below, and other
research studies. The recommendations were selected based
upon key findings from Project EAT regarding correlates
*Address correspondence to: Dianne Neumark-Sztainer, Ph.D., M.P.H.,
R.D., Division of Epidemiology and Community Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454.
E-mail address: [email protected]
of eating behaviors, overweight status, and disordered eating
behaviors. In addition, factors such as feasibility of implementation within clinical settings, and concepts such as ‘‘first
do no harm,’’ also drove the selection of recommendations.
The list of recommendations provided here is not meant to
be an exhaustive or final list; rather, these recommendations
provide a starting framework for thinking in a broader way
about how to work with adolescents and their families to
prevent a broad spectrum of weight-related problems.
Brief description of Project EAT
Project EAT was designed to examine socio-environmental, personal, and behavioral factors associated with
eating and weight-related issues in adolescents. The study
included the following: 21 focus group discussions with
middle school and high school adolescents; surveys and
anthropometric measurements of 4746 middle school and
high school adolescents from diverse ethnic/racial and socioeconomic backgrounds; phone interviews with 902 parents
of participating adolescents; and a 5-year follow-up study
in which 2516 of the adolescents and young adults who
were part of the original cohort completed mailed surveys.
1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2008.11.005
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
All study protocols were approved by the University of Minnesota Institutional Review Board and by the participating
school districts, as appropriate. For further details on the
Project EAT study, the reader is referred to previous publications [8–13] and the Web site for Project EAT Web (www.
epi.umn.edu/research/EAT).
Recommendations for Preventing Obesity and Eating
Disorders
The five recommendations to guide health care providers
are shown in Table 1. Each of these recommendations is
expanded upon below, and research findings supporting
each recommendation are provided.
Recommendation #1: Discourage unhealthy dieting; instead
encourage and support the use of positive eating and
physical activity behaviors that can be maintained on an
ongoing basis
The first recommendation is that health care providers
should clearly inform adolescents that unhealthy dieting is
likely to be counterproductive to weight management efforts.
Adolescents may ‘‘go on a diet’’ to lose weight quickly;
however dieting may not be maintained long enough to bring
about the desired weight change, may not be associated with
appropriate changes in eating patterns, or may end up leading
to episodes of overeating. Instead of ‘‘dieting,’’ health care
providers should encourage adolescents to engage in positive
eating and physical activity behaviors that can be integrated
into their lifestyles and maintained on an ongoing basis.
Because dieting may mean different things to different
adolescents [14], health care providers should ask teenagers
if they are engaging in weight control behaviors, and if so,
what exactly they are doing.
Dieting, as reported by adolescents on surveys, has been
identified as one of the early steps on the route to an eating
disorder [15]. Although the vast majority of adolescents
engaging in different dieting behaviors do not develop clinical
eating disorders, it would be difficult to find individuals with
eating disorders, including anorexia nervosa, bulimia nervosa,
207
and eating disorder otherwise not specified (EDNOS), who
have not dieted. Furthermore, unhealthy weight control behaviors, such as skipping meals, using food substitutes, selfinducing vomiting, and taking diet pills, are associated with
poorer psychological well-being including lower self-esteem
[16,17], higher depressive symptoms [16–18], and greater
use of alcohol and tobacco [19], although the reason for these
correlations is not readily apparent. Furthermore, unhealthy
weight control behaviors are associated with poorer quality
of dietary intake, including lower intakes of grains, fruits,
vegetables, and calcium-rich foods [18,20,21].
Findings from Project EAT [22,23] and other studies
[24–26] show strong longitudinal associations between dieting, as reported by adolescents on surveys, and weight gain or
obesity onset. Informing adolescents that dieting can increase
their risk for an eating disorder may not deter them from dieting. However, telling teenagers who are concerned about
their weight that their dieting efforts will put them at risk
for weight gain over time, rather than weight loss, is likely
to be more effective in directing them away from dieting
behaviors, which are often implemented on a short-term
basis, to positive changes in eating and exercise behaviors,
which can be sustained on an ongoing basis. For example,
in Project EAT, adolescent dieters were at nearly twice the
odds for being overweight 5 years later than nondieters
[22]. These associations were not due to the fact that the
dieters were heavier to begin with, as analyses adjusted for
baseline body mass index (BMI).
A question that often arises is, ‘‘Why does dieting lead to
weight gain over time?’’ Is the relationship a causal one, or is
dieting merely a marker for increased risk for weight gain
above and beyond initial weight status? Dieting may be
leading to weight gain in that teenagers may engage in
dieting as a short-term behavior, which starts and stops. An
adolescent may say, ‘‘I’m starting a diet on Monday, so I
am going to splurge this weekend.’’ Or ‘‘I’ve already broken
my diet so I might as well keep on eating.’’ Using Project
EAT data, we examined the question of why dieting leads
to weight gain over time. We found evidence that adolescents
who diet are at increased risk for binge eating. Furthermore,
they were less likely than their nondieting peers to engage in
Table 1
Preventing obesity and eating disorders in adolescents: Five recommendations for health care providers
1. Inform adolescents that dieting, and particularly unhealthy weight control behaviors, may be counterproductive. Instead
encourage positive eating and physical behaviors that can be maintained on a regular basis.
2. Do not use body dissatisfaction as a motivator for change. Instead, help teens care for their bodies so that they will want to
nurture them through healthy eating, activity, and positive self-talk.
3. Encourage families to have regular, and enjoyable, family meals.
4. Encourage families to avoid weight talk: talk less about weight and do more to help teens achieve a weight that is healthy
for them.
5. Assume overweight teens have experienced weight mistreatment and address with teens and their families.
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
208
behaviors found to be protective against excessive weight
gain such as eating breakfast on a regular basis [27].
However, the effect of dieting on weight gain was not totally
explained by these behaviors, thus also suggesting that there
may be other behavioral differences or that dieters may have
certain characteristics, above and beyond their initial weight
status, that place them at increased risk for weight gain (e.g.,
suppressed weight caused by past weight loss).
It is certainly not enough to discourage adolescents from dieting. It is crucial to provide education and support for alternative behaviors, such as eating fruits and vegetables on a regular
basis, paying attention to portion sizes and internal signs of
hunger and satiety, and increasing physical activity. In an
obesity prevention program, New Moves, which is currently
being implemented and evaluated by our research team [28–
30], we encourage and provide support for a number of eating
and physical activity behaviors that can be sustained over one’s
lifetime as alternatives to dieting (Table 2). To successfully
implement behaviors, such as eating an adequate amount of
fruits and vegetables, adolescents will need support from health
care providers and family members. Within a clinic setting,
support may be provided in the form of individual and family
counseling sessions. Recommendations for doing clinical
work aimed at obesity prevention, in conjunction with broader
community interventions, have been previously described in
detail [31]. In New Moves, which is a school-based intervention, we are using motivational interviewing, which is suitable
for adolescents because it is driven by their personal motivations for change [29,32,33]. We have found the adolescents
to be very receptive this approach.
Recommendation #2: Promote a positive body image among
all adolescents
The second recommendation is to avoid using body
dissatisfaction as a motivator for change. Instead health
Table 2
Behavioral objectives for healthy weight management in adolescentsa
1. Aim to be physically active at least 1 hour each day
2. Limit television/video watching to no more than 1 hour
a day
3. Eat at least five servings of fruits and vegetables each
day/choose fruits and vegetables for snacks
4. Limit pop and other sweetened beverages; instead
drink non-caloric beverages
5. Eat breakfast every day
6. Pay attention to portion size and to your body’s signs
of hunger and fullness
7. Avoid unhealthy weight control practices
8. Focus on your positive traits
a
Based on Ref. 28.
care providers should help adolescents to develop a positive
relationship with their bodies so that they will want to nurture
them through healthy eating, physical activity, and positive
self-talk.
Research has clearly shown that body dissatisfaction is
a key risk factor for disordered eating behaviors and eating
disorders [34]. However, the relationship between body
image (e.g., satisfaction with one’s weight, body shape,
body size, and specific body parts) and behaviors of relevance
to weight management and obesity prevention is less clearcut. On the one hand, one might expect body dissatisfaction
to lead to higher levels of physical activity or increased
consumption of fruits and vegetables in an attempt to change
one’s body. On the other hand, one might hypothesize that
given the centrality of body image to an adolescent’s global
self-image, having a poor body image (e.g., feeling very
dissatisfied with one’s appearance) might impede one’s
engagement in such behaviors. For example, an adolescent
girl who feels badly about herself and her body might not
feel comfortable going to a gym or care enough about herself
to choose fruit as a snack instead of a chocolate bar. It has been
proposed that a mild degree of body dissatisfaction might
serve to motivate overweight individuals to engage in healthy
weight management behaviors [35,36].
In Project EAT, we explored 5-year longitudinal associations between body satisfaction and both health-promoting
behaviors (e.g., physical activity) and health-compromising
behaviors (e.g., unhealthy weight control) to better understand these relationships. We found that higher levels of
body dissatisfaction did not longitudinally predict greater
use of healthy weight management behaviors, such as physical activity or fruit and vegetable intake; in fact it predicted
lower levels of physical activity in girls. For example, adolescent girls in the highest quartile for body dissatisfaction at
Time 1 engaged in 3.9 hours of weekly moderate-to-vigorous
physical activity at Time 2 (5 years later) as compared to
4.5 hours for girls in the lowest quartile for body dissatisfaction. Analyses were adjusted for possible confounders
including race, socio-economic status, Time 1 physical
activity, and BMI. Furthermore, higher levels of body dissatisfaction longitudinally predicted greater use of dieting and
unhealthy weight control behaviors in both girls and boys
and increased binge eating in boys [37]. For example,
11.0% of adolescent boys in the highest quartile for body
dissatisfaction reported binge eating as compared to 3.4%
of boys in the lowest quartile for body dissatisfaction, in similarly adjusted analyses. In analyses conducted only on the
overweight girls, we found that girls who were dissatisfied
with their bodies gained the most weight over time. Girls in
the highest quartile for body dissatisfaction had an increase
of 3.0 BMI units over 5 years, whereas girls in the lowest
quartile for body dissatisfaction only showed an increase of
1.0 BMI units [38]. All of these analyses adjusted for baseline
weight status; thus these associations were not a function of
higher BMI, but were independent associations with body
dissatisfaction.
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
Approximately half of adolescent girls and a quarter of
boys express body dissatisfaction [9]. Among overweight
adolescents (BMI >85th percentile), 66% of girls and 48%
of boys report body dissatisfaction [9]. Thus, if an overweight
girl (or boy) is seen in a clinic, the health care provider should
take into account that she may be self-conscious about her
weight and look for ways to help her feel better about herself.
In opening up a discussion about weight, the health care
provider should simultaneously focus on promoting body
satisfaction. One way to do this may be to talk upfront with
the adolescent about her positive characteristics and then
discuss weight as a specific health outcome.
Recommendation #3: Encourage more frequent and more
enjoyable family meals
The third recommendation is to encourage families to
have more regular, and more enjoyable, family meals.
Ideally, this type of recommendation can be made to both
adolescents and their parents.
Research has clearly shown that more frequent participation in family meals is associated with better dietary intake in
adolescents [39–42]. In cross-sectional analyses from Project
EAT, more frequent participation in family meals was positively associated with fruit, vegetables, grains, calcium-rich
foods, and fiber intake, and negatively associated with soft
drink intake [41]. For example, the mean intakes of fruits
and vegetables of adolescents were 2.9, 3.2, 3.6, and 3.9
servings per day, for no, one to two, three to six, and seven
or more family meals in the previous week, respectively.
Thus, adolescents eating family meals seven or more times
a week consumed a full serving more of fruits and vegetables
per day than adolescents reporting no family meals in the
previous week. Furthermore, longitudinal analyses indicated
that adolescents who eat more frequently with their families
consume more fruits and vegetables, calcium and fiber, and
fewer sugared beverages 5 years later during young adulthood [42]. The ongoing use of these types of eating behaviors
(e.g., greater intake of fruits and vegetables and lower intakes
of sugared beverages) has the potential to contribute to longterm healthy weight management. However, it is important to
note that family meals have not consistently been found to
protect against obesity across cross-sectional and longitudinal studies and across different ethnic groups [43–45].
We have also found cross-sectional and longitudinal associations between family meals and disordered eating behaviors, with particularly strong protective associations in
adolescent girls [12,46,47]. Among girls, in cross-sectional
analyses, we found that greater frequency and enjoyment of
family meals were associated with lower risk for extreme
weight control behaviors, including self-induced vomiting,
and use of diet pills, laxatives, and diuretics in adolescent girls
[46]. Analyses were adjusted for potential confounders such
as overall family connectedness, weight-specific pressures
within the home, and BMI. In longitudinal analyses, we examined associations between frequency of family meals and
209
disordered eating and found that even after 5 years, this association remained statistically significant [47].
These data are observational and do not allow determination of causality. Furthermore the association between family
meals and obesity is not clear-cut, suggesting a need for further
research to examine different aspects of family meals such as
parenting styles around food, talk about food and weight at
family meals, types of foods served, portion sizes, ways of
serving food, location of meals, and methods of food preparation. Nevertheless, given that family meals are unlikely to
have negative outcomes for most families, the findings are
strong enough to provide a basis for the recommendation to
encourage family meals in the homes of adolescents.
How might family meals be operating to improve dietary
intake and decrease risk for disordered eating? Four possible
mechanisms include the following: 1) the availability of
healthier foods than teens would eat on their own; 2) parental
modeling of healthy eating patterns at meals; 3) increased
opportunities for connecting with teens via conversations at
the meal; and 4) monitoring a child’s eating behaviors and
overall state of emotional health to identify problems early
in their stage of development. For example, with regard to
the last point, a teenager’s change in eating patterns (e.g.,
food restrictions) can be detected more readily in a family
where eating together occurs on a regular basis. Thus, if
a parent is concerned about a child’s eating behaviors, health
care providers may want to recommend more family meals,
during which the parent can observe the child’s eating
patterns. If a parent is concerned about a child’s eating
patterns, the topic is probably best raised outside of the
family meal, in order to avoid turning the family meal into
a place of conflict.
Given that many parents feel badly about not having
enough family meals, it is important to address this topic in
a sensitive and nonjudgmental manner. The potential benefits
of more frequent and enjoyable family meals should be
discussed with adolescents and their parents. Realistic strategies for change should be explored with each family; gradual
change and creativity in finding solutions to fit the needs of
each family may facilitate the implementation of more
frequent and enjoyable meals. It may help to explore the
current situation regarding the frequency and atmosphere of
family meals, without making any assumptions given the
diversity in what family meals look like in different homes.
Then, the health care provider can inquire about barriers to
family meals and what adolescents and their parents like about
their family meals. Finally, the discussion can focus on areas
family members would like to change and plans for doing so.
Recommendation #4: Encourage families to talk less about
weight and do more at home to facilitate healthy eating and
physical activity
The fourth recommendation is to encourage families to
avoid weight talk. Weight talk may include parent comments
about their own weight and dieting, discussion about other
210
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
people’s weights, encouragement of a child to diet or lose
weight, and weight teasing. With the exception of weight
teasing, good intentions may be driving many of these
comments, such as concern about the harmful effects of
obesity and a desire to help one’s child avoid these consequences. However, research suggests that too much weight
talk at home may increase risk for both eating disorders
and obesity. Thus, health care providers should advise
parents to talk less about weight and do more to help their
children to achieve a weight that is healthy for them.
In a qualitative study conducted by Loth et al [48], individuals in recovery from an eating disorder were interviewed.
The study aimed to gather their perspectives about factors
contributing to the onset of their eating disorders and the
potential role of families in prevention. Many of the emerging
themes revolved around weight talk at home. Their advice for
parents with regard to weight talk included the following: 1)
lessen or decrease your focus on your own bodies; 2) avoid
making comments about your children’s bodies or weight;
3) do not allow weight-related teasing within your home;
and 4) avoid making comments about others’ weight or
body. For example, one participant said, ‘‘My mom would
say, ‘If you’d lose weight you’d be prettier.’ That kind of
talk. I think at the time I was unaware of any of it. But it
just builds over time.’’ Another participant said, ‘‘She used
to point at heavy-set people on the street and be like, ‘If
you keep eating the way you are eating now, you will look
like that when you get older.’’
In Project EAT, we found that maternal and paternal
weight talk, including parental dieting and parental encouragement to diet, longitudinally predicted the incidence of
overweight status 5 years later in adolescents [23]. Thus,
not only does weight talk at home appear to increase the
risk for eating disorders, but it is counterproductive to
parental efforts to help a child with weight management. A
parent might ask, ‘‘Well, what can I do to help my child?’’
Parents can be encouraged to provide a home environment
that makes it easier for children to engage in healthy eating
and physical activity behaviors. In Project EAT, having
more fruits and vegetables available at home was one of
the strongest correlates of adolescent intake of fruits and
vegetables [49]. Adolescents who had televisions in their
bedrooms were found to watch more television, to be less
physically active, and to have poorer dietary intakes than
adolescents who did not have bedroom televisions [50].
Furthermore, parental behaviors, such as eating fruits, vegetables, and dairy foods predicted similar eating behaviors in
Project EAT participants as they transitioned from adolescence to young adulthood [51]. Thus, parents should be
encouraged to ‘‘talk less and do more,’’ i.e., talk less about
weight and do more in terms of providing a healthy home
environment and modeling healthy behaviors that they would
like to see in their children.
Health care providers can share this information about
weight talk with the adolescents that they see in their practices and, in particular, with the adolescents’ parents. In order
not to ‘‘blame’’ parents, it may help to frame advice about
refraining from weight talk by stating that we all live in an
environment that encourages us to engage in weight talk
because of the attention on weight in the media and concern
about obesity in the health field. It can also be helpful to
inform parents that the easiest behaviors to change with
regard to weight talk may also be the most effective. For
example, it will probably be easier for parents to stop talking
about weight in front of their children than it will be for them
to change their own body image and weight concerns. And
research suggests that weight-related comments made
directly to a child, such as weight teasing and encouragement
to diet or lose weight, are probably the most harmful [52].
Recommendation #5: Assume that overweight teens have
experienced weight mistreatment and address this issue with
teen and their families
The fifth recommendation for health care providers is to
assume that overweight adolescents have experienced some
type of weight mistreatment, such as being the victim of
weight-teasing or being excluded from activities because of
one’s weight, and to discuss this mistreatment with teens
and their families.
In a qualitative study in which we interviewed 50 overweight adolescent girls, we found that all but two of the girls
reported some type of weight mistreatment [53]. The most
frequently reported stigmatizing experiences were direct
and intentional, such as name calling and teasing. Other hurtful comments appeared to be of a less intentional nature such
as comments made ‘‘as if to be helpful’’ but clearly made in
a nonsupportive or destructive manner. Other examples of
weight mistreatment included differential treatment such as
exclusions from social groups, and negative assumptions
about them such as being lazy, eating too much, or being
unclean. The most commonly mentioned place in which stigmatization occurred was within the school setting, followed
by the home. Sometimes it took a while for the girls to report
that they had been teased about their weight or mistreated in
other ways, because they did not recognize the experience as
mistreatment, did not want to discuss it, or did not want to
blame the individual responsible for the mistreatment. Questions that we asked to get at this information may be useful
for health care providers. Some of the questions included:
‘‘Do others treat you in a hurtful or negative way because
of your weight? Do others make negative assumptions about
you because of your weight? If so, what do they do? Tell me
about a time when this happened. How did you react or feel
about what they did? Tell me what you did in response to this
treatment. Has anyone been supportive to you about this?
Have you talked with anyone about this? If so, what did
they say that was helpful or not helpful?’’
In Project EAT, we found that weight teasing by family
members longitudinally predicted overweight status, binge
eating, and extreme weight control behaviors in girls and
overweight status in boys [13]. Even after adjusting for
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
baseline weight status, adolescents who were teased about
their weight were at twice the odds for being overweight 5
years later. Additional cross-sectional and longitudinal analyses from Project EAT [9,54,55] and other studies [56–60]
have found that weight teasing is associated with numerous
negative behavioral and psychological measures, including
body dissatisfaction, low self esteem, depressive symptoms,
and problematic eating behaviors. These findings strongly
suggest that weight teasing can have harmful consequences
on various aspects of an adolescent’s well-being.
Health care providers may be reluctant to bring up the
topic of weight mistreatment, in that they may not want to
make the teen feel uncomfortable or may feel inadequate in
addressing the issue. In a national survey of 1567 health
care providers, we found that only 44% of the dietitians
and 43% pediatricians who deal with weight-related issues
with overweight youth reported discussing weight-related
stigmatization [61]. In contrast, although psychologists and
social workers were much less likely to deal with weightrelated issues with overweight teens, among those who
were involved with this type of work, 90% reported discussing weight-related stigmatization.
Because of the high prevalence of weight mistreatment, its
harmful consequences, and the health care provider’s potential role in helping the adolescent deal with this mistreatment,
it seems crucial for the health care provider to provide a safe
haven in which instances of weight mistreatment may be
discussed. This role can be delegated to a psychologist or
social worker if there is a multi-disciplinary health care
team. Otherwise, the health care provider working most
closely with the adolescent can raise the issue. For example,
one might say something like, ‘‘Many kids get mistreated or
hear hurtful comments about their weight from their family,
other kids, or even strangers. Sometimes they feel like the
other people were just joking around and didn’t mean it.
But just like it’s not OK to joke about people’s race, it’s
not OK to joke about people’s weight. If you have had these
types of experiences and would like to explore ways of
dealing with them, I’m open to talk to you. Would you be
feel comfortable sharing experiences that you have had
with me?’’ Adolescents need to know that they deserve not
to be mistreated because of their weight. Furthermore, family
members need to know that weight teasing should not be
allowed at home and that even comments made in a playful
or joking manner are not funny and can have unintended
detrimental effects. Health care providers may be reluctant
to bring up these issues because they may be afraid that
they won’t know what to do with the information. It can be
helpful to remember that it may be most important to just
listen. Through talking about these experiences, teens may
be able to figure out how to deal with different situations.
Future Directions and Conclusions
The five recommendations described here, of which some
have multiple components, can provide a framework for
211
health care providers working with adolescents to help
prevent a broad spectrum of weight-related problems. An
underlying theme of these recommendations is to help
adolescents and their families focus less on weight and
instead focus more on helping adolescents engage in healthy
eating and physical activity behaviors that can that be maintained on an ongoing basis.
Health care providers may be hesitant about how to
discuss weight with teens, particularly overweight teens.
On the one hand, health care providers may feel that they
need to discuss excess weight, given its health risks. On the
other hand, given the sensitivity of weight-related issues
for teens, health care providers may be concerned that if
they bring up the topic it may deter teens from coming for
clinical visits for other health-related issues. Health care
providers who are aware of, and most concerned about, this
delicate balance are probably the most likely to address the
topic of weight in a sensitive manner. The clinic visit
provides an opportunity for exploring the adolescent’s
body image and weight concerns, experiences with weight
mistreatment and possible ways to reduce or deal with this
mistreatment, and strategies for healthy long-term weight
management. However, to do so, the health care provider
will need to provide a safe and comfortable environment in
which there is adequate time to explore these issues.
An important caveat is that while the recommendations
proposed here are based on research findings, the research
conducted was of an observational nature, including crosssectional, longitudinal, and qualitative studies. The next
step in the research process is to conduct clinical research
studies in which these recommendations are implemented
and evaluated to test their feasibility and effectiveness. It
would also be helpful for health care providers to try to implement some or all of these recommendations and provide feedback on best practices for relaying the messages, suggested
refinements, and perceived impact on adolescents and their
families. Whereas multi-disciplinary teams can probably
best implement these guidelines, in some health care settings
their implementation will be dependent on one or two
providers, because of limited staff or other resources. While
clinical research studies, and less formal input from health
care providers, will lead to refinements in the recommendations presented here, they provide a starting place for guiding
healthcare providers concerned about preventing obesity,
eating disorders, and a broad spectrum of weight-related
problems in adolescents.
References
[1] Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and
adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation 2005;111:1999–2012.
[2] Ogden CL, Carroll MD, Flegal KM. High body mass index for age
among US children and adolescents, 2003–2006. J Am Med Assoc
2008;299:2401–5.
[3] Fisher M, Golden NH, Katzman DK, et al. Eating disorders in adolescents: A background paper. J Adolesc Health 1995;16:420–37.
212
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
[4] Stein D, Meged S, Bar-Hanin T, et al. Partial eating disorders in
a community sample of female adolescents. J Am Acad Child Adolesc
Psychiatry 1997;36:1116–23.
[5] Ackard DM, Neumark-Sztainer D, Story M, et al. Overeating among
adolescents: Prevalence and associations with weight-related characteristics and psychological health. Pediatrics 2003;111:67–74.
[6] Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: Position paper of the Society for Adolescent Medicine. J Adolesc
Health 2003;33:496–503.
[7] Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance—United States, 2007. MMWR CDC Surveill Summ 2008;
57:1–131.
[8] Neumark-Sztainer D, Story M, Perry C, et al. Factors influencing food
choices of adolescents: Findings from focus-group discussions with
adolescents. J Am Diet Assoc 1999;99:929–37.
[9] Neumark-Sztainer D, Story M, Hannan PJ, et al. Weight-related
concerns and behaviors among overweight and non-overweight adolescents: Implications for preventing weight-related disorders. Arch
Pediatr Adolesc Med 2002;156:171–8.
[10] Neumark-Sztainer D, Story M, Hannan PJ, et al. Overweight status and
eating patterns among adolescents: Where do youth stand in comparison to the Healthy People 2010 Objectives? Am J Public Health
2002;92:844–51.
[11] Fulkerson JA, Neumark-Sztainer D, Story M. Adolescent and parent
views of family meals. J Am Diet Assoc 2006;106:526–32.
[12] Fulkerson JA, Strauss J, Neumark-Sztainer D, et al. Correlates of
psychosocial well-being among overweight adolescents: The role of
the family. J Consult Clin Psychol 2007;75:181–6.
[13] Neumark-Sztainer D, Wall M, Haines J, et al. Shared risk and protective
factors for overweight and disordered eating in adolescents. Am J Prev
Med 2007;33:359–69.
[14] Neumark-Sztainer D, Story M. Dieting and binge eating among
adolescents: What do they really mean? J Am Diet Assoc 1998;
98:446–50.
[15] Patton GC, Selzer R, Coffey C, et al. Onset of adolescent eating disorders: Population based cohort study over 3 years. B Med J 1999;
318:765–8.
[16] Crow S, Eisenberg ME, Story M, et al. Psychosocial and behavioral
correlates of dieting among overweight and non-overweight adolescents. J Adolesc Health 2006;38:569–74.
[17] Ackard DM, Croll JK, Kearney-Cooke A. Dieting frequency among
college females: association with disordered eating, body image, and
related psychological problems. J Psychosom Res 2002;52:129–36.
[18] Nowak M. The weight-conscious adolescent: Body image, food intake,
and weight-related behavior. J Adolesc Health 1998;23:389–98.
[19] Rafiroiu C, Sargent RG, Parra-Medina D, et al. Covariations of adolescent weight-control, health-risk and health-promoting behaviors. Am
J Health Behav 2003;27:3–14.
[20] Neumark-Sztainer D, Hannan PJ, Story M, et al. Weight-control behaviors among adolescent girls and boys: Implications for dietary intake.
J Am Diet Assoc 2004;104:913–20.
[21] Story M, Neumark-Sztainer D, Sherwood N, et al. Dieting status and
its relationship to eating and physical activity behaviors in a representative sample of U.S. adolescents. J Am Diet Assoc 1998;98:1127–35.
1255.
[22] Neumark-Sztainer D, Wall M, Guo J, et al. Obesity, disordered eating,
and eating disorders in a longitudinal study of adolescents: How do
dieters fare five years later? J Am Diet Assoc 2006;106:559–68.
[23] Haines J, Neumark-Sztainer D, Wall M, et al. Personal, behavioral, and
environmental risk and protective factors for adolescent overweight.
Obes Res 2007;15:2748–60.
[24] Field AE, Austin SB, Taylor CB, et al. Relation between dieting and
weight change among preadolescents and adolescents. Pediatrics
2003;112:900–6.
[25] Stice E, Cameron RP, Killen JD, et al. Naturalistic weight-reduction
efforts prospectively predict growth in relative weight and onset of
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
obesity among female adolescents. J Consult Clin Psychol 1999;
67:967–74.
Stice E, Presnell K, Shaw H, et al. Psychological and behavioral risk
factors for obesity onset in adolescent girls: A prospective study.
J Consult Clin Psychol 2005;73:195–202.
Neumark-Sztainer D, Wall M, Haines J, et al. Why does dieting predict
weight gain in adolescents? Findings from Project EAT-II: A five-year
longitudinal study. J Am Diet Assoc 2007;107:448–55.
Neumark-Sztainer D, Flattum CF, Story M, et al. Dietary approaches to
healthy weight management for adolescents: The New Moves model.
Adolesc Med 2009;19:421–30.
Flattum C, Friend S, Neumark-Sztainer D, et al. Motivational interviewing as a component of a school-based obesity prevention program
for adolescent girls. J Am Diet Assoc 2009;109:91–4.
Neumark-Sztainer D. New Moves: Obesity Prevention among Adolescent Girls: Grant Proposal. Bethesda, MD: National Institutes of
Health, 2004.
Barlow SE. Expert committee recommendations regarding the
prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics 2007;120(Suppl 4):
S164–92.
Resnicow K, DiIorio C, Soet JE, et al. Motivational interviewing in
health promotion: It sounds like something is changing. Health Psychol
2002;21:444–51.
Rollnick SR, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy 1995;23:325–34.
Jacobi C, Hayward C, de Zwaan M, et al. Coming to terms with risk
factors for eating disorders: Application of risk terminology and
suggestions for a general taxonomy. Psychol Bull 2004;130:19–65.
Heinberg LJ, Thompson JK, Matzon JL. Body image dissatisfaction as
a motivator for healthy lifestyle change: Is some distress beneficial? In:
Striegel-Moore RH, Smolak L, eds. Eating Disorders Innovative Directions in Research and Practice. Washington, DC: American Psychological Association, 2001:215–32.
Heinberg L. The role of body image distress in obesity: Is it motivating
or malevolent? Academy for Eating Disorders International Conference
on Eating Disorders; 2005. Montreal, Quebec, Canada: Academy for
Eating Disorders, 2005. p. 6.
Neumark-Sztainer D, Paxton SJ, Hannan PJ, et al. Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. J Adolesc
Health 2006;39:244–51.
van den Berg P, Neumark-Sztainer D. Fat ’n happy 5 years later: Is it
bad for overweight girls to like their bodies? J Adolesc Health 2007;
41:415–7.
Gillman MW, Rifas-Shiman SL, Frazier AL, et al. Family dinner and
diet quality among older children and adolescents. Arch Fam Med
2000;9:235–40.
ideon TM, Manning CK. Influences on adolescent eating patterns: The
importance of family meals. J Adolesc Health 2003;32:365–73.
Neumark-Sztainer D, Hannan PJ, Story M, et al. Family meal patterns:
Associations with sociodemographic characteristics and improved
dietary intake among adolescents. J Am Diet Assoc 2003;
103:317–22.
Larson NI, Neumark-Sztainer D, Hannan PJ, et al. Family meals
during adolescence are associated with higher diet quality and healthful meal patterns during young adulthood. J Am Diet Assoc 2007;
107:1502–10.
Fulkerson JA, Neumark-Sztainer D, Hannan PJ, et al. Family meal
frequency and weight status among adolescents: Cross-sectional and
five-year longitudinal associations. Obes Res 2008;16:2529–34.
Taveras E, Rifas-Shiman S, Berkey C, et al. Family dinner and adolescent overweight. Obes Res 2005;13:900–6.
Sen B. Frequency of family dinner and adolescent body weight status:
Evidence from the national longitudinal survey of youth, 1997. Obesity
2006;14:2266–76.
D. Neumark-Sztainer / Journal of Adolescent Health 44 (2009) 206–213
[46] Neumark-Sztainer D, Wall M, Story M, et al. Are family meal patterns
associated with disordered eating behaviors among adolescents? J Adolesc Health 2004;35:350–9.
[47] Neumark-Sztainer D, Eisenberg ME, Fulkerson JA, et al. Family meals
and disordered eating in adolescents: Longitudinal findings from
Project EAT. Arch Pediatr Adolesc Med 2008;162:17–22.
[48] Loth KA, Neumark-Sztainer D, Croll JK. A family approach to preventing eating disorders: Perspectives of those who have been there.
Int J Eat Disord (in press).
[49] Neumark-Sztainer D, Wall MM, Hannan PJ, et al. Correlates of fruit
and vegetable intake among adolescents: Findings from Project EAT.
Prev Med 2003;37:198–208.
[50] Barr-Anderson DJ, van den Berg P, Neumark-Sztainer D, et al. Characteristics associated with older adolescents who have a television in their
bedrooms. Pediatrics 2008;121:718–24.
[51] Arcan C, Neumark-Sztainer D, Hannan P, et al. Parental eating behaviors, home food environment and adolescent intakes of fruits, vegetables and dairy foods: Longitudinal findings from Project EAT. Public
Health Nutr 2007;10:1257–65.
[52] Wertheim EH, Martin G, Prior M, et al. Parent influences in the transmission of eating and weight related values and behaviors. Eating
Disorders 2002;10:321–4.
[53] Neumark-Sztainer D, Story M, Faibisch L. Perceived stigmatization
among overweight African American and Caucasian adolescent girls.
J Adolesc Health 1998;23:264–70.
213
[54] Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weightbased teasing and emotional well-being among adolescents. Arch
Pediatr Adolesc Med 2003;157:733–8.
[55] Haines J, Neumark-Sztainer D, Eisenberg ME, et al. Weight-teasing
and disordered eating behaviors in adolescents: Longitudinal findings
from Project EAT (Eating Among Teens). Pediatrics 2006;
117:e209–15.
[56] Fabian LJ, Thompson JK. Body image and eating disturbance in young
females. Int J Eat Disord 1989;8:63–74.
[57] Cattarin J, Thompson J. A three-year longitudinal study of body image,
eating disturbance, and general psychological functioning in adolescent
females. Eating Disorders. J Treat Prev 1994;2:114–25.
[58] van den Berg P, Wertheim EH, Thompson JK, et al. Development
of body image, eating disturbance, and general psychological functioning in adolescent females: A replication using covariance structure modeling in an Australian sample. Int J Eat Disord 2002;
32:46–51.
[59] Hayden-Wade HA, Stein RI, Ghaderi A, et al. Prevalence, characteristics, and correlates of teasing experiences among overweight children
vs. non-overweight peers. Obes Res 2005;13:1381–92.
[60] Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s
children. Psychol Bull 2007;133:557–80.
[61] Neumark-Sztainer D, Story M, Evans T, et al. Weight-related issues
among overweight adolescents: What are health care providers doing?
Topics in Clinical Nutrition 1999;14:62–8.