Many seriously overweight teenagers struggle with depression, social isolation and academics. For those who have not developed refractory chemical dependencies, treatment focused initially on weight loss provides a very efficient and effective route to major improvements in all areas of their life.
Well-meaning clinicians and programs often focus on emotional, behavioral, social and academic problems before considering weight per se in overweight troubled teens. This approach implies that the weight problem is secondary to the psychological and functional problems in other areas of life. The underlying conceptualization for this assumes that by first addressing these non-weight issues, the weight problem will become more of a priority to the teen - who will then deal with it. Alternatively, it could be argued that the other issues are more pressing, and more likely to interfere dramatically with the teen's functioning in the real world. After all, this approach might suggest we can't attack on all fronts at once and win, so pick your battles.
These positions have logic and history to support them. However, science and many years of clinical experience with overweight teenagers suggest that the greatest gains probably come most efficiently from a very different approach. Weight control is the battle to pick that will pay off best. At least five points support this view:
Psychological problems can contribute to the development of weight problems, but obesity itself usually causes considerable stress. Imagine how it would affect you to feel so different, so inferior and so weak, at a time in your life when social acceptance surpasses breathing as a life goal. The prejudice and rejection commonly experienced by obese teens consistently produces social, academic, vocational and emotional challenges.
Focusing on weight loss can generally improve critical life skills. For example, effective weight control requires systematic self-observation, problem solving, understanding and planning.
Focusing directly on weight facilitates the treatment of other issues. The tasks of weight loss (e.g., following through with commitments; self-evaluation) provide a perfect medium for therapists to maximize change in many arenas. This medium lives and breathes in the here and now. It promotes discussions of dispositional tendencies and other issues very directly (e.g., self-love versus self-destructiveness). Focusing on problems from the past (like prior drug use) by contrast, involves abstract discussions of prior behaviors and attitudes. Teens function and learn far better in the here and now, not the there and then. Increasing activity also acts independently of the weight loss to improve emotional and behavioral functioning, as well as health. Weight loss almost always improves moods and health, particularly when pursued using cognitive-behavior therapy.
The case of David at the first boarding school for overweight teens, Academy of the Sierras (AOS), illustrates each of these issues. Aspen Education's Healthy Living Academies Division created AOS in 2004. AOS focuses on intensive treatment via cognitive-behavior therapy, as well as scientifically based diet and activity programs and individualized academics.
Obesity caused some of David's problems. David presented at AOS on September 2004 as a morbidly obese, hedonic, hopeless 17-year-old boy with very little future orientation. He had spent the last two years before admission failing out of traditional and summer school, compulsively playing video games, and regularly consuming alcohol and marijuana. His parents hoped that he would eventually "come around." Rapid weight gain exacerbated David's already maladaptive behaviors by making him feel more hopeless. David openly asserted that his life was not worth changing and that he couldn't make it better anyway.
By focusing on weight loss, David learned to change his overly negative self-perceptions (a critical life skill) and improve another key problem - his academics. Initially, David claimed that he was too "stupid, lazy and forgetful" to remember to bring his self-monitoring journal to therapy sessions. Staff began to cue David to remember; he found himself using monitoring and journaling to begin losing weight and understanding himself. He was able to think more consequentially. These changes were not limited to food choices - they were evidenced in his relationships with peers, staff and within his academics. Using his success in weight management as a template, David - who came to AOS barely a sophomore in high school, left after two semesters with a high school diploma.
Physical activity can improve moods. David learned to play tennis and run during his stay, and became happier and prouder of his accomplishments.
Weight loss can improve other behaviors and health. David's enthusiasm and pride and greatly improved appearance (after losing 150 lbs), helped transform him from a depressed young man into a leader of the AOS community. At the Academy's first Transition Ceremony held at the end of the academic year, David's peers elected him to speak for them all: "I want to thank all of the staff and students who made me who I am today. I came here a lump of clay and leave as a tall and strong statue. Thank you for helping to mold me."
As of this writing, eleven months after leaving AOS, David has maintained his weight loss, holds a part time job and is attending college to become an architect.
The results obtained at Academy of the Sierras show dramatic improvements. In the first 10-month follow-up, data verified by parents were obtained for 100% of the group. Both self- and parent-reporting of social and emotional functioning using validated instruments showed significant improvements. Students changed their average percentage of overweight from 100% to 42% after two semesters and maintained very well (to 41%) at the follow-up. All students decreased their percentages of overweight to medically significant degrees, and some who had significant academic problems are now doing well in high school or college.
About the Authors:Daniel S. Kirschenbaum, PhD, is the Clinical Director of Aspen Education Group's Healthy Living Academies, and a Professor of Psychiatry & Behavioral Sciences at Northwestern University Medical School in Chicago, IL. Molly Carmel, MSW, is the Clinical Director of Aspen Education Group's Academy of the Sierras, Reedley, CA, and Wellspring New York.