Insights from Multiple Stakeholders Regarding Adolescent Obesity in China: An Exploratory Qualitative Study

Abstract

With a significant increase in the obesity epidemic in China, addressing adolescent obesity should be highlighted as a priority. The current qualitative study aims to explore the perspectives of key stakeholders regarding adolescent obesity, providing guidance for developing effective obesity interventions for Chinese adolescents. A total of 12 focus group discussions were convened with a range of representative stakeholders including adolescents (n = 37), parents (n = 28), and school staff (n = 21) from sample schools. Semi-structured topic guides were used for data collection. All data were transcribed verbatim and analyzed thematically. From multiple stakeholder perspectives, we finally identified 3 overarching themes (Understanding adolescent obesity, Key healthy lifestyles, and Barriers to obesity prevention practices) and 8 sub-themes. While participants had mixed perceptions of status and prevalence of adolescent obesity, all acknowledged the serious health consequences associated with it. As significant modifiable risk factors, unhealthy diet and physical activity were identified to be prevalent among Chinese teenagers and lead to excessive weight gain. However, a variety of individual, environmental and sociocultural factors hindered the implementation of healthy lifestyles, affecting adolescent obesity prevention and control. Given adolescent obesity is a complex, multifactorial and multilevel public issue, comprehensive lifestyle interventions are recommended that synergistically engage multiple stakeholders across key communities to fight the ongoing obesity epidemic.

• What do we already know about this topic?

• Adolescents are disproportionately burdened by obesity, necessitating urgent implementation of more effective interventions for this age group.

• How does your research contribute to this field?

• A deeper comparative understanding of the common themes of stakeholders’ perceptions of adolescent obesity, health behaviors and practice barriers could further inform adolescent obesity interventions.

• What are your research’s implications toward theory, practice, or policy?

• Comprehensive lifestyle interventions engaging multiple stakeholders across key communities are needed to address the complex, multifactorial, and multilevel nature of adolescent obesity.

Introduction

Childhood and adolescent obesity persists as a severe public health concern of the 21st century. ¹ It was recently estimated that the prevalence of obesity among children and adolescents was 23% and 13% in developed and developing countries, respectively. ² In China, the combined prevalence of overweight and obesity among children and adolescents aged 7 to 18 years increased from 1.24% in 1985% to 24.20% in 2019, indicating a nearly 20-fold rise during this period. ³ Youngsters with obesity are likely to experience multiple chronic diseases, higher psychological distress and lower body self-esteem, and obesity usually retain into adulthood, which disproportionately reduces life expectancy, impairs quality of life and increases medical costs.^{4 -6}

Obesity is caused by an intricate interaction of genetics, behaviors and environment. Given genetic predisposition is difficult to ameliorate, obesogenic behaviors and environment have been growing concerns since they are modifiable and provide possible targets for population obesity interventions. ⁷ Diet and physical activity were frequently targeted in obesity interventions. ⁸ Adolescence is a critical period with individual physical, emotional and self-image development, where lifestyle is subject to important changes, displaying unhealthier dietary behaviors, less physical activity and more sedentary time. ⁹ Unfortunately, simple strategies for changing diet or activity levels, or both, of adolescents to prevent obesity are of limited success, and fewer interventions focused on adolescents than younger children.^10,11

Although there is no “gold standard” for addressing adolescent obesity, evidence from the latest reviews concludes that the comprehensive strategies, encompassing nutrition and physical activity behavioral intervention with supportive family and school environments, would be promising.^12,13 Family and school—2 key social environments for adolescents—make up important parts of the obesity prevention system where interventions can go beyond targeting individual-level. Family parenting styles and behaviors are known to strongly influence children’s healthy lifestyle choices. ¹⁴ Schools play a continuous impact on school-aged teens through offering necessary personnel, facilities and policies, serving as an optimum setting to achieve maximum impact in obesity prevention efforts. ¹⁵ Several systematic reviews have revealed that the interventions engaging both families and schools were feasible, but overall had short-term positive effects and lower adherence.^16,17 The lack of sustained effectiveness might be explained by the low level of active involvement of key stakeholders in the development and delivery of intervention, thereby influencing the support for and ownership of interventions. ¹⁸

Adolescents have unique insights into the factors that influence their own or peers’ weight and engagement in weight management. The experiences of important others may also influence creation of a supportive environment as part of the intervention orientation to trigger beneficial effects. ¹⁹ Thus, understanding the insights of key stakeholders is crucial to inform adolescent obesity interventions. While studies about the views of multiple stakeholders on adolescent obesity have been reported in high-income countries, there is less from China.^20,21 Therefore, we conducted a qualitative study to gain the key stakeholders’ perspectives on healthy behaviors and practice barriers for Chinese adolescent obesity to inform a culturally-sensitive obesity intervention for adolescents.

Methods

Study Design

The study employed an exploratory phenomenology approach to interpret phenomena from the viewpoint of its experiencers. ²² Guided by this approach, we engaged a range of stakeholders in Focus group discussions (FGDs), which are valued for promoting group dialog and eliciting diverse perspectives to offer rich information. ²³ The FGDs were conducted between May and June 2022 in Hangzhou of eastern China. Given the socioeconomic distinct and school density of the city, we purposeful identified the Xihu District (urban area) and Xiaoshan District (suburbs) as the research area. We collaborated with local education and health authorities to recruit 3 public middle schools of varying scales, referred to as YP school (＜1000 students), SQ school (1000-1500 students), and HL school (＞1500 students). The study was reported following the Consolidated criteria for reporting qualitative research (COREQ) checklist and approved by our institutional ethics committee (ZGL202201-5).

Participants Recruitment

For diverse perspectives, a range of representative stakeholders were identified in each school community, including adolescents, parents and school staff. These key stakeholders were invited by identity groups (based on their shared social roles) to attend FGDs, to ensure group homogeneity, and common experiences. Adolescent groups in each school were further separated by gender to enhance discussion comfort. We aimed to conduct 12 FGDs across 3 sample schools, with each group limited to 10 participants. This was deemed to ensure a manageable group dynamic for discussion and to achieve data saturation thereby gaining sufficient information from diverse key stakeholders. Participants were eligible if they volunteered for the study and were considered able to provide rich verbal information (ie, they were open to discussion with others). Participants who declined to have focus group audio-recorded were excluded. To achieve maximal variation with cases, we recruited adolescents with balanced grades, sex and weight status (determined using BMI calculated from routine school health screenings) and parents of adolescents from different grades. Additionally, we invited staff members from each school with the following roles: class teachers; physical education teachers; school doctors; school health administrators (ie, principals; deputy principals).

Considering the principals acting as gatekeepers for contacting with schools, we firstly visited each school and explained the study objectives to them to gain their support. Based on the pre-defined recruitment criteria, recruitment flyers (paper or electronic) were personally circulated to eligible participants with the assistance of liaison principals and teachers. In each school, class teachers selected representative students from grades 7 to 9. The selection was based on teachers’ knowledge of the students’ ability to work in a group environment and to openly share their experiences with adolescent obesity. Class teachers also reached out to potential parents via telephone, while principals contacted and invited qualified staff members. Initially, 90 participants were approached and invited; however, scheduling conflicts precluded the invited participants of 2 adolescents and 2 parents. As a result, 86 participants (comprising 37 adolescents, 28 parents and 21 school staff) consented and completed the study, achieving a response rate of 95.6%.

Data Collection

We created semi-structured topic guides, combined with the objective of the study and relevant literature review.^24,25 The topics for the FGDs focused on: (1) general awareness of adolescent obesity; (2) healthy behaviors among adolescents; and (3) perceived barriers to adolescent obesity prevention practices. Core topics were broadly consistent across groups while prompts varied slightly by identity. Probes were used to stimulate further discussion on responses. The topic guides were pilot-tested with 4 adolescents and minor modifications were made to improve content relevance and comprehensibility (final topic guides, see Supplemental Appendix 1). Prior to attending focus groups, participants were informed of the study information and signed informed consent. Consented participants also completed a brief sociodemographic survey.

The FGDs took place in school meeting rooms with minimal interruptions. All FGDs were moderated in pairs by 4 trained female researchers (YC, LZ, XYJ, and RJG). Each of these researchers had undertaken training in qualitative research and had sufficient expertise in the fields of adolescent health and behavior intervention. They were interested in the research topic and had no prior relationship with the participants. Moderator 1 guided the participants to talk to ensure the discussion focused on topic within the agreed time. Moderator 2 observed the nonverbal communication and took field notes. Each discussion would end with reaching data saturation, meaning we weren’t receiving new arguments and most arguments had already been discussed per group. ²⁶ To enhance the trustworthiness of data collection, summary notes were presented at the end of each session by the moderators, and participants were invited to provide feedback, clarify information, or refine the summary statements. FGDs lasted 50 to 90 min and were audio-recorded using 2 mobile phones for comprehensive and accurate sound capture. All participants received a practical gift package worth about RMB 100 for their involvement.

Data Analysis

All FGDs audio records were anonymously transcribed verbatim in Mandarin. Hand-written field notes were used for richer understanding and interpretation of transcribed data. With no pre-existing conceptual framework, thematic framework analysis was used to inductively identify emergent themes from the original data. ²⁷ Analysis was undertaken by 2 key members of our research team (YC and LZ) to enhance the accuracy and reliability of findings and interpretations. They held regular discussions to refine and group codes into developing themes. Constant comparison was used to further develop and refine the coding framework, as all data were coded. By examining the differences and relationships among main themes spanned the 3 roles, we established the overarching analytical themes. The scripts quoted in English were presented with a structural participant ID, consisting of labeled school, group (A for adolescents; P for parents; S for staff), and individual number. All data were analyzed with the software NVivo 12.

Results

Participant Characteristics

Overall 12 FGDs were conducted among 86 participants in 3 sample schools: 6 adolescent groups, 3 parent groups, and 3 school staff groups (see Table 1). Among the enrolled adolescents, boys and girls were approximately equally divided (n = 18; 48.6% vs n = 19; 51.4%). Majority of parents were mothers (n = 24, 85.7%). School staff comprised 9 class teachers, 3 PE teachers, 3 school doctors, and 6 school health administrators. Further participant characteristics are provided in Supplemental Appendix 2.

Table 1.

General Characteristics of Participants.

School sites	Adolescents	Parents	School staff
YP school	12 (6M;6F)	9 (2M;7F)	7 (6M;1F)
SQ school	12 (6M;6F)	10 (10F)	7 (4M;3F)
HL school	13 (6M;7F)	9 (2M;7F)	7 (3M;4F)
Total	37 (18M;19F)	28 (4M;24F)	21 (13M;8F)

Note. Figures represent numbers of participants in different FGD types and school sites.

M = male; F = female.

Overall Findings

Three major themes emerged consistently across stakeholders that were Understanding adolescent obesity, Key healthy lifestyles and Barriers to obesity prevention practices. Each theme and its sub-themes were summarized below with representative quotations presented in Table 2.

Table 2.

Overarching themes and quotes from the key stakeholders.

Themes	Illustrative quotes
Theme 1. Understanding adolescent obesity
1.1 Weight status judgment	(1.1.1) “I see with my eyes [to judge whether a person with obesity] . . . How thick their legs are, how big their bellies are and how chubby their faces are.” (HL-A10) (1.1.2) “We all have raised [children], well, and judge from experience. We can compare with the general body size of other peer children [to judge our children].” (YP-P03) (1.1.3) “Children of higher weight will breathe differently after exercise. . . When they go up the stairs after running, they can’t lift their legs and walk breathlessly. Unlike others who can bounce back to classrooms, they need to grasp the banisters and puffed climb the stairs to get back.” (HL-S04)
1.2 Perceived prevalence	(1.2.1) “I think there are not many [people with obesity] because nowadays thinness is beauty.” (YP-A10) (1.2.2) “It seems not a problem. . . there used to have trending topics about obesity on Weibo [similar to twitter], but now these topics haven’t been seen and discussed. Instead, workout videos by Genghong Liu [a Taiwan star] have gone viral on the internet and sparked a fitness wave, and with the majority having body dissatisfaction, they might try to lose weight so that become thinner.” (HL-A12) (1.2.3) “From my 30 years of teaching experience, I have noticed a growing number of adolescents with obesity. This is an increasing trend rather than decreasing. . .” (SQ-S01)
1.3 Health consequences	(1.3.1) “My knees tend to ache quite often when I’m playing ball or running.” (HL-A05) (1.3.2) “Heart disease, hypertension, diabetes. . . many children with obesity would suffer.” (SQ-P05) (1.3.3) “Some teachers would tease us, and some classmates also isolated us because of our obesity.” (HL-A07) (1.3.4) “The effect of obesity on him [a teenager experiencing obesity] is that he doesn’t like to talk much and tries to minimize his presence as much as possible. That’s to say, he would rather not be noticed by anyone.” (YP-S05) (1.3.5) “I think [obesity has] no [psychosocial] effect, because it [psychosocial problem] more result from personal upbringing and family environment.” (HL-P08)
1.4 Risk factors	(1.4.1) “I think it’s possible that eating too much junk food, carbonate beverages and fried foods, and not enough green vegetables. it’s bad for health.” (SQ-A08) (1.4.2) “So, diet is the first [cause of obesity]. As the Chinese saying goes, ‘food is heaven’, and I believe that most kids became larger from their diet. . . children experiencing obesity always eat too much high-fat and high-calorie foods.” (SQ-S07) (1.4.3) “I rank inactivity as the top one. My boy always likes to sit still. Although he started playing basketball recently, he used to just sit and watch TV without any exercising.” (SQ-P10) (1.4.4) “We tend to eat [a lot] when feeling down. After eating, we just lie down and may gain weight. We in turn desire eating more food uncontrollably because of weight gain.” (YP-A06) (1.4.5) “Under the influence of parents who pay attention to health, the children generally develop healthy habits that could lower the risk of obesity. However, if parents themselves enjoy overeating and neglect healthy diet, this will also affect their children unconsciously.” (YP-S06) (1.4.6) “[My son] was brought up by grandparents since he was young, and they always fed him all kinds of food. They thought he wasn’t full enough and kept stuffing him. So, it’s been challenging for me to make him eat less now.” (HL-P06) (1.4.7) “When collecting me, my grandma often brings a sweetened drink or dessert. . . She always encourages me to eat more.” (YP-A11)
Theme 2. Key healthy lifestyles
2.1 Healthy eating	(2.1.1) “We cook balanced meals with meat, vegetables and soup, but our son tends to eat only meat and very few vegetables. He will not eat any vegetables unless you remind him.” (YP-P02) (2.1.2) “They [students] quickly ate braised or fried [dishes], and then threw away the vegetables.” (SQ-S05) (2.1.3) “I feel like kids are drinking less water and more sugary drinks now.” (YP-P07) (2.1.4) “I think the more serious problem is beverage habits. . . Children consume too much cola, milk tea and other beverages, which are in high sugar.” (HL-S06) (2.1.5) “I don’t eat breakfast on weekends. I wake up at 12 o ‘clock.” (SQ-A04) (2.1.6) “Especially holidays, I usually sleep until noon and don’t eat breakfast, sometimes also don’t eat lunch, just have a dinner, and cook midnight snack in the middle of the night.” (YP-A11)
2.2 Physical activity	(2.2.1) “During PE classes, we usually run for high school exam, commonly known as ‘Zhongkao’.” (SQ-A02) (2.2.2) “Our children have PE class in school, and each class content is arranged by PE teachers for them to run or do items for Zhongkao. But I hope that PE classes for children can be more interesting, not just for Zhongkao.” (HL-P02) (2.2.3) “There are many students will stay in their seats after class except for going to the restroom. They sit during and after class all the time.” (YP-S05) (2.2.4) “[My son] arrived home at 6:00 pm, and then sat for doing homework until about 9:30 pm. Then, [he] took a bath and went to sleep, so he would sit for three hours approximately.” (HL-P08) (2.2.5) “[He] can sit all day [If] no one interrupts, that is, just play computer and mobile phones all day, or lie on the bed all day.” (YP-P10) (2.2.6) “I mean, if parents are not at home and no one supervises, [children] mostly play electronic devices.” (YP-S03)
Theme 3. Barriers to obesity prevention practices
3.1 Barriers to healthy eating	(3.1.1) “[If] the food is not yummy, he will have no idea to eat it for health, and he can’t do it. . . For him, fried food tastes more delicious than steamed one.” (HL-P09) (3.1.2) “Sometimes it’s tiring . . . to think about what I should eat and how to eat healthy a day. . . uh, sometimes I also have no time.” (HL-A09) (3.1.3) “The school lunch is just really difficult to swallow, unsanitary, and tastes nasty. I always eat less food at lunch.” (HL-A08) (3.1.4) “I want to eat healthily but I can’t, the school food is very ‘special’, (with) oily, salty and heavy taste. It’s ‘special’.” (YP-A08) (3.1.5) “My dad is always afraid that I would not eat enough, and he frantically buys all kinds of snacks and instant noodles [for me] and stores them at home.” (HL-A12) (3.1.6) “We don’t control treats. . . I would buy lots of his [her son] favorite snacks and store [them] at home, and he could pick them up anytime. . . [He] can drink milk and other snacks as much as he wants, and I don’t control, that’s it.” (SQ-P01) (3.1.7) “If the parents can’t keep healthy eating, how can their children?” (YP-P02) (3.1.8) “As long as the child says ‘I want to eat this [unhealthy] dish, the parents will cook . . .that’s probably the [limited] awareness of parents in our area.” (SQ-S05) (3.1.9) “Parents also want [their higher weight] kids to be slim, but when the kids don’t eat, they also feel a bit distressed. . .[Parents] show their love by [letting kids] eat more. It’s one of Chinese traditional culture.” (SQ-S01) (3.1.10) “You can see, there are grocery stores, milk tea shops and other snack shops next to each school. There are all kinds of cheap snacks. . ., which are crisp, sweet and fried snacks. . . Well, I think these are very unhealthy.” (HL-S01)
3.2 Barriers to physical activity	(3.2.1) “I don’t feel any differences or improvements” (YP-A12) (3.2.2) “I exercised for two weeks, not lose any weight” (HL- A05) (3.2.3) “I don’t have time to exercise at all because of study” (SQ-A02) (3.2.4) “I’m quite busy with my studies now, and I don’t exercise much. Studying is [my] priority” (HL-A03) (3.2.5) “The academic pressure was high. . . and he attended Xueersi [a private tutoring organization]. He had a full class schedule on Weekends. He had no time to exercise at all, limited time for homework, and even no time to sleep.” (HL-P08) (3.2.6) “Actually, my son wasn’t larger-bodied when he practiced taekwondo. But I can’t keep him attending [training classes] because he would go to middle school. I think studying is more important.” (SQ-P03) (3.2.7) “I think nowadays [students] study very hard and [are] very stressful. It’s generally agreed that improving academic performance is the most important, so sports do not get as much attention as they used to.” (HL-S06) (3.2.8) “If my mom said, “let’s go for a walk”, I’d do it with her. Otherwise, I am lazy.” (SQ-A12) (3.2.9) “If we have time, we can exercise with him/her. But we have no time because of work.” (YP-P03) (3.2.10) “I think another important reason for physical inactivity is overprotective parents. [They are] afraid kids will hurt themselves by exercising, and [think] it’s better to stay home with phones and iPad, eat food and study quietly.” (HL-S05) (3.2.11) “There aren’t enough surrounding facilities for students to play cheerfully like we did when we were kids. . . now [they] have to go to a certain place if want to exercise, and that actually requires a lot of willpower.” (HL-S05)

Theme 1: Understanding Adolescent Obesity

Subtheme 1.1: Weight status judgment

All participants tend to assess weight status based on subjective methods. Adolescents viewed physical appearance and body shape as the primary way, and nearly all parents judged children with obesity by appearance assessment, comparison with other children and parenting experience (Table 2, quote 1.1.1–1.1.2). Apart from judgment by outward appearance, school staff additionally referred to using behavioral performance and physical indicators as judgment methods. Youngsters with obesity were characterized by slow movement and poor athletic performance (Table 2, quote 1.1.3). Also, several school doctors and PE teachers mentioned that using physical indicators from students’ annual physical exams, such as body mass index (BMI) and body fat, to define the weight status of adolescents. However, they were confused about what these indicators mean and how to apply them to determine adolescent obesity.

Subtheme 1.2: Perceived prevalence

There were mixed views among all participants on the prevalence of obesity in adolescents. Most teenagers perceived that peers of higher weight in and around schools were uncommon, and some further speculated that the national obesity prevalence may be lower based on the surrounding situation. Two girls agreed and explained it from mainstream esthetic and social media (Table 2, quote 1.2.1–1.2.2). Contrary to the optimism perception of adolescents, most parents viewed a rising prevalence of adolescent obesity in the surrounding community and China. For school staff, the majority described “only 1 or 2 individuals experiencing obesity per class” in school, but deemed a significant increase in the national prevalence of adolescent obesity over the past few decades (Table 2, quote 1.2.3).

Subtheme 1.3: Health consequences

All participants recognized that obesity during adolescence can have adverse effects on both physical development and long-term health. It’s associated with increased risk of chronic disease such as cardiovascular disease, type II diabetes (Table 2, quote 1.3.1–1.3.2). The psychological consequences of obesity were also emphasized, particularly low self-esteem and emotional sensitivity, leading abnormalities in social life (Table 2, quote 1.3.3–1.3.5). Most adolescents with obesity claimed a poor body image isolated them from their normal-weight peers, and this weight discrimination not only from classmates but also teachers. School staff agreed that adolescents with obesity are prone to poor self-esteem, which makes them avoid social interactions and keep their coats on after sports. Several class teachers added that the narrow social circles of adolescents with obesity were not solely attribute to weight discrimination from others, but also to self-devaluation and self-rejection. In contrast to adolescents and school staff, majority of parents gave little thought to the psychosocial problems associated with obesity.

Subtheme 1.4: Risk factors

All FGDs concurred that adolescent obesity was linked to biological heredity, but highlighted poor lifestyle as the more critical risk factors. When asked to list and rank, “dietary” and “physical activity” were most often mentioned (Table 2, quote 1.4.1–1.4.3). Respondents cited a range of unhealthy dietary behaviors, such as unbalanced diet pattern (high animal-source foods and low fruit and vegetable), excessive intake of high-calorie foods (fried snacks, sugar-sweetened beverages). They also identified poor activity pattern, including lower physical activity and more sedentary behaviors, as one of major risk factors. Although academic pressure was commonly linked to weight gain, adolescent groups emphasized that various external pressure affecting mood and well-being may prompt them to fall into a vicious cycle of “eating to eliminate stress,” developing persistent obesity (Table 2, quote 1.4.4).

Apart from adolescents’ behavioral and psychological factors, family widely regarded to be closely associated with adolescent obesity. School staffs almost unanimously stated that family health literacy and parenting practices can significantly influence their children’s lifestyle choices (Table 2, quote 1.4.5). In fact, only 2 mothers reflected the influence that their education and modeling on establishing adolescents’ healthy habits. Majority parents concerned about the inappropriate feeding practices of those grandparents who always persuade children to overeat. This notion was also validated by some adolescents (Table 2, quote 1.4.6–1.4.7).

Theme 2: Key Healthy Lifestyles

Subtheme 2.1: Healthy eating

School and home could provide practical opportunities for adolescents to healthy eating. As school-aged adolescents spend a large proportion of time in their schools, they mostly eat both meals daily. However, adolescents reported that school meals were set menus of “2 meat and 1 vegetable,” with single menu options and overnight dishes. Frozen and fried foods were frequently used in the meals, and it tasted oily and salty. Overall, they were dissatisfied with the quality and palatability of dishes prepared at school, and even indicated that “we would eat rice or bread alone rather than the prescribed meals.” Adult groups (parents and school staff) also observed unbalanced dietary patterns in adolescents, characterized by a selective intake of meat dishes over vegetables during mealtimes. Furthermore, adolescents preferred more fried, ultra-processed and other high-fat foods, causing their excessive caloric intake (Table 2, quote 2.1.1–2.1.2).

Aside from regular meals, adolescents often snacked on sugary drinks, fried and puffed foods. The high consumption of sugary drinks among adolescents was chiefly discussed (Table 2, quote 2.1.3–2.1.4). Also, adolescents generally have poor eating behaviors including picky eating, overeating, eating fast and inattentive eating. Moreover, most adolescents reported habits of skipping breakfast and eating at night, particularly the weekends and holidays, increasing the likelihood of binge eating (Table 2, quote 2.1.5–2.1.6).

Subtheme 2.2: Physical activity

Adolescents’ physical activity was predominantly daily recreational and school structured activities. Participant teenagers listed a series of aerobic exercises as their favorite recreational activities. However, they also noted these activities were usually scheduled on weekends, but the frequency of implementation decreased progressively due to the burden of schoolwork.

In China, physical education (PE) classes and extracurricular sports or activity programs (ie, daily running, physical activity during recess) were reported to be available and delivered to all school-aged youth on weekdays, which ensure to meet “1 h a day” Sunshine Sports requirement on campus daily. Nevertheless, school PE sessions were often replaced by other elements of the academic curriculum during bad weather or when students were scheduled to undergo academic assessments. Again, adolescents expressed frustration at the arrangement of PE classes, which were often structured around preparing for the high school entrance examination, leaving less time for free play during classes (Table 2, quote 2.2.1–2.2.2).

Collectively, consensus was reached across stakeholders that our adolescents failed to meet the recommended 60 min of MVPA per day, and spent much time on being sedentary and excessive screen time (Table 2, quote 2.2.3–2.2.6). Apart from their regular classes sedentary time (8 -9 h), most adolescents still chose to sit during school breaks. This situation was extended to their home environment as well, where adolescents generally have 2 and 3 h of sedentary behaviors after school. Adolescents themselves even reported sitting for half a day or more on weekends or holidays, and the reasons were offered such as, “I have too much homework;” “I’ll sit all afternoon if get mobile phone.” Likewise, both parents and school staff reported adolescents had more screen time at home without parental supervision.

Theme 3: Barriers to Obesity Prevention Practices

Subtheme 3.1: Barriers to healthy eating

All participants emphasized that insufficient intrinsic eating consciousness and motivation among adolescents were major barriers to healthy eating (HE). Specifically, adolescents choose their daily foods based on taste preferences and personal mood. They expressed that HE was so tiring that the motivation for maintaining healthy diet always slack. Meanwhile, lacking of nutritional information and skill would prevent them from adopting HE practices (Table 2, quote 3.1.1–3.1.2).

In addition to teenager individual reasons, the suboptimal meal provision at school and family was another major barrier to HE (Table 2, quote 3.1.3–3.1.5). As discussed previously in Healthy eating (Subtheme 2.1), participant girls commonly perceived that school food was not prepared in a nutritious and palatable manner. At the same time, adolescent girls commented on family cooking that “My family cook food with heavy taste and spicy,” and added that their parents didn’t control over their diets and even offered amounts of junk food. There was a widespread perception among participants, including parents, that family has a key role in adolescents’ HE, particularly parental food guidance (Table 2, quote 3.1.6–3.1.7). Majority of parents acknowledged that they lack control over their children’s eating behaviors and inadvertently encourage unhealthy snacking habits. Moreover, poor parental modeling could be considered as a significant barrier. Such aspect was echoed in school staff who held the view that the aforementioned situation was exacerbated by inadequate health literacy and “Chinese doting” parenting style among parents and other guardians (ie, grandparents) (Table 2, quote 3.1.8–3.1.9).

The food environment in the vicinity of schools was also perceived to influence adolescents’ dietary behaviors (Table 2, quote 3.1.10). The increasing frequency of non-licensed food traders operating near school provide more availability for unhealthy food choices, leading to unbalanced and irregular eating pattern among teenagers.

Subtheme 3.2: Barriers to physical activity

The main barrier to physical activity (PA) revolved around adolescents’ negative beliefs and skills about PA engagement. Firstly, most adolescents reported being too lazy and unmotivated to participate in PA. They described PA as “requiring too much effort” and “causing tiredness;” Secondly, adolescents couldn’t perceive apparent benefits of PA for themselves (Table 2, quote 3.2.1–3.2.2); Then, academic learning significantly shortened teenagers’ leisure time for PA (Table 2, quote 3.2.3–3.2.7). There was more consensus from adult participants on the impact of schoolwork on PA among adolescents. Since children’s academic achievements are heavily valued in China, our parents prioritized academic attainment over PA, and allocated greater resources and time to children’s academic or extracurricular tutoring. Similarly, school staff indicated that adolescents’ huge academic pressure in national exam-oriented education system hindered PA levels. This pressure increases from middle school to high school, leading less time for PA and more time for academic work.

Stakeholders also believed that a lack of family support served as a barrier to promoting adolescents’ PA (Table 2, quote 3.2.8–3.2.10). Parents’ role modeling and exercise participation at home would apparently affect teenagers’ PA. However, some parents had no time to participate in PA with their children due to busy work schedules, and the value of PA was generally not emphasized within the family environment. Moreover, parents were perceived to overprotect of their children because of safety first and foremost, which discouraged teenagers from playing outdoors.

When electronic devices became increasingly portable and accessible to adolescents, excessive media use not only led to reductions in PA, but was also often accompanied by a sedentary lifestyle. Also, the lack of accessible sport spaces and facilities in community circumstances was another barrier, potentially diminishing adolescents’ interest and motivation in PA (Table 2, quote 3.2.11).

Discussion

This qualitative study explored and compared the views of representative Chinese adolescents, parents and school staff about adolescent obesity-related cognition, healthy behaviors and barriers to inform tailored and effective adolescent obesity interventions. We found that limited understanding and knowledge contribute to poor perception toward obesity and related issues among stakeholders. Almost all participants reported using subjective assessment (ie, visual evaluation) to identify weight status, and were unfamiliar with the objective measurements (ie, BMI). One consequence of such subjective assessment tendency was the underestimation of adolescent obesity and its perceived prevalence, especially youths’ pollyannaish optimism, which contrasted with the urgent reality of the issue.^28,29 Our teenagers were unaware of the obesity epidemic in China owing to limited social media propaganda. Simultaneously, school staff broadly believed obesity was a subordinate health problem among students, potentially limiting school-based health promotion for adolescent obesity prevention.

The psychosocial consequences were variously perceived across stakeholders and posed significant challenges for adolescents. While most interviewed parents ignored the negative psychosocial effects, adolescents and school staff argued psychosocial effects should be of greater concerns. Adolescents with obesity reported more frequent negative mood and social isolation owing to weight stigmatization and exclusion. Class teachers, who monitor the general health development of their assigned students, observed students with obesity tend to internalize negative weight perception (ie, body dissatisfaction) and emotional characteristics (ie, low self-esteem; depression) when encountering weight discrimination, leading to greater social difficulties and abnormal behaviors. However, weight-based stigmatization and isolation pervade society, including homes, schools, communities, and healthcare settings, which not only impair adolescents’ psychosocial development but also induce unhealthy weight control behaviors, academical underachievement and clinical care inequalities.^30,31 Worse still, discussing weight with youngsters of higher weight is sensitive with seemly a communication taboo. ³² Hence, obesity intervention and treatment goals for adolescents should also address the harmful psychosocial complications. ³³ Furthermore, constructive and non-judgmental weight discussions based on youth-centered body identity are essential to create supportive and stigma-free environments for teenagers with obesity.

As expected, all concurred that adolescent obesity results from the complex interplay between genetic susceptibility and energy balance-related behaviors (EBRBs), primarily dietary and physical activity patterns. Some psychological and environmental factors affecting adolescents’ dietary behaviors were identified to increases obesity risk. Most teenagers reported stress-induced detrimental eating behaviors (eg, overeating and high-calorie food cravings), which may lead to emotional eating propensity, binge eating habits and disrupt nutritional homeostasis, reinforcing childhood obesity across the lifespan.^34,35 Family was unanimously deemed critical in determining children’s lifestyle behaviors. School staff reiterated that parental practices shaped children’s normative healthy behaviors, whereas the majority of parents found their efforts to promote healthy behaviors were challenged by grandparents who often overfed and pampered adolescents with foods, resulting in excessive weight. Our findings, in conjunction with previous studies, highlighted that the overindulgence among all family caregivers, including parents and grandparents, should be addressed in managing Chinese adolescents’ weight.^36,37

Existing obesity management guidelines and initiatives have largely considered promoting HE and PA as first-line strategies.^38,39 Regarding HE, Chinese adolescents’ food preferences for high-fat and “palatable” foods significantly guided their food choices, particularly for meals and snacks. They would reject fruits and vegetables in favor of higher energy-dense and unhealthier foods, and some even skipped school meals and opted instead to fill up on alternative high-fat and high-calories snacks. Nevertheless, convincing adolescents to eat less tasty healthy foods was notoriously challenging, as many respondent mothers confirmed a conflict between their feeding styles and their child’s food preference, and this conflict was often resolved through preparing foods their child liked. Additionally, adolescents’ poor eating habits such as skipping breakfast, night eating were more common on weekends than school days. Also, less physical activity and more sedentary behaviors were observed on weekends and holidays. The less structured schedule of weekends and holidays was hypothesized to hasten unfavorable shifts in obesogenic behaviors responsible for excessive weight gain. ⁴⁰ Therefore, our findings supported this hypothesis, suggesting unstructured days (weekends and holidays) may exacerbate adolescent obesity a greater extent than structured school days.

Concerning PA, most teenagers had to sacrifice recreational sports during leisure time and relied substantially on school structured activities to meet the daily MVPA recommendation. Yet, a crowded school curriculum, intense focus on academic achievement and poor regulatory power have impeded the enforcement of required PE lesson in China, and school structured PE agreement centered around passing exams was reported to further dampen students’ enthusiasm for PA.^41,42 There is some evidence to show that more than 80% of Chinese school-going adolescents don’t reach current PA recommendations. ⁴³ Accompanying with Chinese adolescents’ physical inactivity was higher engagement in sedentary behaviors. Indeed, sedentary behaviors due to excessive homework was prevalent among middle school-aged youth during or after school, because they were expected to devote most of their time to schoolwork. Besides, recreational screen behavior (eg, watching television; computers and mobile devices) was found to increase sedentary time and displace PA, particularly without parental supervision. These findings aligned with previous studies that shed light on excessive screen time (≥2h hours per day) as an integral part of children’s lives and is closely associated with less parental monitoring.^44,45

Admittedly, stakeholders had largely harmonious views on effectively addressing adolescent obesity would require identifying, understanding, and intervening on the causes and barriers that influencing HE and PA, including adolescent individual, home and school environmental, wider socio-cultural factors. Initially, adolescents often show negative attitudes toward HE and PA, which may stem from their insufficient perceptions of obesity risks and healthy behavioral benefits.^29,46 Our analyses demonstrated that adolescents rarely perceived themselves as having obesity or at risk of health problems, and devalued the benefits of healthy behaviors. Adolescents focus on here and now, and the immediate burden of lifestyle change often outweighs the long-term benefits. ⁴⁷ Since health benefits as the underlying drivers of adolescents’ healthy choices, developing a holistic comprehension of health and health behaviors in adolescents, especially positive health benefits, could facilitate their adoption and maintenance of healthy lifestyles. ⁴⁸ Then, the lack of behavioral skills and self-efficacy reduced the motivation for lifestyle change. These may be countered by providing appropriate behavioral, skill-based health training to adolescents to cultivate healthy taste preference and PA engagement.^49,50

Deficient support from family and school environments was perceived as a significant barrier. Families have a leading responsibility in preventing childhood obesity where parents shape both children’s health behaviors and family healthy environment.^14,51 However, findings suggested that poor parental education, role modeling, and parenting styles and practices have limited adolescents’ access to healthy foods and activities, and hindered their healthy behavior practicing. Misperception of children’s weight status and certain parenting values (ie, indulging feeding, academic priority and overprotective awareness) among Chinese parents or other caregivers particularly grandparents could negatively impact adolescent weight management in the long term. Schools were ideal sites for public health strategies that promote lifelong lifestyles and prevent obesity in adolescents. We also observed several areas where school environments should be improved, such as improving meal quality and ensuring PE classes’ intensity and enjoyment. However, school-based obesity intervention programs had little impact on adolescents’ desirable behavior or BMI changes without family involvement.^12,52 Regrettably, there appears to be a “responsibility conflict” between school and family, with unclear boundaries about whose responsibility it’s to ensure adolescents HE and PA, resulting in a lack of cooperation or contradicting each other. ²⁴ Therefore, concerted efforts by family and school in adolescent obesity programs are necessitated, and establishing shared communication and cooperation among stakeholders is seen as essential enablers for implementing programs.

It’s notable that individual obesogenic behaviors were influenced by wider unhealthy food availability, access to sport space, unsafe neighborhoods and the overexposure of electronic gadgets. What’s more, entrenched socio-cultural norms in China significantly drove multiple community obesogenic environments. Specially, the emotionality surrounding food was strongly associated with parents’ nurturing practices, and some generational parenting practices were negative, as large body size in children is often conceived as a symbol of wealth and wellness by the older Chinese generations. ⁵³ Academic-focused awareness failed to provide supportive PA environment and appropriate PA education or values for adolescents, parents, and teachers. Taken together, there were various barriers at different levels (eg, the individual-, family-, school-, and society level) influencing obesity prevention practices need to be overcome. Research using the social ecological model on identifying effective obesity interventions has also called for developing comprehensive lifestyle interventions that engage relevant stakeholders to affect obesogenic behaviors. ⁵⁴

Strengths and Limitations

These multiple stakeholder insights provide a rich picture of understanding their experience with adolescent obesity and informing future obesity interventions. Our sample was purposively recruited who are socioeconomically and demographically diverse. However, the number of participants was not large and limited to 2 geographic areas within Hangzhou, which may not represent the multicultural demographic in other provinces in China. Further studies are required to increase generalizability and applicability to larger regions or populations. Then, social desirability bias may exist in group-oriented settings, but our participants provided detailed accounts and challenged each other’s opinion, indicating a sense of openness. Besides, we triangulated shared themes among stakeholders without delving into specific themes of singular groups. Future studies should analyze particular groups deeply to formulate more comprehensive understanding on Chinese adolescent obesity.

Conclusion

These shared social, psychological, and cultural themes illustrate the complexity of adolescent obesity as a public concern and community issue and reinforce the notion that it cannot easily be “solved” through simple education and lifestyle interventions. We found a range of individual, environmental and social-cultural levels influencing healthy lifestyles that would accelerate Chinese adolescent obesity development. This steers us to develop comprehensive lifestyle strategies that engage adolescents, families and schools sufficiently to achieve beneficial outcome, including adolescent-focused health promotion, direct caregiver involvement and supportive school environment.