Engaging African American Adolescents and Stakeholders to Adapt Interpersonal Psychotherapy for Weight Gain Prevention

Abstract

Developing culturally appropriate obesity prevention programs for African American (AA) adolescent girls that account for psychological risk factors is paramount to addressing health disparities. The current study was part of an investigation utilizing a community-based participatory research framework to gather qualitative data from urban AA girls, their caregivers, and community health liaisons to develop a novel obesity prevention program based on interpersonal psychotherapy for the prevention of excessive weight gain (IPT-WG). In the current study with urban AAs, data from seven focus groups (total sample size, N = 40) were analyzed using thematic analysis. Participants identified problematic eating behaviors, including binge or loss of control eating; highlighted the importance of interpersonal relationships, mood functioning, and eating; and supported the tenets of IPT-WG. While features of IPT-WG generally resonated with participants, culturally based modifications were suggested. These data will be used to inform the development of a culturally relevant IPT-WG program.

Developing culturally appropriate treatments to prevent obesity are paramount in reducing obesity and associated adverse health outcomes within the African American (AA) community (Kumanyika, Whitt-Glover, & Haire-Joshu, 2014). Compared with the national average of 32% (Ogden, Carroll, Kit, & Flegal, 2014; Ogden et al., 2016), over 35% of AA youth are overweight (body mass index [BMI] = 85th-94th percentile for age and sex) or obese (BMI ≥ 95th percentile for age and sex; Centers for Disease Control, 2000). Obese youth may be at an even greater risk for obesity-related physical (Bibbins-Domingo et al., 2009) and psychological consequences (Witherspoon, Latta, Wang, & Black, 2013). Thus, preventing obesity among AA adolescent girls is paramount. The purpose of this study was to use qualitative data collected from adolescent girls, their caregivers, and community health liaisons to examine the potential acceptability of interpersonal psychotherapy for the prevention of excessive weight gain (IPT-WG) in AA girls.

Most prevention and intervention studies targeting obesity among AA youth and girls have demonstrated short-term success (e.g., Baranowski et al., 2003; Hasson et al., 2012) and have focused on behavior modification. A behavioral focus potentially neglects other important psychological factors related to obesity risk, such as loss of control (LOC) eating. LOC eating is the subjective experience that one cannot control what or how much she is eating regardless of the amount of food consumed and is a key feature of binge eating disorder (Shomaker, Tanofsky-Kraff, & Yanovski, 2011).

Rates of youth reporting LOC eating range from 6% to 57% with the highest rates among overweight adolescent girls (Cassidy, Shank, Matherne, Ranzenhofer, & Tanofsky-Kraff, 2016). Research suggests that AA youth, including girls, are at similar (Austin et al., 2008; Cassidy et al., 2012) or even greater (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011) risk of LOC eating compared with other racial/ethnic minority groups. LOC eating among youth has been linked to poor interpersonal functioning (Elliott et al., 2010; Shomaker et al., 2011), depressive symptoms (Shomaker et al., 2010; Stice, Marti, & Rohde, 2013), and trait anxiety (Shomaker et al., 2010; Shomaker et al., 2011). LOC eating has also been shown to predict the development of social difficulties (Swanson et al., 2011), depressive symptoms (Sonneville et al., 2013), partial or full syndrome binge eating disorder (Tanofsky-Kraff et al., 2011), and increased weight and fat gain over time (Tanofsky-Kraff et al., 2006; Tanofsky-Kraff et al., 2009).

Interpersonal challenges can predict momentary (within the same day) LOC eating episodes among adolescent girls reporting LOC eating (Ranzenhofer et al., 2014). Depressive and state anxiety symptoms have also been shown to mediate the relationship between interpersonal difficulties and LOC eating (Elliott et al., 2010). These data provide support for the associations among interpersonal functioning, negative affect, and LOC eating. Additionally, the societal interpersonal stressors experienced by AA youth due to their minority status (e.g., racial discrimination) may also contribute to LOC eating and may be worth addressing within the context of new obesity prevention efforts tailored to this community (e.g., Rhea & Thatcher, 2013; Striegel-Moore & Smolak, 2000). A program that simultaneously targets interpersonal difficulties, mood disturbance, and excessive weight gain may serve as one selective approach to reduce obesity among AA adolescent girls reporting LOC eating (Tanofsky-Kraff, 2012).

IPT-WG to Address LOC Eating and Obesity Risk

IPT-WG may be suitable to address interpersonal difficulties, mood disturbance, and excessive weight gain in AA adolescent girls reporting LOC eating (Tanofsky-Kraff, Wilfley, et al., 2007). IPT-WG, based on interpersonal theory, posits that interpersonal challenges lead to lower moods that trigger LOC eating to cope with negative emotions (Tanofsky-Kraff, Wilfley, et al., 2007). IPT-WG not only recognizes the roles of individual behavior but also the interaction of the individual with others, both through interpersonal relationships (e.g., relationship with mother) and through larger community or systemic influences on the individual (e.g., microaggressions).

Development and rationale for IPT-WG.

IPT-WG was developed from the IPT program for youth with depression (Mufson, Dorta, Moreau, & Weissman, 2004; Young, Mufson, & Davies, 2006) and adults with binge eating disorder (Wilfley, MacKenzie, Welch, Ayres, & Weissman, 2000). IPT-WG is brief, time-limited, and assists youth with developing strategies for improving interpersonal relationships by identifying links between familial and social challenges, negative emotions, and LOC eating behaviors (Tanofsky-Kraff, Wilfley, et al., 2007). Youth learn to make changes through psychoeducation, communication skill building, communication analysis, and role-playing (Young et al., 2006). Youth learn skills, such as using “I feel” statements, “striking while the iron is cold” (choosing the right time to have a conversation), being specific when talking about a problem, putting oneself in another person’s shoes, and paying attention to body language. Personalized stressful situations are identified and traditionally categorized within interpersonal disputes, role transition, grief, and interpersonal deficits.

Empirical support for IPT-WG.

IPT-WG has demonstrated efficacy among youth. In a randomized-controlled trial to reduce LOC eating among adolescent girls, participants in both IPT-WG and a health education control demonstrated similar reductions in LOC eating after 1 year (Tanofsky-Kraff et al., 2014). However, among a small subset of non-Hispanic AA and Hispanic Caucasian youth, IPT-WG demonstrated more reductions in LOC eating compared with racial/ethnic minorities in the health education control condition (Tanofsky-Kraff et al., 2014). In a 3-year follow-up study of girls who participated in a trial comparing IPT-WG and health education (Burke et al., 2017), AA and Hispanic girls in IPT-WG were more likely to abstain from LOC eating at 3 years compared with Caucasian girls. Although results are from secondary data analysis and require follow-up, they are hypothesis generating. A key step in moving forward is to translate this existing knowledge into culture-based prevention and treatment approaches for AA girls.

Theoretical support for IPT-WG with AA girls.

AA adolescents may be at increased risk for culturally unique stressful life events, potentially due to racism, discrimination, microaggressions, and acculturative stress (Brody et al., 2006; Sawyer, Major, Casad, Townsend, & Mendes, 2012). IPT-WG is expected to function similarly among AA girls by addressing specific circumstances related to LOC eating, regardless of the particular situation. IPT-WG also underscores positive relationships and familial connectivity, which are highly valued among AAs (Hill, 1999). However, IPT-WG has been developed for and with predominately European/Caucasian populations. The understanding of norms for display of affect, communication styles, and problem solving need to be examined as these may differ by culture. The community was engaged to examine the fundamentals of IPT-WG in order to determine whether the current model of interpersonal functioning and skills to improve functioning need tailoring.

Partnership With a Rural Community

In a previous study, the authors partnered with a rural AA community to obtain perspectives from girls, caregivers, and community health liaisons on eating patterns, body shape/weight, relationships, and their perspectives on the IPT-WG program. The sample comprised of 21 adolescent girls, 21 caregivers (19 mothers, 1 grandmother, 1 father), and 8 community health liaisons (Cassidy et al., 2013). Participants shared perspectives based on a thorough description of the IPT-WG program. A total of 15 themes emerged across five domains: general eating patterns, binge/LOC eating, body shape/weight, relationships, and the IPT-WG program. In Domain 1 (general eating patterns), adolescents reported engaging in unhealthy eating behaviors (Theme 1), mindless eating (Theme 2), and eating in secret (Theme 3). In Domain 2 (binge/LOC eating), participants suggested culturally relevant terms for LOC eating, such as “throwing down” (Theme 1) and several triggers to LOC eating, such as boredom (Theme 2). In Domain 3 (body shape/weight), caregivers and community health liaisons identified preferences for larger body sizes (Theme 1), but caregivers noted a generational change in body standards with contemporary adolescents being more preoccupied with weight and being thin (Theme 2). Caregivers and community health liaisons distinguished “overweight” from “obese,” where only obese constituted a medical issue (Theme 3). That is, in the absence of health problems, participants did not necessarily perceive obesity prevention as an important public health issue. In Domain 4 (relationships), adolescents and parents identified difficulties with peers and caregivers (Theme 1) and indicated a desire to improve their relationships with important family members (Theme 2). In Domain 5 (the IPT-WG program), participants noted that the IPT-WG program would likely resonate with adolescents in the community. Several adaptations were suggested, such as needing to adjust some interpersonal skills (e.g., “I feel” statements) in order to maintain respect for parental authority (Theme 1). To enhance communication with adolescents and caregivers, participants suggested a caregiver component (Theme 2) and a nutritional/behavioral psychoeducational component (Theme 3). They also suggested using incentives (Theme 4) and selecting a group leader who could relate to AA adolescent girls (Theme 5). Participants also noted risk factors that might be unique to their geographical location, such as isolation. Several recommendations for adaptations to IPT-WG were made, such as a psychoeducational component for the family on obesity/overweight and nutrition; expanding the definition of LOC eating; education regarding the relationships between interpersonal relationships, negative mood, and binge/LOC eating; and adjustments to the interpersonal skills training whereby adolescents ask parents for permission to share their feelings before using an “I feel” statement.

One strength of this study was the information obtained in adapting IPT-WG to be more appropriate for rural AA individuals, a vulnerable group (Johnson & Johnson, 2015). Another strength was that it incorporated perspectives from multiple informants: adolescents, caregivers, and community health liaisons. A limitation of the study was the lack of generalizability of the results from the rural study to urban AA individuals. While some research has suggested lower rates of obesity among urban youth compared with rural youth (Davis, Bennett, Befort, & Nollen, 2011; Johnson & Johnson, 2015; Liu et al., 2012), they may encounter unique risk factors, such as limited access to physical activity, isolation, poor food environments, and safety concerns. Other evidence has reported that urban youth have increased access to unhealthy fast food options relative to rural groups (Lovasi, Hutson, Guerra, & Neckerman, 2009). Geographic-specific risk factors, such as travel distance and lack of transportation, may also differentiate rural and urban groups. Thus, it was important to obtain feedback on the IPT-WG program from an urban community.

Current Study

The overarching aim of the study was to obtain qualitative data from urban AA adolescent girls, their caregivers, and community health liaisons on the acceptability of IPT-WG and areas needed to consider for a culturally sensitive adaptation. Four sets of factors were examined: eating behaviors; body shape and weight; relationships, mood, and eating; and the IPT-WG program. The four specific study aims were as follows: (a) to obtain information on adolescents’ eating patterns, assessing their understanding of eating behavior, their experiences of different types of eating, and their observations of binge or LOC eating behaviors; (b) to obtain information from caregivers and community health liaisons on body shape and weight; (c) to obtain information from girls and their caregivers about how relationships affect adolescents’ mood and eating; and (d) to obtain feedback on the purpose of IPT-WG program and the specific program components (i.e., skills, role-plays). In addition, participants were asked how program components and the overall program could be improved.

Method

Participants

Forty AAs participated in the study. The sample was 18 adolescent girls, ages 12 to 17 (M = 14.53, SD = 1.70), 8 caregivers (6 mothers, 1 grandmother, 1 father), and 14 community health liaisons (n = 10 women, n = 4 men). There were five mother-adolescent pairs, one mother-grandmother-adolescent triad, and one father-adolescent pair. Eleven caregivers chose not to participate. Reasons for declination were not coded. Focus groups included two groups of younger adolescents (12–14 years; n = 7, n = 4), two groups of older adolescents (15–17 years; n = 3, n = 4), one group of caregivers (n = 8), and two groups of community health liaisons (n = 7, n = 7). Community health liaisons occupations’ varied and included pediatric advocacy, human immunodeficiency virus education, and nursing. Adolescents’ BMI standard scores (BMI z) ranged from 1.40 to 2.85 (M = 2.03, SD = 0.47) and body fat percentage ranged from 26.00 to 50.90 (M = 42.78, SD = 6.46), indicating an overweight/obese sample.

Eligible girls (12–17 years) were AA, overweight/obese, and reported at least one LOC eating episode and/or two correlates of LOC eating (e.g., eating in the absence of hunger; Tanofsky-Kraff, Goossens, et al., 2007). All caregivers of adolescents were eligible, but were not required to participate in the focus group. Community health liaisons were referred by a community center, identified as having familiarity with the community, and were required to have worked in any health care-related field (e.g., nursing).

Procedure

Participants were recruited using advertisements and referrals from the community health clinic serving the St. Louis, MO, area to participate in a study to provide their perspectives on “obesity, eating behaviors, relationships, and an obesity prevention program.” Participants underwent a telephone prescreening to provide information on gender, age, self-reported race/ethnicity, body weight, and LOC eating behavior. If eligible, they were invited to participate in focus groups in September of 2012 at a community health center. Adolescents and caregivers participated in separate 90-minute focus groups. Participants provided the appropriate written consent and/or assent before participating. Researchers from Westat (Rockville, MD), a data collection and management company, moderated the focus groups with a moderator and a note-taker who were AA women. Participants received $50 and refreshments. Child care was provided. Body height and weight measurements were taken following the groups.

Measures

Adolescents’ demographic information was collected during prescreening. Focus group questions were the same as those used in the study in rural participants (Cassidy et al., 2013). In that study, team members initially developed a set of questions based on their research and clinical expertise across the following domains: eating patterns, LOC eating, body shape/weight, interpersonal relationships, and components of the IPT-WG program. Over the course of approximately 4 to 6 months, the research team and Westat researchers refined the questions for a 90-minute focus group (for a sample of questions, see the appendix). Given the time limit, questions were prioritized based upon the group. All groups were asked about eating patterns, LOC eating behaviors, and general IPT-WG components. Adolescents were queried on their own experiences, caregivers on their observations of their adolescents, and community health liaisons on their observations of adolescents in the community. Given that adolescents might not have the broad perspectives of caregivers and community health liaisons, only caregivers and community health liaisons were queried on general body shape/weight issues for their adolescent and for adolescents in the community, respectively. Because researchers were interested in obtaining details about personal relationships, only caregivers and adolescents were queried on their recognition of the associations between interpersonal factors, emotions, and LOC eating. Because adolescents were to be the primary participants and community health liaisons might be leaders, they were queried on the specific skills, while caregivers were queried on the general components of IPT-WG. Community health liaisons and caregivers were also queried on leader qualifications.

Height was measured in triplicate using the Detecto height rod (Detecto Scale Company, 2011). Weight and body fat percentage were measured using the Tanita BF-350 Body Composition Analyzer, a foot-to-foot bioelectrical impedance analysis device (Tanita Corporation of America, 2013), which has demonstrated mixed reliability (intraclass correlations = .98–1.00; Loenneke, Barnes, et al., 2013; Loenneke, Wray, et al., 2013). Given bioelectrical impedance analysis may overestimate body fat percentage, validity of the scores may be limited (e.g., Loenneke, Barnes, et al., 2013). BMI was calculated using the standard formula: kg/m².

Data Analysis

Focus groups were audio recorded and transcribed verbatim. The transcripts were analyzed by a five member team led by a senior analyst and an experienced qualitative researcher using the NVivo 8 data analysis software package. Two (AA women) of the five analysts had also served as moderators for the focus groups. The analysts reviewed identical transcripts independently to generate a list of emergent themes. Before the transcripts were coded, analysts refined the independent lists through group discussion until they reached consensus. Analysts then independently applied the reviewed and agreed on list of themes or codes to the remaining data. The analysis team met continuously over the course of the coding period to monitor progress and discuss interpretations in order to achieve interrater reliability (Berkowitz, 1997; Golafshani, 2003; Morse, Barrett, Mayan, Olson, & Spiers, 2002). The coding schemes were then combined to create a single database for all the groups, which enabled the analysts to see patterns of similarities and differences in the responses across the transcripts. Analysts then worked together to summarize the relevant data.

Results

A total of 12 themes emerged across four domains: eating patterns/LOC eating, body weight/shape, relationships, and reactions to IPT-WG. In Domain 1 (eating patterns/LOC eating), adolescents discussed descriptions and experiences with binge/LOC eating (Theme 1). In Domain 2 (body weight/shape), individuals provided perspectives on obesity (Theme 1), descriptions of overweight/obesity (Theme 2), positive aspects associated with weight (Theme 3), and weight’s impact on social interactions (Theme 4). In Domain 3 (relationships), participants discussed interpersonal relationships among adolescents (Theme 1); improving interpersonal relationships (Theme 2); and interpersonal functioning, mood, and eating (Theme 3). In Domain 4 (reactions to IPT-WG), participants provided perceptions of the IPT-WG program (Theme 1), cultural adjustments to skills (Theme 2), characteristics of preferred leaders (Theme 3), and inclusion of additional components (Theme 4). Responses from adolescent, caregiver, and community health liaisons were combined to create themes. Participant voices were summarized and quoted. Characteristics of the participants were also noted: adolescent, caregiver, or community health liaison. Adolescents were further identified as “younger” if they participated in the 12–14-year-old focus group and “older” if they participanted in the 15–17-year-old focus group.

Domain 1: Eating Patterns/LOC Eating

The first aim was to obtain qualitative data from adolescent girls, their caregivers, and community health liaisons on adolescents’ eating patterns, as well as binge or LOC eating behaviors. There was one theme in this domain: individuals provided definitions of binge/LOC eating, antecedents, and consequences. Some participants recognized the terms binge eating and LOC eating and offered potential antecedents and emotional consequences. Adolescents reported being familiar with the terms, which they viewed as being different from eating to satisfy physical hunger. Instead, they indicated it involves a lack of restraint and an inattention to internal signals of hunger:

Eating just because you’re hungry is like you’re eating to get satisfied. Binge eating is eating just because it’s there. Like if it is a lot of food that you know you can get full of, there would still be more left but you still eat it all just because it’s there. That’s binge eating.

(Younger adolescent)

They also used various terms to describe overeating (potentially with a sense of LOC), such as “being greedy,” “being fat,” “excessive eating,” “overeating,” “unhealthy eating,” “being stingy,” “putting it away,” and “throwing down.”

Some, but not all caregivers, reported an understanding of binge eating and LOC eating and offered various explanations of the two terms: “It’s that I always find that binge eating happens under a pressurized situation … ” (Caregiver). In contrast, LOC eating was viewed as less “pressured”: “ … the person is grazing all day; there’s no sense of structure and they’re just getting stuff out of the refrigerator to eat” (Caregiver). Caregivers’ terms for binge eating and/or LOC eating were “greedy,” “grazing,” and “preoccupational eating.” They also indicated that some individuals, particularly older adults, viewed overeating positively. Positive terms they indicated older adults might use were “good eaters,” “having a good appetite,” and “respecting food.”

Some community health liaisons indicated they were familiar with binge eating, but not LOC eating. They offered that both binge eating and LOC eating were linked to an inability to control one’s eating: “ … Binge eating, when going on … they just eat, just uncontrollably just eat … ” (Community health liaison). Community health liaisons believed that binge and LOC eating should be addressed within the community. However, they indicated that these types of eating behaviors may be considered normative, and thus, remain ignored. In summary, some, but not all, participants indicated that binge and LOC eating referred to a lack of restraint over eating. Adolescents and caregivers offered various terms to describe these types of eating behaviors.

Adolescents, caregivers, and community health liaisons identified several triggers for these eating behaviors. Adolescents identified the following triggers: boredom, emotionally stressful situations (e.g., ending a romantic relationship), sadness, stress, desiring comfort, or being bored while watching television (TV): “Sometimes when I’m sitting down and watching a TV show I’d be like, why am I empty-handed? Like I’d go and get something to eat” (Older adolescent). They reported several emotions and physical states that follow episodes: feeling guilty, regret, physically full, heavier, or sleepy. Younger adolescents denied feelings of guilt:

When I’m eating chips, I eat until morning. I’ll be like, okay, I’m going to stop, and then I eat more. And then once I finally do close the bag up, I will say to myself, okay, I stopped. That’s why I don’t really feel guilty about it. At least I stopped myself.

(Younger adolescent)

Caregivers identified boredom as the primary trigger to binge eating and LOC eating:

I think because she has more time [during the weekend] and I think she may just be bored. She goes back and forth to the refrigerator because she has more time and she’s just bored versus during the week she has to be thinking about school …

(Caregiver)

Community health liaisons identified weight-based bullying and teasing as triggers (based on an observation of an adolescent girl in the community):

The peers are looking at her like she has a … stomach, she has this coming out more, her neck is this big now. So, the bullying is happening more and more and more. So, she’s eating more and more and more and more.

(Community health liaison)

Furthermore, community health liaisons observed that overweight girls were reluctant to eat in front of nonoverweight peers in public to avoid embarrassment, which might precipitate bingeing and LOC eating while at home:

I know one young lady, she’s in the middle school, she’s heavier than some of the girls in school, and she wouldn’t eat at school because they made fun of her … about her weight so she didn’t eat at school. So, whenever she got home, she just ate … [a]te a lot, yes, to make up for it. So, she wouldn’t eat in public in front of people, but in private, she’d eat a lot.

(Community health liaison)

In summary, some, but not all, participants were familiar with binge and LOC eating, although the distinctions were not always clear. They offered various terms to describe the behavior, as well as precipitants and emotional consequences.

Domain 2: Body Weight/Shape

Theme 1: Community perspectives on obesity.

The second aim of the study was to query community health liaisons and caregivers on body shape/weight among adolescents. Overweight/obesity were identified as common in the community. Community health liaisons concurred that high rates of overweight/obesity were normative in the community. Community health liaisons highlighted factors influencing the onset and maintenance of obesity within their community, including the busy modern family life, sedentary lifestyles (e.g., watching TV), poor nutritional knowledge, and limited availability of affordable healthy foods. Adolescents were not queried, and caregivers did not provide any perspectives on the onset or maintenance of obesity.

Theme 2: Description of overweight/obesity.

Participants provided perspectives on whether they ascribed to medical definitions of overweight/obesity. Caregivers challenged the use of labels that identified youth as overweight or obese. Caregivers noted that while they generally accepted medical definitions of overweight/obesity, BMI was not the best indicator of health. However, community health liaisons defined overweight/obesity based on BMI:

Overweight is probably when you are outside of the guidelines that’s set in the medical community. I mean those guidelines are there for a reason. When you look at the medical charts, what you should weigh at whatever particular height you are and along with the body mass index, all of that included could determine whether or not you are overweight.

(Community health liaison)

In summary, participants described overweight/obesity in terms of medical definitions, but rejected certain perceptions of weight equating to health. Caregivers challenged the medical definitions of overweight/obesity, while community health liaisons emphasized the importance of following such guidelines to understand body weight and health risk. Adolescents were not queried.

Theme 3: Positive aspects associated with weight.

Community health liaisons discussed several positive terms to describe individuals who are overweight/obese, such as “thick” or “voluptuous.” Community health liaisons noted that body standards of beauty and health within their community allowed for more flexibility in determining an ideal body size based on factors such as height, proportionate distribution of body weight, and self-assurance:

The acceptable range is whether or not they are proportioned. Because you heard the song, “She’s a brick house” … so if you see a woman of a certain height that has that measurement … she is really proportioned well.

(Community health liaison 1)

A heavyset woman who has herself together, so to speak, clothes, hair … is more acceptable than someone who could be the same size but their clothes don’t fit as well or they didn’t put themselves together as well.

(Community health liaison 2)

In summary, community health liaisons offered several positive terms to describe overweight/obese community members. Neither adolescents nor caregivers were queried on this particular aspect of body shape/weight.

Theme 4: Weight’s impact on social interactions.

Participants indicated that weight affected social interactions, which influenced emotional well-being. Caregivers reported that their adolescents may be directly or indirectly excluded from social activities because they are overweight or “bigger” than their peers. They also highlighted teasing as a major problem that can affect adolescents’ self-confidence, and finding clothes was identified a constant struggle and area of mother-daughter tension. Community health liaisons highlighted that adolescents in the community often receive contradicting messages about weight. They noted that, sometimes, heavier weight among adolescents aligned more with preferences for AA women who are “a little plumper” and are “better padded,” particularly among AA men. Yet adolescents were teased or excluded from social activities because of their weight status: “It affects you—if you’re in school, it affects your schoolwork, also relationships, relationships and your mental state … ” (Community health liaison). Community health liaisons noted that adolescents in the community retained the “psychological scars” of being overweight or obese even after losing weight. Another community health liaison speculated that the desire to have an acceptable weight could lead to anorexia nervosa or bulimia nervosa. In summary, participants indicated that body weight significantly affected social and emotional functioning among adolescents. Adolescents were not queried.

Domain 3: Relationships

Theme 1: Interpersonal relationships among adolescents.

The third aim was to query on how relationships influenced mood and eating. Adolescents and caregivers identified important interpersonal relationships and sources of conflict. Adolescents reported strong and close relationships with some family members (e.g., mothers) and friends. However, they identified conflicts with other family (e.g., fathers) and peers. This example illustrates one adolescent’s perception of her peer’s negative judgments:

Yeah, like most of the kids are really the first to judge. They judge you by the way you look, by the way you talk, by the way you walk, by the way you dress, anything that they can point out that’s wrong about you, they will talk about you about anything.

(Adolescent [age not coded])

Adolescents also noted that the closer and more central the relationship, the stronger the negative feelings associated with interpersonal conflict and the more likely a disagreement would result in a verbal conflict. Caregivers indicated that relationships with daughters were strong. That is, they felt close to their daughters, believed they played important roles in their daughters’ lives, and they could discuss most topics. They noted difficulty discussing romantic relationships, particularly if the caregiver is unaware of certain relationships. They also noted some difficulties with other interpersonal relationships, such as fathers who have not consistently been present in their lives and peers who have been accused of spreading rumors or gossiping. Caregivers noted common conflicts arose around maintaining chores and poor academic achievement. Caregivers indicated they were uncomfortable discussing issues that they perceived as more personal and emotionally laden, such as weight-related issues, expressing concern over hurting their daughters’ self-esteem. They did not want their daughters to feel negatively about their bodies. Mothers admitted to sometimes overfocusing on academic performance. Although important to their daughter’s success and future, they reported it also felt more superficial.

In summary, most adolescents and caregivers characterized their relationship with one another as relatively open and honest describing being able to speak to each other about most topics. Community health liaisons were not queried about interpersonal relationships.

Theme 2: Improving interpersonal relationships.

Adolescents and caregivers indicated a desire to improve interpersonal relationships. Adolescents identified improving communication as the primary way to improve important relationships:

I want to improve my relationship with my grandmother. … She’s very angry a lot. I don’t really know why, but she’s angry a lot now, and she’s always working and tired. I just want to be able to have conversations with her …

(Younger adolescent)

Another adolescent commented that she would like more succinct explanations from her caregiver about decisions:

Actually, to actually know what’s going on instead of them just being like don’t you see, na, na, na [sic]? It’s more like, well, if you just explain, like be more brief about it [sic], then there will be more cooperation and understanding.

(Older adolescent)

They also discussed a desire for mutual understanding—one older adolescent noted she wished her father could “place himself in my shoes.” Although some caregivers believed their relationship with their daughters was “healthy,” they desired improvement in certain areas, including being more open and understanding, as well as communicating in more positive tones. In summary, both highlighted a desire to improve important familial relationships by improving communication and mutual understanding. Community health liaisons were not queried.

Theme 3: Interpersonal functioning, mood, and eating.

Some adolescents and caregivers agreed that interpersonal issues could affect mood, which may lead to problematic eating patterns. Adolescents varied in their views on the validity and credibility of the connections between interpersonal functioning, mood, and eating. A few older adolescents noted that difficulties in communicating did not necessarily trigger eating, but instead might precipitate a variety of other “coping activities,” such as cleaning, sleeping, or watching TV: “I go to sleep because it’s like you’re not worried about it. When you’re asleep, it’s like you’re free. But when you wake up, it’s like, oh dang, this happened” (Older adolescent). Adolescents explained that the behavioral response depends on the intensity of the issue where less intense arguments led to eating:

To me it’s like it depends on how bad the argument was. If it was really bad, normally, I’ll probably try and get out the house to my friend’s house and tell her about that. But if it’s just like a little fight or something, I’ll probably just eat.

(Older adolescent)

The younger adolescents had a more difficult time articulating links between mood and eating. Caregivers indicated they understood the links between interpersonal functioning, mood, and eating. However, one caregiver pointed out that the program seemed to focus on the relationship between overeating and emotions, which does not apply in all cases:

It makes sense to the people who are eating because of their emotions aside from—like my daughter, she doesn’t eat because of her emotions. So there has to be something put in place with that program for her. … She’s not an emotional eater. Like myself, I don’t eat—when I’m upset, I don’t eat. I’d get a knot in my stomach where I can’t eat, so I tend to lose weight when I’m upset. So there’s going to have to be something in place for those people.

(Caregiver)

Overall, while participants indicated that interpersonal conflicts led to negative mood, negative mood did not always precipitate eating or overeating. Caregivers underscored the importance of interpersonal support in improving mood and functioning. Community health liaisons were not queried.

Domain 4: Reactions to the IPT-WG Program

Theme 1: Perceptions of the IPT-WG program.

The fourth aim was to obtain perspectives on the IPT-WG program. IPT-WG generally resonated with participants. Adolescents generally agreed with the basic idea of the program and liked the idea of role-plays. Some asserted that while adolescents overate for various reasons, they would only benefit from the proposed program if overeating was associated with “emotional challenges”:

I think it’s mainly based off the reason that you eat. Like if you’re eating because of your feelings, it might work, if you have someone to talk to about your feelings or something. If you could get this off of your chest, maybe it can. It depends upon the reason that you eat.

(Older adolescent)

Caregivers indicated that the program, and accompanying role-plays, would be welcomed and well attended in their communities, particularly due to the ability to build peer support:

I think that the other part of that is that a lot of times you get in a group and you listen to people talk and you see things—you see somebody else going through something, and you can relate it to yourself. Whereas, you might not have picked it up that hey, I eat when I’m bored, or I eat when I’m doing this. But you hear somebody else talking about their day or how they’re feeling and it kind of registers with you.

(Caregiver)

Community health liaisons also agreed that the basic idea behind the program makes sense:

I think the improved relationships would keep you from binge eating and from loss of control eating. If you are having issues with people and in whatever relationships you may have, this eating thing could be your way of dealing with that. So improved relationships should cause people to eat better and to make better choices.

(Community health liaison)

Similarly, community health liaisons suggested that the program would primarily be effective for those in the community whose eating behaviors are related to interpersonal conflict. In summary, participants agreed on the basic idea of the program, but indicated it would primarily benefit those who ate in response to negative emotions arising from interpersonal conflicts.

Theme 2: Cultural adjustments to skills.

Participants indicated all skills should be retained, but suggested that some undergo adjustments. Adolescents identified the skill, use “I feel” statements, as one that may not resonate with members of their community. As one older adolescent noted, “It depends on the person because some people if you—you have to say it in a mean way in order for them to actually hear you, to get their attention. You have to be … ” Another older adolescent completed the thought by stating, “Assertive with them.” Community health liaisons also indicated that the skill, use “I feel” statements, may not be as effective. They also believed the skill, Strike while the iron is cold (choosing the right time to have a conversation), may need additional adjustments, noting it may be difficult for older teens to change their communication styles: “You’re going to get attitude, you’re going to get baggage, you’re going to get cusses [sic], and everything that might come up out of the woodwork because they think it’s all about them at that age” (Community health liaison). In summary, individuals accepted most skills training and the behavioral strategies, such as being specific when talking about a problem, putting oneself in another person’s shoes, and paying attention to body language. However, cultural considerations are considered necessary to determine the most effective use of some skills, such as using “I feel” statements and striking while the iron is cold. Caregivers were not queried on their perspectives on specific skills.

Theme 3: Characteristics of preferred leaders.

Caregivers and community health liaisons indicated that leaders of adapted IPT-WG program should be suitable to the population. Caregivers thought the leaders should be female, relatively young and relatable, and that race/ethnicity does not matter. They also indicated that community affiliation does not matter because the adolescents will be unaware of the leader’s residence. Community health liaisons preferred individuals who were AA, relatable, affiliated with the community, and had the personality to effectively motivate, encourage, and guide the adolescents. In summary, community health liaisons, but not caregivers, indicated that race/ethnicity and community affiliation were important. Participants discussed several personality characteristics that would be suitable for a leader, including being relatable. Adolescents were not queried.

Theme 4: Inclusion of additional components.

Participants advocated for the inclusion of behavioral components, other family members, and incentives. Adolescents recommended team-building activities and offered incentives of cash or gift cards, scholarships, and/or a general prize to encourage participation. Caregivers suggested team-building and exercise-oriented activities, as well as nutrition education and cooking classes. Following a query on potential involvement of family members, caregivers noted that activities should be incorporated that promote positive interactions between caregivers and adolescents. Community health liaisons highlighted the importance of including information about nutrition and exercise. Others requested participation of other family members, explaining that when adolescents learn the new skills, they will need reinforcement at home. In summary, participants recommended the inclusion of additional activities that may improve group support and assist with behavioral components of healthy eating.

Discussion

The purpose of this study was to obtain qualitative data from AA girls, caregivers, and community health liaisons on the perceived relevance, usefulness, and acceptability of IPT-WG for urban AA girls. The long-term goal is to use this information to adapt the IPT-WG program for this community. Twelve themes emerged that were categorized into four domains: eating patterns/binge or LOC eating (one theme), body weight/shape (four themes), relationships (three themes), and reactions to the IPT-WG program (four themes). From these themes, we have identified five areas that should be considered in order to culturally tailor the IPT-WG program: (a) providing psychoeducation to elevate the problem of obesity/overweight as a community health concern, (b) defining terminology addressing different problem eating behaviors, (c) adjusting IPT-WG skill delivery and identifying leaders, (d) providing nutritional education, and (e) including caregivers in the program. The scientific rationale for these adjustments is presented along with approaches to addressing the modifications.

Additional Psychoeducation on Weight and Health

Caregivers and community health liaisons noted that obesity was a problem in the community. More psychoeducation appears to be necessary before participants choose to participate in the program. Rural participants appeared not to value obesity prevention when other health consequences, such as hypertension or diabetes were not present (Cassidy et al., 2013). Although the disconnect between health and obesity was not evident among urban participants, psychoeducation would likely help both groups as all participants would benefit from relevant and accurate information regarding the links between LOC eating behaviors, obesity, and other obesity-related health risks, such as hypertension and type 2 diabetes.

For some youth, psychoeducation may assist in addressing weight and eating concerns (Tanofsky-Kraff et al., 2016). Psychoeducation may also be one way to encourage participants to take initial steps toward preventative care, especially if coordinated with health care providers (Durant, Bartman, Person, Collins, & Austin, 2009) or community stakeholders (Wallace & Bartlett, 2013). Care should be taken to elevate the problem of obesity/overweight as a community health concern without endorsing a thin beauty ideal or diminishing nonweight-based definitions of attractiveness. In addition to a session that would occur once participants enroll in the program, an additional group information session could be instituted prior to beginning the program to discuss the links between disordered eating behaviors, obesity, and well-known adverse health outcomes.

Notably, participants indicated that body weight significantly affected adolescents’ social and emotional functioning through weight-based teasing and social exclusion. Weight-related teasing and social exclusion among adolescent girls who are overweight/obese are common (Haines, Kleinman, Rifas-Shiman, Field, & Austin, 2010) and have been associated with a myriad of psychological difficulties, including severe eating pathology, low self-esteem, anxiety, and depressive symptoms (Libbey, Story, Neumark-Sztainer, & Boutelle, 2008). Because AAs tend to accept larger body sizes and have higher body satisfaction (Kronenfeld, Reba-Harrelson, Von Holle, Reyes, & Bulik, 2010), it is often assumed that AAs are protected from such teasing. In the scant literature on such racial/ethnic differences, frequency of weight-related teasing among AA youth appears to be similar to other racial/ethnic groups (van den Berg, Neumark-Sztainer, Eisenberg, & Haines, 2008), particularly among those with extreme obesity. Thus, the adapted IPT-WG program needs to be aware that weight-based teasing and social exclusion may exist for AA youth. It is also suggested that leaders monitor whether urban participants experience increased weight-based teasing.

Additionally, urban participants mentioned nonweight-related elements of one’s body image, such as hair. Dissatisfaction with nonweight-related elements, such as skin tone, has been associated with lower self-esteem and self-worth among AA youth who are overweight (Young-Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003). Although the impact of self-esteem and self-worth has been linked to disinhibited eating in some adolescents (Rhea & Thatcher, 2013), the affect among AA girls requires further examination (Capodilupo & Kim, 2014). In addressing weight- and appearance-related concerns, the adapted IPT-WG program may focus on appearance considerations that are common among AAs (Okazawa-Rey, Robinson, & Ward, 1987), but may not usually be included in the conceptualization of weight-related teasing or traditional conceptualizations of body image. Throughout the adapted IPT-WG program, it is recommended that leaders be sensitive to circumstances that may be unique to weight-based teasing and eating pathology risk among AA girls.

Understanding Problem Eating Behavior: Terminology and Consequences

These qualitative data regarding binge or LOC eating indicated that participants understood the concepts, but offered various terms to describe this eating behavior, including “being greedy” and “throwing down,” which was similar to the rural group (Cassidy et al., 2013). The recognition of binge or LOC eating, yet the offering of alternative terms, may highlight the need develop more appropriate sociocultural models of disordered eating (Cassidy, Sbrocco, & Tanofsky-Kraff, 2015). Some adolescents and caregivers underscored the connections among interpersonal relationships, low mood, and LOC eating, while others emphasized alternative mechanisms leading to eating concerns and weight gain. Only some participants perceived the connections to manifest as proposed. Specifically, some adolescents noted that mood disturbance might lead to coping strategies other than eating, such as sleeping. This adapted IPT-WG program is being developed specifically for individuals who report LOC eating as a means of coping with negative affect.

It is recommended that the adapted IPT-WG incorporate culturally relevant terminology and descriptions for this group. In particular, the language in role-plays could be adjusted (e.g., more culturally appropriate names and scenarios) and leaders could be instructed to incorporate alternate terms for LOC eating, including “throwing down,” “pigging out,” and “being greedy.” Furthermore, participants’ perspectives also highlighted the importance of personalizing terms for eating pathology. Therefore, in the adapted program, leaders could be encouraged to elicit participant feedback regarding use of other terms describing LOC or binge eating. Leaders would also be instructed to discuss the particular mechanism of LOC eating, so that participants understand the difference between nondisordered overeating and LOC eating, and the concept of LOC eating remains consistent with prior research and clinical definitions (Shomaker et al., 2011). These adjustments—specifically terminology—are typical components of cultural adaptations (Kumanyika et al., 2014). The research is mixed regarding whether these adjustments alone produce more effective outcomes; therefore, systematically reviewing how such adjustments may affect obesity prevention outcomes will be critical.

Adjusting IPT-WG Skill Delivery and Leader Qualifications

There was consensus among most of the responses from adolescents, caregivers, and community health liaisons; however, there were a few notable differences. While all participants agreed that the skills should be retained in the program, group members put forth different considerations when implementing certain skills. Participants found the communication skill teaching the use of “I feel” statements misaligned with culturally based communication styles. This perspective is consistent with prior literature regarding AA communication styles that may differ from “mainstream” Caucasian culture (Kochman, 1981). The use of emotionally laden, provocative, or—what may be perceived as—more assertive and direct conversational tones are viewed as an effective and acceptable approach to articulate one’s emotional experiences within the AA culture (Hecht, Jackson, & Ribeau, 2003; Kochman, 1981). While “I feel” statements are identified as a more effective communication style within the IPT-WG paradigm, which is based on Caucasian culture (Weissman, Markowitz, & Klerman, 2000), AAs may view this approach as less directive, and therefore, ineffective. In the rural group, participants indicated that using such statements might be too assertive when speaking with caregivers and disrespect parental authority (Cassidy et al., 2013).

Thus, for the adapted IPT-WG, it is recommended that leaders help adolescents determine effective communication based on the recipient. For instance, for adolescents who perceive “I feel” statements to lack assertiveness when speaking to peers, they may be encouraged to supplement verbal communication with more assertive nonverbal cues (e.g., direct eye contact; Aguinis, Simonsen, & Pierce, 1998). For adolescents speaking with caregivers, leaders may propose several options for explaining the “I feel” statements. Rather than initiating a conversation with an “I feel” statement, adolescents may be encouraged to first request permission from caregivers to express their emotions. In this way, the caregiver’s role may be respected and maintained. It is also recommended that leaders be trained to introduce skills as different rather than better approaches to communication. These discussions would provide both adolescents and caregivers opportunities to gain clarification and problem solve potential barriers.

Related to skill delivery are the qualifications of the group leaders. Community health liaisons and caregivers thought it important that the leaders be chosen for the population (AA adolescent girls) though they differed on whether race/ethnicity mattered. The adapted program needs to be delivered by individuals with a multidisciplinary skill set that allows them to deliver IPT, nutrition, and health information. Additionally, they should be culturally competent, ensuring that they understand the needs and values of the AA community and can deliver the tailored program in a respectful and effective manner.

Inclusion of Nutritional/Behavioral Component

Another major suggestion provided was a need to place greater emphasis on nutritional habits by incorporating a nutritional/behavioral component. In the original IPT-WG program, nutrition is not explicitly discussed or targeted (Tanofsky-Kraff, Wilfley, et al., 2007). Prior research on behavioral modification for weight loss in AAs is inconsistent (Baranowski et al., 2003), and data in adults suggest that behavioral treatments may be less effective at reducing LOC eating episodes than specialized treatment for binge eating disorder (Wilson, Wilfley, Agras, & Bryson, 2010). Yet building social support networks for healthy eating and physical activity across home, school, and community contexts may increase engagement in such beneficial behaviors (Salvy, de la Haye, Bowker, & Hermans, 2012) and sustain long-term weight loss (Wilfley et al., 2007). In the adapted IPT-WG program, it is suggested that a parallel nutritional/behavioral component be incorporated to address nutrition and physical activity concerns. The inclusion of nutritional strategies could be combined with a caregiver involvement.

Inclusion of Caregiver Component

Another important adaptation may be the inclusion of a caregiver component. Although this inclusion was primarily emphasized in the authors’ previous study with a rural sample (2013), several issues identified in this study suggest including caregivers would be important. These reasons include the community and family need for further psychoeducation on obesity, binge/LOC eating, and nutrition as well as the need to respect community communication styles. In IPT, adolescents typically use skills to role-play difficult conversations with other adolescents and the facilitators (Mufson et al., 2004; Young et al., 2006). Adolescents are then instructed to attempt the conversation with a caregiver outside of group and report the outcome during the following session. Adolescents may be unknowingly deterred by the caregiver’s confusion or impatience. In the adapted IPT-WG program, it is suggested that caregivers be present at the initiation of each session, so leaders may share the session agenda and reconvene toward the end of sessions to role-play conversations in vivo. In this way, leaders could provide immediate feedback, allowing both the caregiver and adolescent an opportunity to learn and practice new ways to communicate in the safety of the therapeutic environment.

Caregivers could also partake in parallel nutritional/behavioral sessions designed to emphasize the importance of achieving and maintaining healthy weight, to teach skills regarding nutrition and physical activity, and to provide information regarding the use of social support. Once caregivers reconvene with adolescents, they could share nutrition and physical activity information. Providing caregivers these skills not only maintains the caregiver’s role as authority in their families, but also will provide an avenue for caregivers and adolescents to collaborate on improving communication, nutrition, and physical activity.

Because caregivers typically play such a critical role in youths’ daily lives (Young, Northern, Lister, Drummond, & O’Brien, 2007), improving social support surrounding eating- and weight-related goals may lead to better weight outcomes (Goldschmidt, Best, Saelens, Epstein, & Wilfley, 2014). Nevertheless, there is a paucity of research with AA youth and, therefore, it is unclear whether family involvement produces the same level of effectiveness (Barr-Anderson, Adams-Wynn, DiSantis, & Kumanyika, 2013). In a review of 27 family-based interventions targeting obesity in AA girls, Barr-Anderson et al. (2013) could not determine whether family involvement uniquely predicted improvements in physical activity and nutrition. However, these studies primarily targeted behavioral changes, which are rarely sustained long-term (e.g., Black et al., 2010). When targeting communication and relationship issues—as in the proposed program—including the family may be critical to uptake and sustainability (Dietz, Mufson, Irvine, & Brent, 2008). Based on other family-based techniques used for coping with distressing situations and problem solving, such as social perspective taking (communication analysis) and alternative response generation (decision analysis; Dietz et al., 2008), the adapted IPT-WG could be adjusted to include weight-related goals focused on eliciting social support for healthy behavior change and to involve caregiver facilitation and assistance in the practice of interpersonal skills (Wilfley et al., 2007).

Limitations of the Study

One limitation of the study is the small sample size. A larger sample size may have provided an opportunity to obtain more extensive insights regarding the reviewed concepts. Therefore, results are tentative and generalizability is limited. Similar to other focus groups, another limitation is that individuals’ responses or failures to respond may be influenced by others via the “group think” phenomenon. However, the risk is believed to be outweighed by the benefit provided by the group’s ability to facilitate critical thinking and reflection that might not otherwise occur with individual interviews (Peterson-Sweeney, 2005). Another limitation was that not all questions were asked of all participants; thus, some perspectives might not have been considered. However, researchers attempted to utilize the participants’ time most effectively by tailoring questions to what would be most pertinent. Furthermore, to limit participant burden, demographic information on factors such as social status of the family, health status of the participants, and prior involvement in a weight management program was not collected. Thus, the applicability of these findings to different groups is limited. Data regarding the percentage of participants who agreed or disagreed with one another was also not collected. However, unlike quantitative data, the purpose of qualitative research is to highlight themes that emerge based on saturation rather than numerical differences (Krueger & Casey, 2009). Additionally, though concepts of body image and weight were queried, other factors generally considered to define beauty and attractiveness within AA culture, such as skin tone and hair, were not explicitly explored. Finally, due to the limited reliability and validity of the scores from the Tanita BF-350 scale, body fat percentages may not accurately reflect the sample.

Implications of the Study

In this study, we sought to use focus groups to identify the acceptability of IPT-WG for urban AA youth and to identify key factors to address adapting a program for use with this community. There appears to be preliminary support for the acceptability of IPT-WG as an approach for mitigating excess weight gain among AA girls. We have identified specific variables and strategies within the approach that can be culturally tailored to fit the program to urban youth to include a psychoeducational component, culturally tailored language to describe problematic eating, and increased caregiver involvement.

Future Research

Obesity prevention among AA adolescent girls is critical. In addition to the high obesity rates among adolescent girls, AA women have the highest prevalence of obesity among all adults (Flegal, Kruszon-Moran, Carroll, Fryar, & Ogden, 2016). Such rates underscore the need to find effective and sustainable ways to address obesity in this community. Given that the efficacy of obesity prevention and interventions efforts among this population is limited, the goal of the study was to obtain data that could be used to adapt IPT-WG to be a more culturally appropriate and sustainable program. While it was not discussed among focus group members, stigma regarding seeking mental health care (Alvidrez, Snowden, & Kaiser, 2008; Murry, Heflinger, Suiter, & Brody, 2011; Turner, Jensen-Doss, & Heffer, 2015; A. S. Young & Rabiner, 2015), as well as obesity treatment (Kelleher et al., 2017), may still be a barrier to participating in any group program, regardless of whether it has been tailored to the community’s culture. In the current study, we take the community-based participatory research approach that involves community members from the study’s initiation. This community-academic partnership may provide an avenue for discussing and strategizing ways to appropriately communicate information about the program to reduce stigma associated with seeking mental health and/or obesity treatment. In this way, researchers can collaborate closely with community members to employ stigma-reduction strategies, such as providing appropriate psychoeducation about the program prior to participation (Alvidrez, Snowden, Rao, & Boccellari, 2009) or helping participants navigate system-level barriers to seeking care (Turner et al., 2015). Notably, the initiative of the former First Lady Michelle Obama’s Let’s Move! campaign likely contributed considerably to raising consciousness about the importance of addressing childhood obesity, particularly among racial/ethnic minorities and community-based organizations (e.g., faith-based organizations; White House Task Force on Childhood Obesity Report to the President, 2010). While there are no available outcome data of this public health campaign, it is important that such awareness continues and the outcomes of such awareness and community engagement warrant evaluation.

Not only might the involvement of community members likely reduce stigma but also the inclusion of caregivers as they can often influence the choice to seek treatment among youth. There is a paucity of data regarding the effectiveness of involving caregivers in obesity interventions among AA adolescents. In one review, researchers examined studies involving caregivers in interventions addressing several obesity-related factors, including interpersonal and organizational factors (Nichols, Newman, Nemeth, & Magwood, 2015). Notably, AA adolescent girls lost more BMI points when caregivers were involved. Similarly, in a qualitative study examining obesity-related health behaviors among low-income adolescent boys and girls, parental monitoring was viewed as a “favorable” part of the relationship (St. George & Wilson, 2012; St. George, Wilson, Schneider, & Alia, 2013). Parents were important in providing positive influence toward adopting healthy obesity-related behaviors. Similar results were found when querying which components within the family context influence obesity-related factors among urban AA adolescents (Christiansen, Qureshi, Schaible, Park, & Gittelsohn, 2013).

Peers also serve an important role in influencing healthy obesity-related changes among adolescents (St. George & Wilson, 2012). However, in St. George and Wilson’s study, teasing from peers was sometimes identified as helpful, although research shows this method may exacerbate excessive weight gain (Olvera, Dempsey, Gonzalez, & Abrahamson, 2013). Peers who are not part of the program will not be included in the adapted IPT-WG program. Nevertheless, their influence on assisting with adoptions of healthy psychological and behavioral factors warrants further study.

Data from our focus groups with adolescents, caregivers, and community health liaisons will be used to inform the adaptation of IPT-WG for urban AA adolescent girls. Once the IPT-WG program has been adapted to address these cultural adjustments, a pilot study and larger randomized-controlled trial will be conducted to assess its feasibility, efficacy, and effectiveness. As the field of obesity expands, our knowledge of the multifaceted system of influence on obesity expands as well. While this program combines two components of this system—individual and interpersonal—future studies should incorporate community-level factors, as well as institutional,organizational, and/or policy-level factors in their investigations.

Appendix. Sample of Focus Group Questions.

Domain 1: Eating patterns/LOC eating

Can you think of times when you feel like you eat more than you really wanted to or you are not able to stop yourself from eating? (adolescent)

Is there a special name or term you use to describe it when this occurs? (adolescent)

Can you think of what is usually going on in your life when this type of eating happens? How do you feel when this happens, before and after? (adolescent)

Are there times when your daughter seems to lose control over her eating or she eats a great deal of food in one sitting and her eating appears to be uncontrolled? (caregiver)

Do you have any idea why it happens when it does for her? Is there a trigger? (caregiver)

What are your teen’s emotions like when this happens? (caregiver)

Domain 2: Body weight/shape

In your family and your community, how would you say a girl’s weight/body shape affect how others see her? (caregiver)

How does a girl’s weight/body shape affect other parts of her life? (caregiver)

Have you heard the terms “overweight” and “obese?” If so, what do they mean to you? Are there other words you, or your friends and family use to describe carrying extra weight? (caregiver)

How does someone get to be overweight or obese? (caregiver)

How would you say a girl’s weight/body shape affects how others see her?

How does weight/body shape influence ideas about who is seen as “pretty” or “beautiful’? (community liaison)

To what extent would you say being overweight or obese is perceived/recognized as a problem by community members? (community liaison)

Domain 3: Relationships

Who are the people you aren’t getting along with/communicating with so well? (adolescent)

Do you think there’s a connection between overeating/LOC eating and times when you are not getting along with or not communicating well with other people? (adolescent)

How would you describe your relationship with your daughter? (caregiver)

If you could improve one thing about your relationship with your teen, what would it be? (caregiver)

Do you think there’s a connection between your teen’s eating patterns and what’s happening in her relationships to other people? (caregiver)

Domain 4: Reactions to the IPT-WG program

Does the idea behind the program make sense to you? (adolescent)

Do the skills make sense? (adolescent)

What type of person do you think would be best qualified to lead the group in this community? (caregiver)

Would you encourage your teenager to attend? (caregiver)

How likely is it that teens in this community would attend all or most of these meetings? What might you see as barriers to their attendance? (community liaison)

What other activities or program format do you think would make the program more appealing to teens and their families? (community liaison)

Note: LOC = loss of control eating; IPT-WG = interpersonal psychotherapy for the prevention of excessive weight gain. Based upon previous publication (Cassidy et al., 2013). Readers may request full list of questions from the authors.