What are the experiences, perceptions and expressed needs of adolescents living with obesity and their mothers in Indonesia? a qualitative multi-method study

Abstract

Objectives

This study aimed to explore the experiences, perceptions and expressed needs of adolescents living with obesity (ALOs) and their mothers.

Design

Data were collected through ALOs’ diary journals, short-term ethnographic fieldwork at ALOs’ schools and semi-structured individual interviews with both ALOs and their mothers. Reflexive thematic analysis was conducted using an inductive approach with two independent coders.

Setting

The study was conducted at one paediatric outpatient clinic at Dr Sardjito Tertiary Referral Hospital and in three selected junior and one senior high schools in urban and suburban areas of Yogyakarta and Sleman, Indonesia.

Participants

Twelve participants including 6 ALOs and 6 of their mothers. Data were collected through diary journals, a week of school-based observation and individual in-depth interviews with both ALOs and their mothers.

Results

Five key themes emerged: (1) Recognition, emotional responses and perception to obesity, (2) Awareness and desire for change, (3) Self-control and coping strategies, (4) Challenges in adopting a healthy lifestyle and (5) Support systems and weight management preferences. ALOs experienced bullying, shame and physical discomfort. They struggled with physical activity and diet due to social pressures and a lack of healthy food options at school. They believed that parental support, better nutrition literacy and regular reminders were crucial for improving their body weight. The adolescents’ commitment to weight loss was driven by both internal motivations (eg, masculinity, family medical history) and external factors (eg, social and cultural pressures on body image).

Conclusions

This study highlights the diverse psychosocial and emotional experiences associated with living with obesity, offering important insight into how ALOs and their mothers experience and navigate everyday life. These findings are essential for developing future human-centred obesity interventions that are both effective and empathetic.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study employed a multi-method approach with diary journals, semi-structured interviews and ethnographic fieldwork at the adolescents living with obesity school to explore the lived experiences and perspectives of living with obesity.

• The inclusion of mothers as secondary participants provided valuable additional insight into the family dynamics surrounding the adolescents’ experiences.

• The findings have limited generalisability due to the small sample size and focus on only a single urban region, potentially missing diverse national experiences.

• The study did not include fathers, school personnel and adolescents from rural or underserved populations, which limits the breadth of perspective captured.

Introduction

Adolescent obesity is a growing public health concern worldwide including in Indonesia. The three consecutive Indonesia National Basic Health Surveys conducted in 2013, 2018 and 2023 reveal a rising trend in the prevalence of obesity among Indonesian adolescents aged 13–15 years, with rates of 10.8%, 16% and 16.2%, respectively.1,3 Despite the implementation of various interventions targeting individual behavioural changes such as dietary modifications and increased physical activity (PA), recent meta-analyses including the latest from Cochrane,⁴ have shown limited effectiveness in reducing body mass index (BMI) in adolescents aged 12–18 years.

Most current obesity prevention and management strategies rely heavily on behavioural and lifestyle based intervention specifically those targeting dietary intake and PA level at the individual or household level.⁴ These approaches often overlook the complex social, cultural, environmental and emotional contexts that shape adolescents’ behaviours. This narrow focus contributes to the high relapse rate and poor adherence to long-term lifestyle changes among adolescents living with obesity (ALOs). Furthermore, these interventions rarely consider the lived experiences, subjective challenges and actual needs of adolescents and their families, resulting in limited relevance and impact in real-life settings.^{5 6}

According to the socio-ecological model, obesity in adolescence is influenced not only by intrapersonal factors such as knowledge, motivation and self-control but also by interpersonal relationships, organisational environments (eg, schools), community norms and broader policies.⁵ In the Indonesian context, these multi-level determinants intersect with cultural values, family dynamics and limited access to adolescent-centred health services, underscoring the need for more holistic and contextually grounded approaches.

This study addresses a critical gap in adolescent obesity management by exploring the experiences, perceptions and expressed needs of obese adolescents and their mothers in Yogyakarta. Through a qualitative study using a multi-method approach, this research aims to go beyond clinical definitions and BMI scores to understand how adolescents perceive their bodies, cope with stigma and lifestyle barriers and envision the kind of support that they require.

Objectives of the study

This study was guided by the following overarching research questions: what are the experiences, perceptions and expressed needs of ALOs and their mothers in Indonesia?

By using a multi-method approach to capture the perspective of ALOs and their mothers, the findings from this study are expected to inform healthcare providers, school health coordinators and local health policymakers in the design of more empathetic, adolescent-centred and sustainable interventions for obesity management.

Methods

Study design

This study is part of a bigger study entitled the development model of intervention through human-centred design for obesity management among adolescents. This study employed a qualitative research design with a multi-method approach involving the collection of ALOs’ diary journals, short-term ethnographic fieldwork at ALOs’ schools, and semi-structured individual interviews with ALOs and their mothers, to gain insight into their experiences, perceptions, expressed needs.^{7 8} This multi-method approach was used to capture both the subjective meanings and the social-contextual dimensions of living with obesity in daily life. This paper follows the Standards for Reporting Qualitative Research (SRQR).⁹

Study participant, recruitment and sampling strategy

The study included six adolescents aged 13–16 years, identified as overweight or obese (BMI-for-age Z-score > +1 SD), along with their six mothers, all residing in Yogyakarta or Sleman, Indonesia. The final sample size was determined based on the principle of theoretical data saturation. Recruitment and preliminary analysis were conducted concurrently; after the sixth dyad, researchers noted that themes had become repetitive and no new informational categories were emerging from the coding process. To ensure the richness of the data despite the small sample, maximum variation sampling was used to include adolescents of different genders, age groups (13–16 years) and socioeconomic backgrounds. This approach aligns with qualitative best practices where the depth and ‘information power’ of the data are prioritised over statistical representativeness.¹⁰

Inclusion criteria for adolescents were: being categorised as overweight or obese based on WHO z-score; living with a parent or guardian; having the ability to communicate their experiences meaningfully and agreeing to participate in the study. Adolescents with syndromic or secondary obesity, or with significant cognitive impairments such as intellectual disability, were excluded.

Participants were recruited through two primary channels: a hospital-based paediatric outpatient clinic (Dr Sardjito Tertiary Referral Hospital, Yogyakarta) and active screening within three selected junior and one senior high schools in the urban and suburban districts of Yogyakarta and Sleman, primarily to ensure diversity in participants’ prior exposure to clinical obesity management. These channels were not analysed separately, as the aim was to capture a range of adolescent perspectives rather than to compare groups. A total of 14 adolescents were initially screened for eligibility. Within the clinical channel (n=7), five adolescents were excluded: four lived outside the Yogyakarta region and one presented with non-nutritional (syndromic) obesity. Of the two eligible clinical candidates, one declined to participate due to time constraints. Within the school-based screening channel (n=7), all identified adolescents met the inclusion criteria; however, two declined participation. The eligible participants were purposively approached and followed by informed consent procedure. Study information for participants was explained, and written assent and informed consent were collected from all adolescents and legally acceptable representatives (mothers). Informed consent included voluntary participation, confidentiality and publication of anonymised responses. This recruitment process resulted in a final purposeful sample of six adolescent-mother dyads (n=12 individuals) who provided informed consent and met all study requirements.

Table 1 summarises the characteristics of the six adolescent participants consisting of four females and two males, aged 13–16 years (mean ~14.3 years old) and their mothers. The adolescents’ BMI-for-age (BMI/age) Z-scores ranged from 1.94 to 2.96, placing them in the overweight or obese category. Four participants were in junior high school and two in senior high school. All adolescents lived with their mothers; three mothers were married and three were widowed (two of the widowed mothers had since remarried). The mothers’ ages ranged from 40 to 52 years. These demographics reflect a small yet diverse sample of urban youth and their mothers in Yogyakarta.

Table 1. Respondent characteristics of adolescent participants.

Characteristic	Category	n (%)
Gender	Female	4 (67%)
	Male	2 (33%)
Age	13–14 years	4 (67%)
	15–16 years	2 (33%)
Education	Junior high school	4 (67%)
	Senior high school	2 (33%)
BMI/age Z-score	Mean (SD)	2.32 (0.35)
	Range	1.94–2.96
Mothers’ age in years	Mean (SD)	45 (5.06)
	Range	40–52
Maternal marital status	Married	3 (50%)
	Widowed (single/remarried)	3 (50%)

BMI, body mass index.

Instrument and data collection methods

Data collection was conducted over a 4 month period from January to April 2025 using a multi-method approach designed to ensure data triangulation. The process began with diary journals, where adolescents provided a 1 week reflective account of their eating habits, emotional states, physical activities and peer interactions. This was followed by short-term school observations, during which the researcher spent 1 week at each participant’s school. To minimise the ‘observer effect’ and monitor natural behaviours, the researcher assumed the role of a teaching assistant, focusing on social environments, peer influences and food choices. Finally, individual in-depth semi-structured interviews (IDIs) were conducted separately with both the adolescents and their mothers. These interviews, held at either the participants’ homes or schools based on their preference, used semi-structured guidelines to explore daily routines, health behaviours, and family dynamics in greater depth.

The first author MRA, a male PhD student with a public health nutrition background and over 5 years of experience in adolescent health research, conducted interviews and observations, assisted by BPA, a female dietitian. The interviews were conducted in Bahasa Indonesia, audio-recorded with participants’ consent and transcribed verbatim by BPA. Each interview lasted approximately 45–60 min. Each transcript, diary journal and fieldnotes was independently coded directly by MRA and BPA, followed by peer debriefing sessions with AAPP (a female senior researcher and Doctor of Nursing Practice) and FSTD (a female medical doctor and professor in the field of health promotion in chronic diseases, experience in qualitative research) to enhance the credibility and confirmability. Fieldnotes and diary entries were also documented and coded as part of the analysis. The researcher had no prior relationship with the participants. All respondents who consented to participate were interviewed face-to-face, with adolescents and their mothers interviewed separately.

The integration of individual interviews, diary journals and school-based observations (1 week per participant) yielded the ‘thick description’ essential for achieving thematic saturation. By the sixth case, the fieldnotes, diary entries and interview transcripts consistently triangulated and corroborated the emerging themes. This indicated that the data had reached saturation.

Data quality

A multi-faceted strategy for ensuring data quality was employed to enhance the credibility and reliability of this study. Methodological triangulation served as a fundamental approach to maintaining the rigour of our findings. By using a multi-method approach, we effectively cross-verified emerging themes and insights. For instance, a participant’s self-reported effort to limit calorie intake and mitigate hunger by increasing plain water consumption was corroborated by fieldnotes suggesting that the individual frequently drank water from her tumbler during school hours. A participant’s self-reported successful eating window during intermittent fasting was validated by observations made during the school lunch break.

Fieldwork captured the most authentic adolescent behaviours. The researcher temporarily served as a teaching assistant, enabling extended interaction within the participants’ natural environment. This discreet presence enabled the collection of genuine fieldnotes and reduced the likelihood of participants modifying their behaviour in response to an external observer. Additionally, to minimise individual researcher bias throughout the analysis phase, two independent coders (MRA and BPA) were assigned to directly code all transcripts, diary journals and fieldnotes. This procedure entailed distinct initial coding followed by consensus discussions to address inconsistencies, hence enhancing the confirmability of our findings. Ultimately, peer debriefing was performed with a senior qualitative researcher. The external audit critically assessed the research method, facilitating the examination of alternate interpretations and the validation of our final themes, thus enhancing the study’s overall credibility.

Data analysis

The verbatim transcripts, diary journals and fieldnotes were labelled and managed anonymously. Data management and coding were facilitated using NVivo V.12 software. Intercoder agreement was ensured through independent coding by two researchers (MRA and BPA) followed by discussion and consensus-building with other research members to resolve discrepancies.

Data were analysed using reflexive thematic analysis following the six-phase framework proposed by Braun and Clarke.^{11 12} This approach was chosen for its flexibility in capturing the complexities of the participants’ experiences while acknowledging the researcher’s active role in the production of knowledge. We adopted an inductive approach, where codes and themes were derived directly from the data (interviews, diaries and observations) rather than being fitted into a pre-existing theoretical framework. This reflexive process allowed us to identify shared patterns of meaning across the three distinct data sources. The initial phase involved familiarisation with all data sources, including interview transcripts, fieldnotes and participant journals. This immersion allowed for a comprehensive understanding of each participant’s experiences and perspective and the overall context of the study. The next step was initial coding, in which significant features of the data were meticulously tagged and labelled. This granular coding captured a broad range of concepts, from specific actions and emotions to broader ideas. The codes were then organised into meaningful preliminary categories to identify early patterns and relationships within the data.

Next, these categories were used to construct broader themes representing shared meanings and experiences across participants. To ensure the themes were robust and consistent, a collaborative review and refinement process was conducted among the researchers. This step involved in-depth discussions to challenge assumptions, resolve discrepancies, and confirm the coherence of each theme. The next stage involved naming and defining the final themes, to accurately reflect the core findings. A detailed analytic narrative was then finally reported for each theme, supported by direct quotations from participants to give voice to their perspectives and strengthen the study’s conclusions. This rigorous approach to data analysis enabled the researchers to authentically capture the voices of adolescents living with obesity and generate insights grounded in their lived experiences.

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting or dissemination plans of our research. However, the adolescent and parent’s perspectives based on the findings of this study were defined as the key output required to inform the design of future, more empathetic and sustainable interventions.

Results

Analysis of the triangulated data of individual interviews, fieldnotes and diary journals yielded five themes characterising the experiences of ALOs and their mothers (table 2). The findings reveal a complex interplay between internal emotional responses and external environmental influences, spanning recognition of obesity status, desire for change, coping strategies, lifestyle barriers and perceived support needs.

Table 2. Themes and categories emerging from the dyadic interviews, diary journals and school-based observations.

No	Theme	Categories
1	Recognition, emotional response and perception of obesity	Unawareness of obesity status; emotional response; perception of obesity.
2	Awareness and desire to change	Health-related fears; masculinity; body image and aesthetic standards; social and cultural pressure.
3	Self-control and coping strategies	Regular medical check-up; physical activity; dietary management; information seeking via social media and friends; pharmacologic/herbal use.
4	Challenges in adopting a healthy lifestyle	Barriers in adopting healthy diet; barriers to being more physically active.
5	Support systems and weight management	The need for professional counselling; digital support; maternal and paternal involvement; peer support; supported schools environment.

The thematic analysis resulted in five major themes (table 2), described in detail below. Participants are identified as A (Adolescent) or M (Mother), followed by a numerical ID. Age is presented as ranges to protect participant anonymity: early adolescent (13–14 years) or older adolescent (15–16 years). The data source for each quotation is specified in parentheses: (IDI) for in-depth interview and (D) for diary journal; findings drawn from the school-based observation fieldnotes are reported as narrative excerpts and identified by participant ID. Online supplemental figure 1 presents the specifics of coding, categories and the emergent theme.

Table 3 presents an audit trail of the coding process, illustrating how the themes were corroborated across different data sources to ensure the credibility and confirmability of the findings: IDIs, diary journals, and school-based observations. This multi-method approach allowed for a more nuanced understanding of the experiences, perceptions, and expressed needs of ALOs and their mothers. The consistency of findings across these three distinct sources (as exemplified in table 3) strengthens the ‘thick description’ of the socio-cultural and environmental factors influencing adolescent obesity management in this context.

Table 3. Exemplar of the coding process and data triangulation across multiple qualitative sources.

Main theme	Sub-theme	Example data excerpt	Primary data source
Recognition, emotional response and perception of obesity	Unawareness of obesity status (bullying)	“During school football play, A1 was positioned as a stationary target; peers intentionally kicked the ball at his body while making taunts about his size” (A1)	School observation fieldnotes
Awareness and desire to change	Health concerns (dysmenorrhea)	“My period wasn’t regular… I haven’t had it for months. The doctor said it’s also related to my weight” (A5)	In-depth interview
	Physical discomfort	“I realised that I feel easily tired and have difficulty breathing after heavy physical activity during school hours” (A5)	Diary journal
Self-control and coping strategies	Intermittent fasting	“Today, my weight decreased once more to 64.40 kg… Intermittent fasting from 8:00 PM to 1:00 PM is highly gratifying” (A1)	Diary journal
	Calorie restriction	“I try to avoid hunger by only consuming water in the whole day” (A3)	In-depth interview
	Calorie restriction	“Participant A3 observed eating only mineral water during school hours” (A3)	School observation fieldnotes
Challenges in adopting a healthy lifestyle	Obesogenic environment	“Observation of the school canteen revealed that all six vendors primarily sold sweetened packaged goods and deep-fried ready-to-eat items (eg, batagor, fried sausages and fried chicken smashed), with no visible fruit or fresh vegetable options” (A2)	School observation fieldnotes
	Food temptations	“During school hours, A3 was observed consuming canteen snacks with friends, violating his self-imposed intermittent fasting window (8 PM – 12 PM)” (A2)	School observation fieldnotes
	Social and peer influences	“My companions and I collectively ordered meals… I ordered French fries, instant noodles and an iced sweet cappuccino. We shared narratives and initiated a velocity dance trend” (A5)	In-depth interview
Support systems and weight management	Role of mother	“I don’t provide dinner… I offer fruit, but he doesn’t want it. His solution was to order food through Go-Food or go out and buy it himself” (M5)	In-depth interview
	Role of mother	“I feel more confident when mum reminds me of my goals” (A3)	Diary journal

Recognition and emotional response to obesity

Adolescents often reported not recognising their overweight status until an external trigger made it salient. Many initially believed that their weight “could be normal” until a doctor’s diagnosis, physical discomfort, social comparison and bullying experiences made them aware of their condition. Once aware, they described emotional reactions ranging from shock and embarrassment to frustration. For instance, one male adolescent in the early adolescent range stated that he had been “completely unaware” of any problem until a paediatrician informed him he was obese:

Well, I don’t realise it, Sir. Then suddenly when I go to the doctor – at Sardjito General Hospital, with Doctor X – she tells me, ‘You’re obese’. Well, I was shocked, Sir. It felt like my weight had been the same all along and my body felt normal. So then, I was disappointed with my body, Sir (A2, IDI).

Similarly, one mother observed her son’s ambivalence who noted that her son tends to compare himself only to heavier peers, saying

Yes, because some of her friends are also overweight. So she just take it easy, like, ‘I’m not as big as them’. She don’t look at the other thin kids, she look at the friend next to them. If she looked at the thin kids, she might think, ‘Ah, my body is like this’. Sometimes we do that, right? She think, ‘Am I fat?’ like, compared with their friend, not looking at the thin ones, but looking at the overweight ones, ‘Ah, they’re fatter.’ It’s difficult when her mindset is like that. They even said once, ‘My friend is even fatter than me, Mom,’ that’s how she talks. This kid is tough (M5, IDI).

This quote reflects both denial and shifting pride. Such quotes above illustrate that recognition of obesity was often accompanied by mixed emotions such as embarrassment, sadness or even pride as adolescents began to perceive their weight as a problem requiring attention. Moreover, adolescents and their mothers viewed obesity as an ambiguous and complex issue resulting from the interaction of various underlying factors. For example, one female adolescent in the early adolescent range stated that being fat could be either perfectly acceptable or problematic. She expressed ambivalence about whether obesity was truly a problem or not.

Well, you know, it could be a problem, or it could be totally normal. Like… those kinds of indirect jabs are the issue. Sometimes you feel like, ‘Ugh, I’m so embarrassed’, and other times you’re like, ‘Wow, I’m so cool’, it’s just… you know, it changes all the time like that (A3, IDI).

So, she really is ageing prematurely (perceived that the physical appearance is like an adult). Plus, now, perhaps one just has to understand. There are many factors, but I don’t know if this is actually relevant or not, but at least I’m telling you everything. I’m not sure if I need to see a psychologist, or if I need to see a nutritionist; to look for what’s the solution for my child? (M5, IDI).

Awareness and desire to change

Once their weight status became clear, most adolescents expressed a strong desire to change, often motivated by health concerns or body image pressures. Health-related issues frequently served as a trigger for action. For example, one older female adolescent described discovering that her menstrual irregularities and physical discomfort were linked to obesity:

This… what… my period wasn’t regular. Like that, I think it’s been almost how many months now that I haven’t had my period. And then yesterday, I went for a check-up, and doctor said it’s also related to my weight (A5, IDI).

In her diary, she reflected on her declining physical stamina: ‘I realised that I feel easily tired and have difficulty breathing after heavy physical activity during school hours’ (A2, D). This feeling of physical limitation, combined with clinical concerns such as irregular menstruation, created a powerful internal drive for lifestyle modification as the adolescents recognised that their weight was actively hindering their functional capacity as students. Another experience shared by some boys was having difficulties undergoing circumcision during childhood, which made them become aware of their body weight.

Initially, you know, Sir, I had a condition called micropenis. The doctor said, it was related to my body weight. So, because of that, I was told to get hormone injections several times, yeah, I think around 12 times, Sir, at first. I don’t know the full story, but it only ended up being six times, Sir. They said the shape was right already (A2, IDI).

Body image and social factors also played a role in heightening awareness. One early adolescent female recounted that a childhood crush had started dating her and made a remark about her body size, which embarrassed her:

Oh gosh, I’m so embarrassed, God. This was back when… this was because of my boyfriend. So, like, I used to have this, you know, a crush. So, he liked me since fourth grade, he told me, around when was that, yeah, when we were about to go into sixth grade elementary school, he told me, and then it was HTS (a casual dating relationship). Ever since then, that’s when I started dieting, you know, to be a little prettier or something (A3, IDI).

Likewise, some boys noted that thinner peers were perceived as more desirable. One adolescent remarked that skinny classmates easily got girlfriends.

If you look at people like X and Y (classmate), they’re thin, Sir. They must find it easily to get a girlfriend. If I’m fat, all that kurukan daging (Javanese language means flesh) will definitely make people look and think, ‘Wow, he’s really fat, huh (A2, IDI).

These accounts show that internal (ie, health concern and self-esteem) and external (ie, peer and cultural) factors heightened awareness and motivated youth to initiate weight-loss efforts.

Self-control and coping strategies

Adolescents and their mothers described various strategies to exercise self-control and cope with issues related to obesity. Teens often tried to distract themselves to reduce food intake. For example, one early adolescent female said:

I often drink plain water, yeah, because the idea is to not feel hungry (A3, IDI).

School observations corroborated this, as the researcher noted the participant was observed consuming only plain water during school hours (A3). The participant also stated that she practised time-restricted eating:

I do…what is it… intermittent fasting, you know. So from 12 PM, I can eat anything until 4 PM, but after 4 PM, I don’t eat anything else. That’s all (A3, IDI).

Intermittent fasting is equally common among male participants. This was evident in one male adolescent’s diary entries, where he noted his sense of achievement over his weight loss following intermittent fasting: ‘Today, my weight decreased once more to 64.40 kg. Intermittent fasting from 8:00 PM to 1:00 PM is highly gratifying’ (A2, D). Mothers also took active steps to support their children’s coping efforts. One mother explained that she tried to change her child’s eating habits at home by limiting food intake, specifically by stopping dinner meals and replacing them with fruits even though the attempt was unsuccessful:

One thing I do is I don’t provide dinner. Then I offer fruit, but he doesn’t want it, he won’t eat the fruit. He’s the type of kid who only likes sweet fruits like longan or durian. If I offer pears, bananas, oranges, he doesn’t want them. So, I get confused trying to pick, you know. That’s why his solution was to order food through Go-Food (an online food delivery service) or just go out and buy food himself (M5, IDI).

These comments reflect conscious efforts by both adolescents and mothers to replace unhealthy habits with healthier behaviours and to manage food cravings through alternative coping strategies. In addition, adolescents reported using various approaches to manage their body weight, including seeking information through social media platforms such as TikTok and Instagram, increasing PA, taking herbal supplements and consuming pharmaceutical medications.

Challenges in adopting a healthy lifestyle

Despite good intentions, adolescents faced numerous barriers to sustaining lifestyle changes. They identified environmental and social obstacles to maintaining a healthy diet and engaging in regular PA. For example, one early adolescent female noted that her school lacked healthy food options, particularly in the school canteen.

The food is oily, you know. Sometimes I like it, sometimes I don’t, when it’s oily like that. The other food are fried tempura (fish cake) and then fried banana. Then there are also noodles, instant noodles, and that’s it. They don’t sell fruits like that. It’s rare, at the school canteen (A1, IDI).

School observations showed that all six vendors in her school canteen primarily sold sweetened packaged goods and deep-fried ready-to-eat items (eg, fried fish cakes, fried sausages and fried chicken smashed), with no visible fruit or fresh vegetable options (A1).

Others mentioned social situations with their peers as leading to food temptation and overeating.

There are so many temptations at school, yaaa like friends will invite me, ‘Hey, let’s go here and eat instant noodles,’ so I join in, I’m hungry. ‘Hey, let’s buy nasi geprek’ (crispy smashed chicken with chili), iced tea, etc (A2, IDI).

During observation at school this behaviour was repeatedly observed. A2 was seen consuming canteen snacks with peers, contravening his self-imposed intermittent fasting schedule (8 PM – 12 PM) (A2). Mothers also highlighted practical constraints. One mother described her child’s strong preference for instant noodles and aversion to other foods.

You know, when she has Indomie (local well know brand instant noodle), it’s always taken two packs with two eggs. Honestly, just watching her eat makes me feel full, but she finishes it all. I asked my husband, ‘What are we going to do about our daughter?’ Because if she doesn’t get his Indomie, she just gets restless, like she absolutely needs it. So, I told her, ‘Try eating something else!’ I even tried introducing her to fish, but she hates fish, she hates meat, and she hates vegetables (M6, IDI).

Furthermore, various barriers to increasing PA were identified in this study. Some adolescents stated that they had limited time for exercise due to their demanding academic schedules. They preferred to relax at home by playing online games on their mobile phones. Most adolescents also reported feeling more comfortable exercising with their peers than doing so alone. Another adolescent girl expressed particular concern about engaging in PA at school. She reported dissatisfaction with the body odour that resulted after exercise, which made her hesitant or unwilling to participate.

No, it’s just that I’m worried about feeling hot and sweaty by the time I arrive to school. Moreover after exercising, the smell can get out of control and make me uncomfortable (A3, IDI).

In summary, easy access to calorie-dense foods, peer influences, food temptations and uncontrolled appetites were cited as major challenges that undermined adolescents’ healthy eating habits. Meanwhile, a lack of time for exercise, dependence on peers and concerns about body odour were identified as obstacles to engaging in PA among adolescents.

Support systems and weight management preferences

Strong social support emerged as a key factor for facilitating change. Adolescents expressed the need for support from experts through counselling or health coaching as well as from family, peers and digital applications. Two adolescents perceived that they needed guidance from others, particularly health professionals, to help them improve their healthy lifestyles, particularly in meal planning.

Perhaps I really need a guidance from someone else to help me improve better food habit. Because when Mom tries to guide me, it sometimes feels like it’s just her personal preference, not necessarily what’s best for me. So maybe someone who’s truly consistent would help me become more consistent as well (A5, IDI).

What I really want is to be disciplined, you know, Sir. To have a regular eating pattern, not, what’s the word, not ‘naughty’ with food. At school, eating is just like that, you know how it is, Sir, the eating is chaotic. What I want is to be more disciplined, really disciplined (A2, IDI).

This quote is also consistent with the mother’s perspective. One mother who had remarried expressed that her child’s obesity could be related to internal family problems and therefore considered visiting a psychologist as a necessary step:

Actually, what I want is to go to a psychologist, you know, to see if my kids are actually okay with me being married to this person, if they’re happy with it, you know, that kind of thing, because they don’t object directly, but the second one, you can already see that he’s not comfortable just being at home, right? (M5, IDI).

Some adolescents also mentioned that digital app support could help them become aware and disciplined. They expected that such apps would provide healthy lifestyle monitoring and reminders, sources of relevant information and access to peer support groups:

Yeah, the apps would be good in my opinion. So, it has the ability to monitor how many steps I take in a day and it can also monitor whether my weight is progressing well or not, you know?. Then there would be access to information about how to diet and also how to lose weight properly. That also seems like it would have an effect to me (A6, IDI).

That’s interesting, because maybe there are a lot of people who aren’t confident, you know, to talk in person, but through a chatting app maybe they can feel more confident to talk (A5, IDI).

The mothers were aware that their children might need their assistance in providing healthy meals at home. Therefore, they also expressed the need for information about meal planning.

Basically, the idea is, for example, if I’m told what the menu should be, you know, then I also, you know, even if it’s not exactly followed, but at least along the lines of ‘you can’t eat this’, and what kind of exercises would be, you know… more suitable to my son (M4, IDI).

The mother’s perspective was aligned with the adolescent’s emotions, indicating a need for maternal assistance. Diary entries corroborated that ‘I feel more confident when Mum reminds me of my goals’ (A3, D). Overall, these accounts show that encouragement and practical assistance from parents, along with support from digital apps, helped the adolescents persist in their weight-management strategies.

Discussion

Using a multi-method approach to gather data, we identified five interrelated themes that illuminate the psychological, behavioural, social and environmental dimensions of ALOs. These themes (1) Recognition, emotional response and perceptions to obesity, (2) Awareness and desire to change, (3) Self-control and coping strategies, (4) Challenges in adopting a healthy lifestyle and (5) Support systems and weight management preferences offer important insights into why many adolescents struggle to achieve sustainable weight loss despite recognising the need for change. The findings of this study emphasise that the problem of obesity among adolescents extends beyond body weight itself and highlight the essential needs for empathetic, experience-based weight management strategies that address both adolescents and their mothers.

The first theme underscores the delayed recognition of obesity among adolescents, the emotional responses accompanying this realisation and the perception that obesity is a complex problem. Many participants initially normalised their weight until a triggering event, typically a doctor’s diagnosis, bullying incident or social comparison within the family, made them aware of their condition. This finding aligns with findings from Øen et al study, who noted that body dissatisfaction among adolescents often arises not from objective health information but from interpersonal and socio-emotional triggers.¹³ Recent qualitative work using participatory methods has similarly found that adolescents’ perspectives on obesity treatment are deeply shaped by body image concerns and social comparison.¹⁴ Obese adolescents frequently experience verbal or physical bullying, which contributes to stigma and mental health issues.¹⁵ These results underscore the importance of addressing adolescents’ psychosocial and emotional difficulties when managing obesity.¹⁶ The reported emotional burden ranged from humiliation and shame to irritation and remorse, emphasising the psychological costs of obesity that often precede and complicate behaviour change efforts.¹⁷ The findings are consistent with earlier research indicating that obesity is a complex and multi-factorial condition that necessitates multifaceted interventions. The adolescents’ narratives revealed that obesity was influenced by factors beyond diet and PA, and many expressed ambivalence about whether their weight truly constituted a problem.¹³

Once adolescents became aware of their weight status, they expressed a strong desire to lose weight, as revealed in the second theme. However, this desire was influenced by various factors, including health problems, self-esteem issues and cultural expectations regarding attractiveness. Several participants identified body image ideals and peer or family pressure as major motivators. Similar phenomena have been observed in European contexts, where social relationships and family expectations about appearance can both motivate and cause psychological distress.¹⁸ Some adolescents experienced difficulties with friends, particularly thinner peers, because they found it hard to refuse instant noodles or high-sugar drinks that their friends brought. On the other side, friends and peers may be able to help stimulate transformation. Some participants received encouragement from their friends, primarily those who were also overweight, by discussing the difficulties they faced. Peers in the programme received the same level of support, which was motivated by a sense of equality.¹⁸ While external pressures might stimulate change, they do not always translate into sustainable behaviours, especially when adolescents lack the resources or environment that support healthy choices. Our findings suggest that while external pressures may act as initial motivators, internalised motivation is essential for sustaining long-term behavioural change among adolescents. This observation aligns with previous qualitative research by Liu et al, which highlighted the importance of internal drive in weight management maintenance.¹⁹

The third theme illustrates our adolescents participants’ efforts to regulate their eating and activity levels through various coping strategies, including the use of pharmacologic or herbal regimens, dietary management such as dietary or calorie restriction, distraction techniques and seeking health-related information on social media. These findings are consistent with previous qualitative studies in Indonesia that describe the central role of mothers as family caregivers. In those studies, mothers described various experiences in helping family members with weight loss, such as limiting certain foods by type and quantity and increasing PA. However, both the adolescent and mothers in our study perceived that such efforts at home were often thwarted by obstacles originating from both the individual’s internal struggles and external environmental influences. Specifically, the adolescents in our study were reported to struggle with maintaining consistent weight loss effort over time. Our findings suggest that support from the family and various stakeholders was perceived as a vital, yet often fragmented, element for maintaining the discipline required for obesity management.²⁰ While the involvement of mothers in reinforcing healthy habits remains an important buffer against misinformation, it is equally important to recognise the agency of adolescents as potential change agents within the family. However, in the current study, this individual and family agency was frequently challenged by a lack of synchronised support across social and environmental contexts.

Some child participant strategies, such as intermittent fasting or social media-driven dieting found in this study, reflect a broader global trend of youth turning to non-evidence-based or potentially harmful practices due to limited access to reliable guidance.²¹ Instagram and Facebook were among the most popular social media platforms that influenced healthful eating behaviours (ie, fruit and vegetable intake) as well as unhealthful eating behaviours related to fast food advertising.²² Intermittent fasting has gained popularity among young people, with studies indicating some weight loss benefits. However, evidence supporting its efficacy and safety in this demographic is limited.²³ This issue showed that the overwhelming amount of information available online can lead to confusion, making it difficult for youth to discern safe dietary practices from harmful ones. It emphasises the need for valid information access and reliable guidance from health experts to prevent potential harm and ensure safe dietary practices among youth.

Despite a strong desire to change, most adolescents encountered substantial barriers in their efforts to adopt a healthy lifestyle. As highlighted in Theme 4, these included easy access to energy-dense foods, a lack of healthy food options in schools, time constraints, peer influences and body image stigma associated with PA. These findings echo the socio-ecological model of health behaviour, which emphasises how environmental and interpersonal contexts rather than individual willpower alone shape health-related choices.⁵ Adolescents in this study struggled to maintain dietary discipline in social settings, particularly when surrounded by peers who consumed unhealthy foods, reinforcing that obesity management must address the broader food environment, not just individual behaviour.²⁴ It indicates that school environment modification is an essential step to support ALOs.

This study also found that young people with overweight and obesity place a strong emphasis on a social network where they feel equal to others when engaging in PA. Research indicates that these adolescents are more likely to participate in PA when they feel supported by peers who share similar experiences and challenges. This emphasis on social equality and peer support can significantly influence their motivation and willingness to engage in physical activities.²⁵ The fifth theme highlights the critical role of support systems, as perceived by the adolescent, in helping them navigate their weight-management journey. Consistent with the findings of Schalkwijk et al, our findings revealed that adolescents expressed a need for both instrumental support (eg, preparing healthy meals) and emotional support (eg, encouragement, positive reinforcement) from peers, families or mothers particularly.¹⁸

Our findings also underscores that adolescents with obesity experience a range of psychosocial problems that significantly affect their quality of life and well-being. Comorbid psychosocial and emotional problems of obesity generally act as causal or maintaining factors of obesity and thus significantly affect the treatment outcome.¹⁶ Both adolescents and mothers agreed that psychological interventions were needed. Psychological interventions were defined by Haslam in Baygi et al as non-pharmacological interventions that target cognitive, behavioural, emotional, interpersonal, social or environmental factors to improve a particular health outcome or condition. They involve psychological therapies (eg, cognitive behavioural therapy), education and social support approaches, social environment and norm-based strategies or a combination of these.²⁶ Recent meta-analysis showed that the psychological interventions targeting overweight and obesity in school-aged children through motivational interviewing and cognitive behavioural therapy were effective and durable to reduce BMI z-score and waist circumference.²⁶

Digital supports were also identified as promising, especially when they are personalised, accessible, co-designed and engaging. The desire for apps featuring reminders, tracking and monitoring tools, nutrition literacy resources and peer interaction aligns with findings from Partridge et al, who highlighted that adolescents are highly receptive to mHealth tools when these interventions are co-designed with them, personalised and adapted in real time using data from wearable devices.²⁷ Taken together, the findings emphasise the need for adolescent obesity interventions that are holistic, contextually relevant and adolescent-centred. Single-focus strategies, such as school-based dietary education or physician-led advice, are unlikely to succeed without complementary emotional, social and environmental support systems. The participatory insights from this study suggest that interventions should integrate behavioural change communication, mental health support, parental counselling and school environment reform, while also leveraging digital health platforms for greater engagement and adherence. Critically, interventions must be co-designed with adolescents to ensure they are tailored to their lived realities. For example, interventions should consider adolescents’ social routines, food preferences, emotional vulnerabilities and digital habits. Human-centred design principles, as advocated by Cheng et al offer a promising framework for developing interventions that are both effective and sustainable.²⁸

Strength and limitations

This study’s strengths include its multi-method approach using interviews, observations and diary journal deepened the understanding of adolescents’ and their mother experiences from multiple perspectives. The inclusion of mothers as secondary participants provided additional insight into family dynamics. However, this study has several methodological limitations that should be considered when interpreting the findings. First, the small purposive sample of six adolescent-mother dyads limits the transferability of findings to broader populations, though this is consistent with qualitative research conventions where depth is prioritised over breadth. Second, the study was conducted exclusively in urban and suburban areas of Yogyakarta and Sleman, which may not capture the diversity of experiences across Indonesia’s varied geographic, socioeconomic and cultural contexts, including rural and remote communities. Third, the exclusion of fathers and school personnel as participants limits the scope of perspectives captured; future research should include these key actors in adolescents’ social environments. Longitudinal and experimental designs are needed to assess the long-term impact of integrated interventions on adolescent obesity outcomes.

Taken together, the recommendations from this study emphasise the need for a multi-level, collaborative approach to adolescent obesity one that integrates individual motivation with structural support, family engagement, emotional care and digital innovation. Only by addressing the problem from multiple dimensions can sustainable change be achieved for this vulnerable and often overlooked population.

Conclusion

In conclusion, this study provides an in-depth understanding of the experiences, perceptions and needs of ALOs and their mothers in Indonesia. By using a multi-method approach, we identified that adolescent obesity is not solely a matter of body weight and individual lifestyle choices, but a complex condition influenced by emotional awareness, motivational triggers, coping strategies, environmental barriers and the quality of social support. Adolescents often become aware of their weight status only after external cues trigger self-recognition, typically followed by ambivalent emotional reactions. While many express a strong desire to change, they are frequently hindered by obesogenic environments, limited self-regulation strategies and inconsistent or inadequate support systems. Mothers play a pivotal role in both facilitating and impeding change, while digital tools and peer influences offer promising yet underutilised avenues for engagement. The findings underscore the urgent need for adolescent-centred, multidimensional interventions that integrate psychological support, behaviour change communication, parental involvement and environmental modifications particularly within school and community settings. Recognising adolescents’ voices and experiences is essential for designing more effective, empathetic and sustainable solutions.

Data availability statement

No data are available.