Background

Currently ~ 9% of 12- to 19-year-olds in the United States have severe obesity (body mass index or BMI at or above 120% of the 95th percentile adjusted for age and sex [1]). Severe obesity is associated with elevated blood pressure and lipids, type 2 diabetes, asthma, sleep apnea, liver disease, joint problems, and mental illness, including anxiety and depression [2]. Metabolic and Bariatric Surgery (MBS) is an effective, safe, and durable weight loss treatment option in adolescents with severe obesity [3,4,5]. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), MBS is recommended for individuals with (1) a BMI ≥ 35 kg/m2, regardless of presence, absence, or severity of comorbidities; and (2) BMI of 30–34.9 kg/m2 and the presence of associated comorbidities [6]. In addition, the American Academy of Pediatrics (AAP) has endorsed MBS as safe for the pediatric population based on large prospective observational studies [7]. Recent analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) has shown an increase in the use of MBS among youth in the United States [8].

In 2017, a National Institute of Health workshop titled “Developing Precision Medicine Approaches to the Treatment of Severe Obesity in Adolescents,” hosted by the National Institute of Diabetes and Digestive Kidney Disease (NIDDK), discussed opportunities to expedite research aimed at advancing precision medicine approaches for the treatment of severe obesity in adolescents. The NIDDK report from this workshop concluded that more research is needed to better understand the underlying etiology of severe pediatric obesity to develop effective intervention approaches, specifically calling attention to the need for more research dedicated to MBS in adolescents, and how behavioral lifestyle interventions can complement and support these youth [9]. While stand-alone behavioral lifestyle interventions have shown promise in pediatric populations with obesity, they are insufficient to achieve long-term clinically significant weight loss among adolescents with severe obesity [4, 10]. Despite the significant increases in the prevalence of adolescents with severe obesity, a systematic review of 36 published articles that included the combination of healthy lifestyle intervention and MBS among adolescents (1995–2019) showed no studies reporting outcomes or effect sizes for the combination or compound effects of lifestyle intervention in partnership with MBS. Moreover, only one study included a theoretical framework with key, testable constructs to support the combination of lifestyle and MBS interventions [11]. In a second systematic review examining the use of digital platforms to deliver behavioral lifestyle interventions to MBS patients [12], results showed that studies varied widely in design (qualitative to randomized controlled trials) and eHealth delivery method (telemedicine to blog post content) for pre- or post-MBS use. Further, no studies included adolescents, and very few reported (1) a conceptual framework to support study design/outcomes; and (2) race/ethnicity composition of participants.

Indeed, Ortiz et al. [13] recommended ecological approaches [14] to examine MBS outcomes among racial/ethnic minorities using mixed methods to understand how support systems influence postoperative adherence and health outcomes. The social-ecological model’s (SEM, Fig. 1) [15] four levels (intrapersonal, interpersonal, group/community, societal/environmental) are ideal as a framework to develop and adapt a pre- and post-MBS support intervention for the adolescent MBS population. Figure 1 provides examples explicit to our target population that are important to address to provide comprehensive support. We describe here the methods used to develop and adapt an MBS lifestyle support intervention for adolescent MBS patients.

Fig. 1
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Socioecological model to support the adaption of a lifestyle support intervention to improve health outcomes for adolescents completing metabolic and bariatric surgery

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Methods

Study purpose

Based on literature documenting the effectiveness of MBS for durable weight loss among adolescents, [16] the lack of existing lifestyle interventions to support youth pre-and post-MBS, and strong empirical support from the Diabetes Prevention Program in the prevention of diabetes in adults, we describe here the development of “TeenLYFT (lifestyle support for teens)”, completed by a collaborative team of experts in pediatric obesity and related fields (i.e., exercise physiology, nutrition, psychology) to expand and adapt the intervention for pre-post MBS support in youth. We describe the intervention adaptation process, which involves three phases. Our study flow is adapted from the Obesity-Related Behavioral Intervention Trials (ORBIT, Fig. 2) [17] systematic framework that focuses on the proof-of-concept phase of intervention development. ORBIT is used to guide efforts to translate basic behavioral science findings into behavioral treatments for preventing and treating chronic illness. The first phase took place over the course of 6 months and involved collecting mixed methods data via an online survey and in-depth interviews with parents and adolescents to inform the development and adoption of TeenLYFT. This coincided with ORBIT’s pre-phase I (Significant Clinical Question, Fig. 2). The second phase, which took place over an additional 6 months, focused on adapting and refining the information collected from adolescents and their parents. The third phase of the study, which coincides with ORBIT’s Phase II, is currently conducting a proof-of-concept trial of the adapted intervention among 20 adolescents who have completed MBS, and will not be discussed in this paper as it is in progress. Data were collected and managed using Research Electronic Data Capture (REDCap) web-based application hosted at Children’s Health System of Texas. The University of Texas Health System Institutional Review Board approved the study.

Fig. 2
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Study schematic adapted from the Obesity-Related Behavioral Intervention Trails (ORBIT) that focuses exclusively on the early, pre-efficacy phases of behavioral treatment development

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Phase 1

The aim of Phase 1 was to generate quantitative and qualitative, or mixed methods data necessary to adapt the Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) [18] content, strategies, and delivery methods to explicitly support pre- and post-MBS, ethnically diverse (non-Hispanic white and black; Hispanic, other), adolescent patients and their families. This formative research included a survey and key informant interviews with adolescents, parents, and clinical team members. The survey and interviews consisted of ranking the priority of DPP/GLB information provided in the pre-post MBS support intervention, questions about method of delivery, and weight bias experiences. The interviews also focused on what content participants were interested in receiving pre-and post-operatively to support their weight loss. Below we describe the DPP/GLB content all participants were asked to rank in terms of preference in the survey on and discuss in an in-depth qualitative interview.

Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) description [18]

The Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) was developed by the University of Pittsburgh. Its goal is to prevent or delay the development of the comorbidities associated with obesity, prediabetes, and diabetes by providing tools and education to adults who have overweight, prediabetes, or diabetes to help them achieve a healthy weight and lifestyle. This is based on the principles of self-monitoring and using mindfulness and problem-solving skills to work toward specific goals. The DPP/GLB program contains 22 sessions including topics supporting nutrition, exercise, motivation, and stress management education and skills. Table 1 [19] summarizes the topics covered. These sessions are delivered in a group setting over one year. Sessions 1 to 12 are the core sessions, and they are delivered once a week over 4 months. The core sessions are designed to provide the basic education. Sessions 12 to 16 are transition sessions, and they are delivered once every 2 weeks over 2 months. The transition sessions reinforce the core sessions and encourage the participants to practice their behavior change skills independently. Sessions 17 to 22 are support sessions, and they are delivered once a month over 6 months. In the support sessions, the core diabetes and cardiovascular health messages are further discussed and are devoted to describing how skills learned in the previous session are or were practiced over the last month, and to review new topics or skills.

Table 1 Summary of diabetes prevention/program group lifestyle balance [18] sessions and content
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DPP/GLB Procedures. [19] In the first session, each participant receives a binder with material for the first session. At each subsequent session, participants receive material for that session for the binder. Session one introduces the participants to the DPP/GLB program and asks them to reflect on the reasons why they are taking part in this program. In addition, all participants set a weight loss goal of 7% and at least 150 min of physical activity (PA) per week. Each participant records his or her goal and is provided a weight and PA activity tracking sheet in the DPP/GLB material. Participants are encouraged to weigh themselves once a week. Each session starts with the presentation of the topic covered and then participants are asked to fill up a worksheet related to the topic. The teacher makes sure that the worksheets are being completed and then goes over the worksheet questions in a discussion format. At the end of each session there is a to-do list that is completed at home by each participant. For example, if the session subject is calorie tracking, then participants must track the calories they are eating by measuring their food and record the number of calories eaten per day in their binder. These to-do lists are checked at the beginning of each class to ensure compliance.

MBS patients often have prediabetes or diabetes [2] and many adolescent patients will transition into adulthood soon after surgery; therefore, the DPP/GLB is appropriate for pre- and post-MBS lifestyle changes and has been proven as an effective program for diabetes management in adults with excess weight. The current study aimed to determine what aspects of the established DPP/GLB needed to be adapted to support teens [17].

Survey procedures

Study inclusion/exclusion criteria

Participants must have met the following inclusion criteria to complete the survey and qualitative interview; (a) Be between 12 and 18 years; (b) must meet National Institutes of Health criteria to qualify for MBS for adolescents (BMI > 35 kg/m2 and at least one existing co-morbidity [e.g. elevated blood pressure, hypercholesterolemia, etc.] or a BMI > 40 kg/m2) and (c) Consents/assents to participate in the study [17]. Conversely, exclusion criteria included the following; (a) Does not meet National Institutes of Health (BMI > 35 kg/m2 and at least one existing co-morbidity [e.g. elevated blood pressure, hypercholesterolemia, etc.] or a BMI > 40 kg/m2); (b) Is type 1 diabetic or type 2 insulin dependent diabetic; and/or (c) Refuses to participate in the study [17].

Participants. A total of 19 participants (76% females, 41% Hispanic, 42% non-Hispanic Black, 17% other, mean age 15.2 years) preparing for MBS were recruited from the Children's Health System of Texas in Dallas. Following parental and adolescent consent, the adolescents completed a brief online survey. This survey encompassed inquiries about demographics, exercise habits, utilization of weight loss support tools, preferred types of support tools to assist with their pre and post MBS weight loss journey, DPP/GLB content preferences, and desired platforms for receiving these support tools.

Survey results

Adolescent Summary Results. Adolescents ranked the following as their top three preferred areas of content interest: (1) steps to adopt better eating habits and healthier foods; (2) healthy ways to cope with stress; and (3) steps to stay motivated and manage self-defeating thoughts. Nearly all adolescent participants preferred online delivery of content versus in-person.

Parent Summary Results. Mothers chose similar topics with the addition of information on eating healthy outside the home.

While presentation of all qualitative analysis is beyond the scope of this paper, key themes identified in analysis from the adolescent interviews included familial support, body image and self-confidence, and comorbidities as key motivating factors in moving forward with MBS.

Phase 2

The aim of phase 2 was to adapt the DPP/GLB content described above, as informed by AIM 1 qualitative and quantitative data, to support pre-and post-MBS among racially and ethnically diverse adolescent patients and their families. Below we describe this process in detail.

TeenLYFT adaptation

“TeenLYFT” [17] is an ongoing study conducted at Children’s Health System of Texas. It has three aims described in Fig. 2. For AIM 2 which involves the adaptation of DPP/GLB, based on our AIM 1 findings, we have developed an adolescent MBS-focused intervention by applying the SEM and Social Cognitive Theory (SCT) (Fig. 1) [15] constructs which are shown in Table 2. The SCT explains behavior in terms of personal factors and the environment interacting constantly in a way that a change in one area has implications for the others. Its constructs include observational learning skills and monitoring as well as the development of self-regulation.

Table 2 DPP/GLB content by the socioecological model (SEM) and social cognitive theory (SCT) constructs, examples of adaptation for the TeenLYFT metabolic and bariatric surgery support intervention for adolescents
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Adaptation Procedures. Over 6 months, the study team met multiple times weekly to adapt the original DPP/GLB curriculum modules as informed by the survey findings and qualitative data/analysis acquired from participants during Phase 1. The adapted DPP/GLB TeenLYFT intervention consists of four pre- and post-surgery modules based on the survey results from Table 3. The modules focused on (1) motivation, (2) healthy eating, (3) physical activity, and (4) stress management and were adapted based on standardized DPP/GLB content and survey and qualitative interview data and feedback (Table 4). Each module contains seven to eight videos ranging from one to three minutes except the physical activity module which contains 36 videos. The videos were created with the graphic design software Canva [20]. They are based on scripts provided by the registered dietitian and the psychologist on the team. Artificial intelligence (AI) voices were used to narrate the videos’ content.

Table 3 DPP/GLB Education Module Preference Survey Results, TeenLYFT participants
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Table 4 Teen LYFT pre-metabolic and bariatric surgery content summary by module and weeks
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Cultural Adaptation Process. To ensure content was culturally-adapted and relevant to our diverse participants, the following principles were used in the adaptation stage; (1) Peripheral, e.g., ensuring that relevant materials appeal to all participants such as exercises that are relevant to all adolescents; (2) Evidential e.g., using data and information relevant to target population (how we address the knowledge constructs) including ways to socialize with their adolescent peers; (3) Linguistic, e.g., ensuring the inclusion of commonly used words such as tracking, healthy, nutritious, mindful, tips, stress; and (4) Sociocultural, e.g., using concepts that reflect knowledge of the groups’ culture .that contain graphics from all cultures that were relevant to their background.

Readability Assessment. All content was designed for a 6th−grade reading level. Readability was assessed by Readability Calculations. [21]

Delivery Procedures. The four modules are delivered via Facebook and YouTube. The pre- and post-surgery videos are separated and each contain four modules. They are available to watch at any time. At the beginning of the Facebook page a guide is provided. It contains a suggestion of the order in which the videos are to be watched and the rules to follow while on the TeenLYFT Facebook page. A short quiz is available at the end of each module to test the participants’ knowledge. Participants can also like the videos or leave a comment. The same format is used to deliver the videos through YouTube. However, due to limitations within YouTube, participants are not provided a one-off quiz to fill out rather they are included in the framework of the videos.

Pre surgery modules (Table 4). Pre-surgery modules are designed to guide and support adolescents with lifestyle change requirements ideally in the month to 2 months before the procedure. However, we realize that this may vary by patient and the time necessary to complete all pre-operative medical and insurance clearances. Acknowledging the diverse timelines driven by individual patient needs, the TeenLYFT content was designed to accommodate these variations, emphasizing flexibility of delivery, and adaptability to individual circumstances, ensuring comprehensive support. The motivation module focuses on identifying reasons for pursuing MBS. It also includes tips to track exercise and food intake. Finally, it explains why tracking is important for increasing self-awareness and providing opportunities for self-reward. The physical activity module includes exercise safety rules and demonstrations of upper and lower body weight training exercises. It also includes some examples of cardiovascular exercises and ways to make physical activity a part of their daily routine. The stress management module describes mindful eating and the importance of eating slowly while enjoying food. It provides tips to avoid emotional eating such as removing junk food from sight and maintaining a regular eating schedule. The last module is the healthy eating module. It contains tips to incorporate different fruits and vegetables in their daily diet. It also has a list of healthy snacks to choose from. Content offered provides skills to stay on track with clinic preoperative requirements. Finally, it tackles the importance of eating healthy while away from home and provides tips to make healthy choices.

Post-surgery modules (Table 5). The post-surgery modules extend to 6 months after MBS is completed. The module topics are the same as the pre-surgery modules, but content is geared toward post-MBS guidelines [5]. Both the pre- and post-MBS content are aligned with topics covered in pre-and post-operative standard of care visits. Additional video content related to time-post-MBS guidelines is available every 2 weeks for 6 months. For example, in the first week after surgery, participants can only drink clear liquids, moving on slowly to full liquids at 4 weeks, soft foods around 6 weeks, and then full pieces of food after 6 to 8 weeks. They are also encouraged to start exercising a few days after surgery by walking, and then to move on to weight training, stretching and core exercises once cleared by their clinical surgery medical providers, often about 6 weeks after their surgery date [22]. The motivation and stress management modules support ongoing adherence to nutrition and physical activity recommendations by providing tips to manage stress and stay motivated across time. A short quiz is available for every 4 weeks, or for each set of eight videos, of content. Similar to the pre-surgery modules, participants can leave a comment or “like” each video. A survey is sent to the participants at 3- and 6-months post-surgery. In addition to the surveys, participants are contacted by one of the study team members to conduct 6-week and 6-month post-surgery interviews. The purpose of the surveys and interviews is to assess participant’s health and weight loss progress and get to collect feedback on perspectives about MBS, the education modules and their suggestions to improve any of the content. The post-surgery modules are summarized in Table 5. A sample of narration content from weeks one and two post-surgery is provided in Table 6.

Table 5 Teen LYFT post-metabolic and bariatric surgery content summary by module and weeks
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Table 6 Week 1 and 2 teen LYFT post-metabolic and bariatric surgery content for adolescents
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Discussion

The adaptation of the Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) to create TeenLYFT described here aimed to address the unique requirements and preferences of adolescent MBS patients. This adaptation process was guided by valuable mixed methods data from both patients and their families, as well as standardized preoperative MBS guidelines. In contrast to the original DPP/GLB content, which consisted of 22 in-person sessions over a span of one year, TeenLYFT streamlined this content into four key modules: motivation, healthy eating, physical activity, and stress management. This work addresses a significant gap in the healthcare landscape by providing a tailored and evidence-based lifestyle intervention for adolescent MBS patients. With the increased prevalence of severe obesity among young people, TeenLYFT can help support adolescents in achieving sustained weight management and overall health improvements.

The motivation module of DPP/GLB primarily focuses on elements such as goal setting, self-monitoring, and problem-solving skills. TeenLYFT integrated these elements with a clear recognition that motivation was a crucial area of interest for adolescent MBS patients. The program emphasized aligning personal motivations with specific health behavior goals. Patients are encouraged to reflect on their individual reasons for engaging with recommended behaviors and to continuously assess their progress towards these objectives. TeenLYFT videos include explicit examples of how to practice these skills, since staying motivated was indicated as a primary area of interest for participants. Low motivation or being uncertain about how to develop consistent behavioral compliance to lifestyle recommendations was a relevant theme when adolescents and their parents were asked about barriers to health behavior adherence in Phase 1. Consequently, this was a primary topic throughout our adaptation process in Phase 2. We prioritized individual patient values, goals, and reasons for engaging with and maintaining health compliance and this was embedded throughout our intervention videos which was consistent with the DPP/GLB content. For example, one of the DPP/GLB sessions is dedicated to reminding participants about the reasons why they joined the program and how to stay on track with their original weight loss goal. Similarly, in our adapted TeenLYFT program, the patients are asked to consider “their why '' or main reasons, at any given time, for engaging with healthy lifestyle recommendations, such as weekly weighing, regular exercise, or consistently eating a nutrient-dense meal plan. A constant focus on patient-driven motives for healthy behaviors was emphasized throughout all modules and videos. This was a way for patients to build motivation for using recommended tips and it provided an opportunity for patients to check-in with their current progress. Prioritizing personal motivation via “their why” offered a starting point for establishing new goals or staying committed to goals, even when perceived motivation, or feeling like doing necessary health behaviors, was limited.

Stress management was identified as a critical topic for adolescent MBS participants, and TeenLYFT took a distinct approach to address this concern. Unlike DPP/GLB, which dedicated a single module to stress management and another to mindfulness, TeenLYFT embedded stress management skills throughout all of its modules. This approach ensured that stress-related topics, including mindfulness, managing negative thought patterns, and avoiding emotional eating, were consistently addressed to provide comprehensive support. These included specific tips for mindfulness, or using present-focused attention, and managing unhelpful thinking and behavior patterns, such as negative self-talk, skipping meals or neglecting to track calories or exercise, and not getting adequate sleep. Although stress management was a module itself, we incorporated stress management skills within other modules (e.g., mindful eating and mindful movement in the healthy eating and physical activity modules; gratitude and recognizing progress in the motivation module).

Physical activity emerged as a top priority for participants in the pre-adaptation survey. In response, TeenLYFT introduced a new pre-surgery module that emphasized the importance of staying active and provided practical sample exercises. Similar to DPP/GLB, the videos included cardiovascular and strength training exercises, with a strong focus on proper form and safety. In the post-surgery modules, TeenLYFT guided patients through gradual activity increases as they recovered, [22] adhering to the FITT principle (frequency, intensity, time, type) and emphasizing the development of self-efficacy. The DPP/GLB aims to help participants develop exercise skills throughout the year and includes several sessions reinforcing the importance of physical activity. Engaging in consistent physical activity is one of the requirements of MBS, thus the adapted TeenLYFT videos serve as an exercise guide to advance patients toward that goal. Post-MBS physical activity content was designed to incrementally introduce activities as their surgical wounds start to heal and they become more comfortable with increased activity levels. Similar to the DPP/GLB layout, content changes every 2 weeks based on the FITT (frequency, intensity, time, type) principle. The videos not only contain exercise ideas, but every video includes tips to increase adolescent self-efficacy and confidence in their abilities to stay active.

Finally, healthy eating was another area of great interest for adolescent MBS participants. DPP/GLB includes sessions on topics such as reading food labels accurately, making healthy choices when dining out, and adopting healthy snacking habits. However, additional specialized dietary education is required for patients undergoing MBS. Food is digested differently post MBS, as the stomach is much smaller and cannot hold as much food as before. Thus, adolescents post MBS should eat a very limited amount of food at a time. Only clear liquids can be consumed the first week after surgery, followed by full liquids the second week. Following surgical recovery, they can start eating regular foods, but they are limited to a recommendation of 500–800 cal per day. It is not recommended to eat and drink at the same time since the stomach will fill up with liquids and will not be able to process additional solid food. In addition, patients must concentrate on foods containing a high density of protein and nutrients to support the body’s needs and ongoing healing process. Patients must also take multivitamins for life since they are unlikely to absorb enough from the foods that they are eating daily [23].

Tailored specifically for MBS patients, TeenLYFT reinforced the recommendations of the MBS clinic dietitian, including calorie tracking and the post-operative dietary requirements described above. The program also addressed portion sizes, healthy snack options, and strategies for making nutritious choices when eating outside the home. Specifically, videos reinforce the MBS clinic dietitian recommendations such as consuming and tracking daily calories and replacing one meal with a low-calorie, high protein shake post-operative. In addition, the clinic provides a handout including how to make healthier food choices as patients prepare for MBS. An extensive list of healthy food options in protein, carbohydrate and fat categories is part of the handouts. The videos also identify portion sizes and healthy snack options. In addition, they reinforce the importance of eating healthy even when out of the home environment and provide tips for healthy choices from restaurant menus. There is a new video every 2 weeks that covers the foods that participants can eat following MBS-specific guidelines. In addition to the motivation and stress modules, the healthy eating module reinforces their self-efficacy and self-management skills to lead them toward a successful weight loss journey long-term.

While adapting the DPP/GLB for TeenLYFT, several limitations were considered. The relatively small sample size of 19 adolescent participants may impact the generalizability of findings, and the availability of all pre and post-surgery intervention content at once could lead to non-linear consumption. To address these concerns, in a currently ongoing proof-of-concept study, TeenLYFT is conducting interviews and surveys at 6-weeks, 3- and 6-months post-MBS to collect valuable feedback and insights for the ongoing improvement of the program.

Overall, TeenLYFT represents a promising approach to supporting adolescent MBS patients, building upon the foundation of the DPP/GLB while tailoring it to meet their specific needs and preferences [17]. Future directions for this research will involve the continuous refinement of the TeenLYFT program based on ongoing feedback and evaluation, ultimately aiming for broader implementation in clinical settings. Additionally, exploring the potential integration of mobile applications and digital platforms to enhance accessibility and engagement among adolescent MBS patients could be a promising avenue for further development.