Self-regulation for behavior change.

Adolescents described finding it difficult to change established behaviors. As one adolescent stated: “I know I wouldn’t make healthy food myself […] If I made my own food it would just be a bunch of junk food.”–Bill

Difficulties in healthy eating were especially present for those who reported having anxiety related to food or eating disorders (bulimia nervosa). For example, one adolescent described enjoying food in the moment, which was followed by vomiting either foods or drinks (both more and less healthy options) to avoid weight gain: “It's not that it's like, the having healthy food choices, like a hard thing for me. It's just the fact that food is a hard thing for me […] I just think it’s like bad to eat, I guess.”–Nixy

This can be contrasted with some adolescents whose upbringing focused on healthy eating, predisposing them to preferring the taste of healthier foods. One adolescent described the process of behavior regulation as follows: “If you grew up from a life of like, just eating junk food and not a lot of healthy food, it’s pretty hard to adjust, and you got to maybe like, you got to do stuff you don’t like, and you have to know you’re not going to like it, but you still have to do it.”–Bill

Controllability and competence beliefs.

A common barrier to a healthy diet was a perceived lack of controllability over eating patterns and preferences (e.g., taste, portion control, mindless eating). As one adolescent stated: “It’s easier to make healthy food choices if you like the food choice. You shouldn’t like, force anything into your mouth just to be healthy.”–Bill

Adolescents shared numerous examples to suggest that intrinsic motivation was a common enabler of a healthy diet. Most adolescents shared that change had to come from within themselves, and reported a number of factors that enhanced their motivation, including adequate knowledge of health and nutrition, likeability of the food, setting realistic and gradual goals, and not viewing change as dieting. The following example illustrates this: “Not thinking of it as a diet because if I think of it as a diet and try to restrict myself, it’s like I want it so bad because you’re trying to convince yourself in a diet, but if you’re in a diet it just makes you want the thing more.”–Daniel

Social relationships and interactions.

Social barriers to healthy eating included a lack of parental involvement in behavior change, low perceived parental confidence in adolescents’ ability to change eating habits, and negative parental judgments about adolescents’ eating behaviors. For example, some adolescents reported feeling pressured to eat unhealthy foods in response to their parents’ or peers’ practices and expectations. One adolescent shared her experience: “Um, I don’t like, my Mom is kind of always trying to do her own thing for healthy eating, so she kind of just switches from like different diets or like plans or whatever and then she like will go and like random baking sprees where she’ll bake like all of this unhealthy stuff that’s just like packed with sugar and then she won’t eat any of it. She just wants everyone else to eat it and you can’t not eat it because then she’ll get offended.” She continued: “My mom a lot, like it bothers me, like bugs me a lot about what I eat, like how much of it I’m eating, and so like, I already kind of like, struggle with those issues myself, like kind of like beating up on myself for it […] so that like makes it really difficult because then it kind of just makes me feel bad and then also creates spite, and so then I end up eating more anyways in order to like spite her.”–Courtney

Adolescents were also subject to direct or indirect peer pressure to conform to social expectations in relation to eating. For example, while some described feeling pressured to eat unhealthy foods in social outings as a means of conformity, others reported being bullied for attempting to eat healthy foods: “Um, things that are stopping me they’re like sometimes people like to make, uh, fun of me for trying to like eat healthy. They’re like what are you doing? You’re never going to actually be able to eat healthy. Just do it the way you’re doing it right now. And whenever I try to confront someone after they keep telling me to start eating healthy they tell me it’s nonsense and that they’re never do that to me. So that’s kind of, people are what is stopping me kind of.”–Dipti

Social enablers of healthy eating included interpersonal support from family members, peers, and HCPs. This support came in the form of encouragement, active participation (e.g., role modeling), availability (e.g., abundance of healthy foods, limited access to unhealthy foods), and accommodation (e.g., premade foods). One adolescent shared the value of home visits as an example in helping to navigate the aforementioned factors: “Um, we like the one thing that really, really helps is when the dietitian and the physical activity nurse who help you, when they come to home and because they do home visits as well, so that really helps to manage our time and like that way I don't skip my school and things like those.”–Zaid

Accessibility to and availability of opportunities for lifestyle enhancement.

The affordability, availability, and convenience of unhealthy foods in different settings (e.g., home, school, restaurants) were highlighted as barriers to healthy eating. At the home, some adolescents described being challenged by the availability of unhealthy foods and the lack of availability of healthy foods. Unhealthy foods were dictated by family members’ preferences, which adolescents reported having no control over. This visibility of unhealthy foods, coupled with an insufficient abundance of healthy foods at the home, the increased cost of healthy foods, and the presence of unhealthy foods in their surroundings (e.g., school cafeteria, workplace, restaurants) further added to the challenge of healthy eating. This is demonstrated by the following quote: “So it’s harder to like go to the store, buy an apple, if we don’t have any, and pay for it than it is to just like, I’m just going to grab a bag of chips because they’re about the same price and they taste better or just as good.”–Daniel

In some households, parents of adolescents ensured that a system was set in place for healthy eating. Adolescents described valuing this approach, which included availability of healthy premade foods at the home and the unavailability of unhealthy foods.

Physiological mechanisms and physical health status.

Adolescents described multiple reasons for limited physical activity. For instance, adolescents experienced physical discomfort due to a number of factors (e.g., knee pain, feeling tired / lack of sleep, side effects of medications taken for mental health). As quoted: “I think, because I’ve always been bigger, like even when I was younger, I was skinny, but I was well-built. Like, I have big… I’ve got wide shoulders, broad hips, and all that. So, I don’t know. I find running uncomfortable and I’m busty, so when I run, it’s uncomfortable.”–Eliza

Self-regulation for behavior change.

Many adolescents attributed their low levels of physical activity to preferential factors (e.g., dislike of organized sports, especially running), and commented broadly on their behavioral regulation: “Now I realize it’s not really my family stopping me. It’s me. So even though it’s like a bit easier now that I can, I have some opportunities. It’s just kind of me stopping myself from going.”–Dipti

When not active, adolescents described a preference to sedentary activity, especially using digital technology, including social media. Adolescents also attributed their sedentary behaviors to their upbringing, lack of parental monitoring, feeling bored, and immediate gratification and enjoyment.

Some adolescents shared numerous examples to suggest that they practiced self-regulation, where they established a set routine for their physical activity, avoided excessive sedentary time, and thus heightened their chances of participating in physical activity. As one adolescent stated: “Routine really plays a big role because once you maintain one thing, it stays with you for the rest of your life so yeah.”–Zaid

Controllability and competence beliefs.

In addition to logistical (e.g., lack of time and practice) and personal (e.g., perceived lack of skills) factors, adolescents shared not having control over their mental health, which was reported to be a major barrier to being active. The following quotes reflect this reality:

“Um, anxiety and, uh, kind of just feeling down. It’s, um, kind of plays a huge role I know, because I’m always nervous, I’m always paranoid. That’s the main thing stopping me from going out. And then there’s the depression, which makes me tired all the time and then it makes me lose my reason to do anything. And, um, yeah it kind of just, um, traps me to doing nothing, just staying inside […] School isn’t really that bad anymore, I guess. It just, everyday, it seems to get worse for some reason. I don’t really know why, it’s just kind of in my brain.”–Dipti

“Just anxiety in general because sometimes it just makes me not want to get out of bed because the world is a mess and that kind of thing.”–Ace

According to adolescents, and as can be seen by the following quotes, they further lacked control on how to handle their anxiety and depression due to dismissal from parents:

“Um, I have a really low self esteem so I don’t really, um, love myself that much and I don’t feel loved by others that much, either. So that kind of ties into depression and anxiety because no one loves me anymore, is just kind of screaming in the back of my mind […] They don’t have the time for me anymore and if I try to tell them [parents] something, they always brush it off like it’s nothing, so.”–Dipti

“I try to bring up the thought of me maybe having anxiety too, really, when ‘It’s nothing, get over it, just stop things for a bit’ and I was like cool! Ha-ha! No.”–Ace

Adolescents also described a perceived lack of control over their sedentary activity in the context of not realizing the amount of time spent being sedentary. This can be seen in the quotes below:

“I lose track of time when I’m playing [video games]. It’s kind of hard for me to stop.”–Dipti

“You start playing [video games], and because you’re playing, you become tired. When you get to bed, you can’t sleep. You get up, you play again to make yourself tired again, but with this, you can be here for like 11 hours, 12 hours. You can stay here for an entire evening.”–Dominic

Motivation was described by some adolescents as an important enabling factor of being physically active. They explained how they were motivated either by instant (e.g., enjoyment, feeling energized, relieving stress and anger) or delayed (e.g., avoiding long-term health consequences, losing weight) gratification. For example: “If it’s fun, like… if it’s not fun, I don’t think that I would be interested. I won’t really try to do it.”–Abdi

Social relationships and interactions.

Many adolescents described barriers to physical activity experienced in social settings related to mental health problems and interpersonal relationships. For example, adolescents described how they avoided physical activity in public for concerns of feeling watched, judged, and embarrassed if unfamiliar with the sport or equipment. Adolescents shared how these feelings were sometimes driven by learned helplessness; that is, previous negative experiences with Physical Education teachers threatening to lower grades when wearing baggy clothes, and peer judgments. Further, some adolescents indicated that the lack of peer and parental involvement in physical activity discouraged them from being physically active. For example: “A lot of my friends have very high metabolism, so it’s like they don’t have to exercise or anything, so we’ll just sit around and watch Netflix so that doesn’t help and that’s pretty much it.”–Chloe

For numerous adolescents, use of digital technology was seen as an escape from reality and an alternative to social interaction. As one adolescent stated: “Yeah, I really don’t like to think about what is going on in real life sometimes, so I have a better life in video games than this one.”–Dipti

Whereas some adolescents discredited verbal encouragement from family and peers regarding food and nutrition, they explained that they benefited from verbal encouragement and support for physical activity. For example, when adolescents were encouraged to commit to organized programs or plans, especially those that were more challenging and competitive, they explained that they were more likely to be motivated to persist with their activities. As one adolescent shared: “If someone told me, go to the gym every second day, I’d be like, why? Then, if someone told me, come to the gym every second day, get help with a personal trainer, and push your limits, that sounds a lot more fun.”–Daniel

Accessibility to and availability of opportunities for lifestyle enhancement.

In addition to having to depend on parents for transportation, some adolescents noted that the lack of safety of their neighborhood prevented them from performing activities by the home. The weather, with temperatures ranging across the spectrum, was also considered a barrier to being active. For example: “Even though I really don’t because then I complain about it being too cold out because I don’t really like putting all these winter clothes on and having to take them back off, so it’s like even in the winter if the sun is out, it’s not, it’s just I hate the sun. Like I look at it and I shame it, I won’t look at it whatsoever.”–Nixy

Those who had more facilitated means for physical activity (e.g., equipment at home, school gymnasiums) commented that it was advantageous in helping them be active.

Self-regulation for behavior change.

Adolescents shared examples to suggest a lack of structure was dependent on their schedules (e.g., flexibility during non-school periods or work commitments) or their parental involvement (e.g., limit-setting). As one adolescent admitted when asked about the reason for her delayed bedtime the night before the interview: “I just stayed up and was like on my phone and reading some books and watching TV and then all of a sudden it was three a.m. and I was like oh, I guess I should go to sleep.”–Courtney

Many adolescents described being aware of the influence of screen time on sleep with advice from their HCPs. These adolescents described following a regular sleep schedule by outlining a specific sleep time and digital curfew. Other suggested contributors to better sleep included coping mechanisms via medications or audio books or next-day commitments. For example: “People think I’m completely irresponsible, but it’s summer right now. My parents can’t really make that excuse that I have to wake up early and I have really nothing to worry about, but then when it’s school, I really have a lot of things to worry about, so I try to go to sleep. It’s just one less thing.”- Dipti

Controllability and competence beliefs.

Adolescents described not having control over their sleep time (e.g., poor bladder control during sleep, anxiety, depressive thoughts, emotional distress). As one adolescent shared: “My sleeping is okay, although sometimes I got like, I wake up and I stay up a few hours, but I think that’s kind of normal […] I stayed up a bit later. That’s not really a problem because it’s kind of what everyone does.”–Dipti

Social relationships and interactions.

Adolescents also reported social barriers to sleep, including the use of technology before bed to connect with their social circle or not having any parental restrictions, leading to poor sleep quality and duration. This is demonstrated by the following quote: “Because I don’t, like my parents don’t force me to go to bed so I can just do what I want. I mean they don’t force me to go to bed now because I just tell them that I stuff to do.”–Nixy

This reality is compared with other households, where parents were said to have a more supportive role in reminding adolescents of their commitments and the need for sleep to be energized.