Adolescent obesity in Kuwait: consequences and treatment

Background: Obesity is a global problem that resulted from excessive positive energy balance. Decreased physical activity and other dietary, environmental and genetic factors all contribute to its development (Han et al., 2010). On a larger scope, social, economic and cultural factors also predisposed to its occurrence globally (WHO, 2000). Of particular concern is the rise in paediatric obesity with subsequent rise in morbidity during childhood, adolescence and young adulthood, and rise in morbidity in adulthood, including adult obesity, as well as increased risk of premature mortality in adulthood (Reilly and Kelly, 2011, Reilly, 2006). In Kuwait, paediatric obesity prevalence is high and may be continuing to rise in all age groups (Mirmiran et al., 2010, Al-Isa and Thalib, 2008, Al-Isa and Thalib, 2006). Affluence and rapid transformation of Kuwaiti society after the discovery of oil is one theory behind the changes that took place in the dietary and physical activity patterns which could be the main mediators for the obesity epidemic in Kuwait (Ng et al., 2011). However, despite the paediatric obesity problem in Kuwait there is not a widely available treatment solution or attempts to find obesity treatment solutions locally (Al-Isa et al., 2010b). At an international level, effective treatment strategies were traditionally confined to the Western world, particularly the Epstein group in the USA (Epstein et al., 2012, Oude Luttikhuis et al., 2009, Epstein, 1996), though other successful treatment programmes have been published since the early pioneering work of Epstein (Ho et al., 2012). The aim of the thesis was to: a) test the hypothesis that obesity impairs health related quality of life in Kuwaiti adolescents and test the differences in health related quality of life assessed by self-report and parent-proxy report, b) determine the prevalence of cardiometabolic risk factor abnormalities and metabolic syndrome in a sample of obese Kuwaiti adolescents, and c) test the effectiveness of a treatment intervention for adolescent obesity and compare it to a primary care control. Methodology: Chapter 4 describes the health related quality of life study (HRQL) that was conducted at baseline comparing the HRQL between obese and healthy-weight Kuwaiti adolescents (aged 10 to 14 years). Five hundred eligible consenting participants were assessed using the Peds QL™ self-reports as well as 374 parent-proxy reports. From the obese group (n= 224), 82 participants agreed to participate in the National Adolescent Treatment Trial for obesity (NATTO) (chapter 6), an assessor-blinded randomised controlled trial, and were randomised to the intervention programme or primary care control over 6 months. The intervention programme aimed to change sedentary behaviour, diet and physical activity in low intensity doses through 6 hours contact over 24 weeks. At baseline, 80 blood samples were collected from 80 out of the 82 participants from the NATTO study, for the assessment of cardiometabolic risk factors namely C-reactive protein, intracellular adhesion molecules, interleukin-6, fasting blood glucose, fasting insulin, alanine aminotransferase, aspartate aminotransferase, gamma glutamyltransferase, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and adiponectin. Metabolic syndrome was assessed using two criteria modified for use in younger individuals. Results: From the health related quality of life study, obesity was not associated with impaired health related quality of life in regression analysis. In a structured paired comparison of 98 pairs of obese adolescents vs healthy weight peers, impaired health related quality of life reached significance only for the physical quality of life domain (obese group score = 87.5, healthy weight group score = 93.7, 95% CI for quality of life score = -1.5, -9.4, p 0.007). In a paired comparison between parent-proxy vs self-reports for the obese adolescents, physical quality of life score (parent-proxy score 81.3, self-report score 87.5, 95% CI = -3.2, -11.0, p < 0.001), psychosocial score (parent-proxy score 76.7, self-report score 85.0, 95% CI = -4.2, -10.8, p < 0.001) and total score (parent-proxy score 78.8, self-report score 84.8, 95% CI = -4.9, -10.9, p < 0.001) were all significantly lower in the parent reports. The cardiometabolic risk factors with highest prevalence of abnormal values in the sample (n = 80), described in chapter 5, were; aspartate aminotransferase (89% of samples abnormal), insulin resistance by homeostasis model assessment (HOMA) (67% abnormal ), intracellular adhesion molecule (ICAM) (67% abnormal), fasting insulin (43.5%), C-reactive protein (42.5%), low density lipoprotein (LDL) (35%), total cholesterol (34% abnormal), and systolic blood pressure (30% abnormal). Of all participants (n=80), 77 had at least one impaired cardiometabolic risk factor besides their obesity. Prevalence of Metabolic syndrome was 21.3% using the International Diabetes Federation definition and 30% using the Third Adult Treatment Panel definition. At 6 months outcome in the treatment intervention NATTO, the trial had acceptable retention (n =31 from the intervention group and n =32 from the control group), but engagement with both the intervention and control treatment (as measured by attendance at treatment sessions) was poor. The intervention had no significant effect on BMI Z score relative to control, and no other significant effects of the intervention were observed. Conclusion: In a sample of obese Kuwaiti adolescents, obesity was not associated with marked impairment of health related quality of life; however, marked impairment in multiple cardiometabolic risk factors was present. Conducting the National Adolescent Treatment Trial for Obesity in Kuwait was feasible but not efficacious, and future obesity treatment trials should incorporate a qualitative assessment for better participants’ engagement.