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Obesity in adolescents and children has risen to significant levels globally with serious public health consequences (WHO, 2000). The prevalence of child and adolescent obesity has increased dramatically in recent years in the Kingdom of Saudi Arabia (KSA). In a recent study, estimates of combined overweight and obesity prevalence among Saudi adolescents aged 13-18 years were 36.6% for males and 38.4% for females (El Mouzan et al., 2012). Gender differences are evident in the prevalence of overweight/obesity in Saudi Arabia (Mahfouz et al., 2011). The rates of obesity are increasing more in women (Bakhotmah, 2012) than in men (Al-Nozha et al., 2007; Al-Othaimeen et al., 2007; Al-Hazzaa, 2004). It is assumed that the development of child and adolescent obesity is associated with the modern environment and personal lifestyle choices (Stewart et al., 2012; Dehghan et al., 2005). While prevention of obesity is paramount, most preventive interventions have had only a modest effect, and there is a need to offer weight management interventions for adolescents who are already obese (Luttikhuis et al., 2009; Collins et al., 2006).
On the other hand, PA is the most important aspect of any obesity treatment programme, because PA results in energy expenditure, which plays a fundamental role in the regulation of body weight and the prevention of obesity (Bonomi & Westerterp, 2012; Duncan, 2007).
The Gulf Cooperation Council (GCC) countries including the KSA have witnessed significant lifestyle changes due to dominance of the automobile for personal travel, availability of high fat and dense-caloric foods, satellite TV, increased reliance on the computer and telecommunication technology, as well as decreased occupational-work demands. These lifestyle changes have had a considerable effect on reducing the physical requirements of daily life and encouraging sedentary lifestyles amongst both young people and adults, and they have become responsible for the emerging obesity in children and adolescents as a major public health issue in these countries (Rasoul et al., 2012; Al Hazzaa et al., 2011; El-Hazmi et al., 2002; Epstein et al., 2000). There is a relationship between the two epidemic problems: obesity and physical inactivity. Significant associations between BMI, PA and sedentary behaviours were widely reported.
Youths with higher BMI reported lower levels of PA and longer periods of sedentary time (Al-Nakeeb et al., 2012; Gourlan et al., 2011).
Locally, the high prevalence of sedentary behaviours, physical inactivity and unhealthy dietary habits among Saudi adolescents is a major public health concern Data using objective physical activity measurements indicated that 60% of Saudi children and 71% of youths fail to engage in health-enhancing PA of sufficient duration and frequency (Al Hazzaa et al, 2011). Moreover, the proportion of Saudi children and adults who are at risk of coronary heart disease due to inactivity is much higher than for any of the other coronary heart disease risk factors (Al Hazzaa, 2002). Guidelines state that all adolescents aged between 11 and 21 should be active every day for at least 30 to 60 minutes as part of play, games, sport, work, transportation, recreation, physical education, or planned exercise in the context of family, school, or community activities (WHO, 2010; Hallal et al., 2012; de Moraes et al., 2013). Adolescents who did not meet the PA guidelines for youths of 60 minutes/day moderate-to-vigorous physical activity (MVPA) increased their risk of obesity (Gomez et al., 2010; Deforche et al., 2010).
Clinic-based weight loss interventions can lead to successful improvements in BMI and other metabolic parameters in paediatric populations and may be more likely among adolescent females than in younger children or males (Walker et al., 2012; Dyson, 2010). Several lifestyle factors associated with obesity may represent valid targets for the prevention and management of obesity among Saudi adolescents (Al Hazzaa et al., 2012). In other words, lifestyle interventions can lead to improvements in weight and cardio-metabolic outcomes (Huang et al., 2007). Paediatric weight management clinics offer a multidisciplinary holistic approach to the obesity epidemic. These clinics typically involve weekly to monthly visits with a focus on lifestyle changes that include behaviour modification, improved nutritional intake and increased PA (Halvorson et al., 2012; Hughes et al., 2006).
1.1 Purpose of the Study
i) To compare PA performance between obese adolescents and weight managed obese adolescents enrolled in an obesity treatment programme.
ii) To examine whether gender affects adolescents’ response to an obesity treatment programme.
iii) To measure the effectiveness of obesity treatment programme by measuring PA differences between groups and BMI changes in the weightmanaged group.
iv) To determine the sedentary behaviours and lifestyle characteristics of obese adolescents referred for a clinical obesity treatment programme.
1.2 Research questions
- Is there a difference in the performance of PA between obese adolescents and obese adolescents enrolled in a weight management programme?
- Does gender affect adolescents’ responses to an obesity treatment programme?
- Does PA performance increase and BMI decrease with enrolment in a weight management programme?
- What are the sedentary behaviours and lifestyle characteristics of obese adolescents who referred to obesity clinic?
This study aims to verify the following three major hypotheses:
- PA performance will be greater in the treatment group than the control group.
- Boys’ participation in PA will increase more than girls’ participation in PA after a treatment programme.
- The obesity treatment programme will positively influence participation in PA and effectively reduce BMI.
1.4 Significance of the study
Obesity is considered a global epidemic and a major risk for chronic diseases (Cole et al., 2000). When energy intake exceeds energy expenditure, the fat cells increase and stimulate cell proliferation; an increased number of cells leads to obesity (Carvalhal et al., 2007; Kelly et al., 2013).
Lifestyle modification interventions including behavioural treatment, diet modification and PA are the cornerstones of primary and secondary prevention/treatment of paediatric obesity (McGovern et al., 2008; Danielsen et al., 2013; Hughes et al., 2006). Despite the importance of treatment interventions for adolescent obesity, recent systematic reviews have found almost no evidence on treatment interventions outside the western world. Specifically, the recent Cochrane review conducted by Luttikhuiss and colleagues (2009) found 29 eligible trials of adolescent obesity treatment, none of which were from the Arab world.
PA is the most important aspect of the obesity treatment programme, because PA results in energy expenditure (Cliff et al., 2010; Gourlan et al., 2011).
Unfortunately, epidemiological evidence suggests that activity levels begin to decline during the teen years, when daily PA decreases at a rate of about 2.7% per year for males and 7.4% for females (Sallis et al., 2000). Similarly, according to Rowlands & Eston (2007), the decline in PA rates is more dramatic among teenage girls than boys. At age 13, only about 6% of all teens report no PA, but by the age of 19, 25% of all girls and 20% of all boys report no PA at all. In addition, PA provides adolescents with important physical, mental and social health benefits (WHO, 2002).
Measuring PA following obesity treatment is important for understanding how treatment affects behaviour that influences energy expenditure. However, studies evaluating the effect of adolescent obesity treatment trials on PA are limited in both quantity and quality (Cliff et al., 2010). The National Obesity Observatory (NOO, 2012) shows a lack of evidence about what works to prevent obesity. Therefore, it is essential to examine the types of interventions that are effective for obesity treatment (Dinsdale et al., 2012; Lee et al., 2010).
Furthermore, studies about PA levels among Saudis remain inadequate. To our knowledge, there are no published studies measuring PA levels among obese adolescents after an intervention.
1.5 Definition of Terms
Adolescents: The period in human growth and development that occurs after childhood and before adulthood, from ages 10 to 19. It represents one of the critical transitions in the life span and is characterised by a tremendous pace in growth and change (Dagkas et al., 2007).
Obesity: An excess accumulation of body fat that impairs health (WHO, 2000).
Physical activity: Any bodily movement produced by skeletal muscles resulting in energy expenditure (Berlin et al., 2006).
Diet modification: Can be in the form of increased or decreased total amount of food consumed, limiting the time food or liquid is available, or an increase or decrease in an element of the diet (Croaker et al., 2012).
Behavioural modification: The use of basic learning techniques, such as conditioning, biofeedback or reinforcement to alter human behaviour (Swinburn et al., 2008).
Lifestyle modification: The typical way of life of an individual. The therapeutic use of lifestyle interventions in management of obese people that include behavioural treatment, diet modification and PA (McGovern et al., 2008).
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