Treatment of severe obesity in adolescents; a mixed method approach
Adolescent obesity is a public health problem associated with significant immediate and long-term health complications (Kelly et al. 2013). Amongst obese adolescents, a third are severely obese (BMI >99.6th centile UK90 reference charts) (Ogden et al. 2012) with severe obesity the fastest growing classification in this age group (Wang et al. 2011). The evidence for managing and treating child and adolescent obesity generally is poor, with multidisciplinary lifestyle programmes failing to derive significant and sustained weight loss and often reporting high attrition (Luttikhuis et al. 2009). Furthermore, this evidence has predominantly focused on young people as a whole with little differentiation of treatment and outcomes by age and severity of obesity. As a result, successful treatments for severely obese adolescents are lacking with permanent bariatric surgery increasingly considered. This thesis aimed to enhance the understanding of the needs of obese adolescents, contribute to what is known about current treatment options for severely obese adolescents specifically and pilot a novel treatment approach within this population. A qualitative enquiry (Study 1) of the lived experiences of obese adolescents (n = 12) reinforced the complexity of the impact of obesity on the lives of obese adolescents across social, emotional, behavioural and cultural contexts. All participants experienced low self-esteem and feelings of shame and there were frequent accounts of debilitating bullying. Adolescents required intensive support to develop skills for coping and managing emotional choices, and the importance of family-support within treatment was highlighted. Data confirmed weight loss programmes need to consider the complex experience of obese adolescents in their design, focusing on how to implement long-term lifestyle changes into their ‘real’ lives. Informed by the findings from Study 1 and a comprehensive review of existing treatment options for severely obese adolescents, the use of an intra-gastric balloon alongside a lifestyle support programme (BOB; Study 2) to promote weight loss was piloted in 12 severely obese adolescents (5 males, 7 females; mean age 15 yrs; BMI >3.5 SD; puberty stage 4 or above). Mean weight loss at 12 months (n=9) was 3.05 kg ± 14.69; d=0.002 with improvements in psychosocial health, physical activity and cardiorespiratory fitness also maintained at 12 months. Although, the use of an intra-gastric balloon as an adjunct to a lifestyle programme was well tolerated by participants, large variations in outcome data suggest alternative treatment solutions in this population are warranted. That said, the comprehensive reporting of the intervention and the focus on validated behaviour change techniques to support change is a strength of this study. The qualitative experiences of treatment for participants and their family members were captured throughout treatment (Study 3). All participants acknowledged the experience was harder than anticipated, but recognised the importance of creating shared ownership over making lifestyle changes. Single case data pointed to successful and sustained weight loss where the whole family were actively engaged in treatment, modelling positive lifestyle changes alongside the adolescent. Future studies are encouraged to explore the most effective methods for engaging family members in treatment.
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