بسم الله الرحمن

الرحیم

Dr Ali Akbar Sayyari professor of pediatric gastroenterology and

nutritionShahid Beheshti

University of medial science

Leptin

Adiponectin Resistin

Angiotensinogen

IL-6

TNF-Alfa Cortisol

Stored Triglycerides

• Fat cells are continually absorbing or releasing substances in response to the body’s energy needs

• Fat cells are better adapted to preserving calories than shedding them

Fat Cell

Etiologic considerations for overweight children and adolescentsEndocrine disorders:Cushing syndromeHypothyroidismPseudo hyperparathyroidismType2 diabetesGenetic syndromesPrader- Willi syndromeBardet-Biedel syndromeCohen syndromeCentral Nervous system disordersHypothalamic tumorTraumaInflammationMiscellaneousDrug-induced (e.g., resperidone, tricyclic, antidepressants)Bring eating disorderBulimia nervosa

0

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8

10

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14

16

1976-80 1988-94 1999-00

Male

Female

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2

4

6

8

10

12

14

16

1971-74 1976-80 1988-94 1999-00

Males

Females

0

2

4

6

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10

12

14

16

1971-74 1976-80 1988-94 1999-00

Males

Females

Prevalence of overweight and obesity in children

Selected surveys on overweight/obesity in IranSelected surveys on overweight/obesity in Iran

Investigator(s)Investigator(s)Year/LocationYear/LocationSample SizeSample SizeAgeAgePrevalencePrevalence(%)(%)

OverweightOverweightObesityObesity

TehranianTehranian10-1910-19 yearsyears

M:11.8M:11.8

F: 13.3F: 13.3

M: 6.9M: 6.9

F : 4F : 4

TotalTotal10-1910-19

yearsyears

12.612.65.45.4

Ashrafi et alAshrafi et al2000-012000-01//Tehran Tehran CityCity

378237826-146-14 yearsyearsUM:5-12UM:5-12UM:3-5UM:3-5

Mohammadpour et Mohammadpour et alal..

20002000//Tehran cityTehran city2321232111-1711-17UM:18.8UM:18.8

UF:23.1UF:23.1

UM:7.3UM:7.3

UM:8.3UM:8.3

GhavamzadehGhavamzadeh20022002//Urmia cityUrmia city396139616-176-17 yearsyearsUM:13.4UM:13.4

UF:15.1UF:15.1

UM:5.5UM:5.5

UF:4.6UF:4.6

Veisi & KarandishVeisi & Karandish20022002//AhwazAhwaz395939596-176-17 yearsyearsUM:18.0UM:18.0

UF:17.0UF:17.0

UM:9.2UM:9.2

UF:5.7UF:5.7

Investigator(s)Investigator(s)Year/LocationYear/LocationSample Sample SizeSize

AgeAgePrevalencePrevalence)%()%(

OverweightOverweightObesityObesity

National Study National Study 20032003

6-186-18 yearsyears

3.43.4

Sayyari et alSayyari et al..19991999//NationalNational3420034200Under-Under-55

M:4.6M:4.6

F:4.1F:4.1

Nour-Balaa & Nour-Balaa & MohammadMohammad

19991999//NationalNational417741772-52-5 yearsyearsUM:11UM:11

RM:6.9RM:6.9

UF:9UF:9

RF:7.3RF:7.3

Ashrafi et alAshrafi et al2000-012000-01//Tehran Tehran CityCity

378237826-146-14 yearsyears

UM:5-12UM:5-12UM:3-5UM:3-5

Mohammadpour Mohammadpour et alet al..

20002000//Tehran cityTehran city2321232111-1711-17UM:18.8UM:18.8

UF:23.1UF:23.1UM:7.3UM:7.3

UM:8.3UM:8.3

GhavamzadehGhavamzadeh20022002//Urmia cityUrmia city396139616-176-17 yearsyears

UM:13.4UM:13.4

UF:15.1UF:15.1UM:5.5UM:5.5

UF:4.6UF:4.6

Veisi & KarandishVeisi & Karandish20022002//AhwazAhwaz395939596-176-17 yearsyears

UM:18.0UM:18.0

UF:17.0UF:17.0UM:9.2UM:9.2

UF:5.7UF:5.7

The etiology of obesity includes both

genetic and environmental factors

Dietary factors Psychosocial stressors Genetic Factors behavioral factors Exercise style Culture Disorders/ endocrine/

Energy Energy IntakeIntake

EnergyEnergyExpenditureExpenditure

High fat, High fat, high-calorie diethigh-calorie diet

GeneticGeneticPredispositionPredisposition

Sedentary Sedentary lifestyle lifestyle

Etiologic considerations for overweight children and adolescentsEndocrine disorders:Cushing syndromeHypothyroidismPseudo hyperparathyroidismType2 diabetesGenetic syndromesPrader- Willi syndromeBardet-Biedel syndromeCohen syndromeCentral Nervous system disordersHypothalamic tumorTraumaInflammationMiscellaneousDrug-induced (e.g., resperidone, tricyclic, antidepressants)Bring eating disorderBulimia nervosa

• Environmental factors play a significant role in the development of obesity

• Genetic influence on adipose tissue accumulation and distribution • More than 300 genes, markers and chromosomal regions have been associated or linked with human obesity

Obesity GeneticsObesity Genetics

Leptin

Adiponectin Resistin

Angiotensinogen

IL-6

TNF-Alfa Cortisol

Stored Triglycerides

• Fat cells are continually absorbing or releasing substances in response to the body’s energy needs

• Fat cells are better adapted to preserving calories than shedding them

Fat Cell

Environmental factors (lifestyle) and cultural or socio-economic conditions

Psychological factors Metabolic factors Drugs (high dose glucocorticoids) Secondary to a variety of

neuroendocrine disorders

Certain group of people are more likely to become obese. Risk factors include:

• High-fat, high-energy diets• Sedentary lifestyle/physical inactivity

• Family history• Ethnicity• Genetic

• Age• Stopping smoking

Obesity increases the likelihood of: type 2 diabetes (majority are obesity-related) cardiovascular diseases (CHD, MI, and stroke) several types of cancer gallbladder disease sleep apnea osteoarthritis perhaps others (e.g., Alzheimer's,

depression, back pain) Responsible for a bunch of deaths each year

2.52.5

2.02.0

1.51.5

1.01.0

002020 2525 3030 3535 4040

BMIBMI

MortalityMortalityRatioRatio

VeryLow Low Moderate High Very

High

MenMenWomenWomen

Assessment of the obese

child and adolescent

ProcedureDescription ValidationComments

Body mass index (BMI)

BMI is defined as weight (kg) /height squared (m2), and is widely used as an index of relative adiposity among children, adolescents and adults. For children, various cut-off criteria have been proposed based on reference populations and different statistical approaches

BMI has been compared with dual-energy X-ray absorptiometry (DEXA). True positive rate of 0.83 for 10–11 year olds, 0.67 for 12–13 year olds and 0.77 for 14–15 year olds, while the false positive rate ranged from 0.03 in 12–13 year olds to 0.13 in 10–11 year olds.

BMI is more accurate when height and weight are measured by a trained person rather than self-reported. BMI may not be a sensitive measure of body fatness in people who are particularly short, tall or have an unusual body fat distribution, and may misclassify people with highly developed muscles

International cut off points for mass index for overweight and obesity by sex between 2 and 18 years, defined to pass through body mass index of

25 and 30 kg/m2 at age 18, obtained by averaging data from Brazil, Great

Britain, Hong Kong, Netherlands, Singapore, and United States.

BMI/ Age percentileInterpretation

< 5thUnder weight

5-85th Normal

85-95th Overweight

>95thobese

HistoryGeneral historyPregnancy details and birth weight, including maternal gestational Pregnancy diabetesEarly medical historyEthnicityWeight historyHistory of development of obesity, including onset durationPubertal historyImpact of obesity on the young person's life and in the family complication historyPsychological effects of obesity, including teasing and bullyingPresence of sleep apnoea/ disturbed sleep.

ExaminationHeightWeightWaist circumferencePubertal stage( according to Tanner)Blood pressure (use appropriate- sized cuff and age norms)Acanthosis HepatomegalySpecific symptoms, such as knee or hip painMenstrual history (girls)Exercise tolerance

Family's weight and metabolic historyBMI or BMI percentile for first- degree relativesRelative weights of other family membersFamily history, including obesity, types 2 diabetes,

cardiovascular and cerebrovascular disease or obstructive sleep apnoea

•Life style history Daily physical activities, including sports

participationDaily sedentary activities (e.g., TV, video

games, computer use)Dietary history, including normal meal

pattern, fast- food intake and snakesStriate, intertrigo Gait and mobility

Social historyComposition of the home nuclear family

Location of meals and snacks

Participation in organized sports

Hours per week of physical education

Home exercise equipment

Hours of television viewing per day plus location of TVs in home

Computer/video game activity

Formation of appropriate peer group

Laboratory assessment of children with BMI>95th centile should include:

Thyroid and liver function tests, fasting glucose, insulin, and lipid profile

Periodic oral glucose tolerance tests from age 10 for those at increased risk of the metabolic syndrome

Screening for other co morbidities, e.g. hypertension, sleep apnoea problems, etc

Prenatal Care: appropriate weight gain, glycemic control and tobacco cessation during pregnancy to prevent… Small for Gestational Age Large for Gestational Age

Birth to One Year:exclusive breast feeding to 6 month-complementary food at 6 months and limit juice.

One to Two Years: Wean from bottle at 12 months, limit TV, avoid using food as a reward and “clean the plate.”.

Two to Five Years: low-fat/at 2 years, no TV in bedroom,–

Prevention & Early Intervention StrategiesPrevention & Early Intervention Strategies

RREGIONALEGIONAL H HEALTHEALTH E EDUCATIONDUCATION

Family strategies for prevention obesity in children

Breast- feeding

Reduction of television time

Feeding interaction

Parents decide what children are offered

Children decide weather to eat it or not

No encouragement to eat

No forbidden foods

Small portions

Family meals

Dietary changeAvoid severe food restrictionReduce energy intakeReduce portion size Select foods with lower fat content and low glycaemic

indexIncrease vegetable and fruit intakeReduce high- sugar foods and drinksUse water as the main beveragez

چربي و قند

1.Increase physical activity2.Incidental activity3.Lifestyle activity4.Exercise programs5.Active transport (walking,

cycling)

Decreased sedentary behaviorReduce time spent watching

television, playing computer games, using other electronic mediaEncourage alternatives to

motorized transport

Family involvementBehavior change needs to involve the

whole family, and provide support for the child

Developmentally appropriate approachPreadolescent children: focus on parents as the agents of changeAdolescent: parents and adolescent attend separate sessions

Community- Based prevention programs

School-based prevention programs

Classroom curriculum intervention

School food service intervention

Physical education intervention

The approach to therapy and aggressiveness of treatment should be based on risk factors, including: Age Severity of obesity and morbidities Family history and support

Primary goal for all children with uncomplicated overweight is to achieve healthy eating and activity pattern

For children with secondary complication, improvement of complication is an important goal

چربي و قند

2-7 years with BMI>= 95% without complication

Maintenance of baseline weight, allowing the child to” grow into” their height, with gradual normalization of BMI

2-7 years with BMI>= 95% with secondary complication

Weight loss is indicated

>7 years with BMI between 85th and 95 percentile, without complication

Weight maintenance is an appropriate goal

>7 years with BMI between 85th and 95 percentile, with secondary complication

Weight loss is recommended, and appropriate goal is 1 lb weight loss per month until a BML less than 85th percentile is achieved.

DRUGS (FDA approved over 16 years) SIBUTRAMINE Inhibition of serotonin and

noradrenalin reuptake side effects: dry mouth, constipation,

insomnia ORLISTAT Selective inhibitor of pancreatic lipase Side effects: Fecal fat loss, Decrease

in fat soluble vitamins

Summary of recommendationDefinitionsThe following definitions for obesity should be used:

BMI>95th centile on national charts) for clinical purpose, BMI>85th centile for overweight

IOFT cut offs for epidemiological purpose and international comparison

Preventive strategies

Action is required antenatally, in schools, community facilities, marketing, government, and regulatory agencies

ScreeningPopulation screening is required to identify children with BMI>85th centile

AssessmentLaboratory assessment of children with BMI>95th centile should include:

Thyroid and liver function tests, fasting glucose, insulin, and lipid profile

Periodic oral glucose tolerance tests from age 10 for those at increased risk of the metabolic syndrome

Screening for other co morbidities, e.g. hypertension, sleep apnoea problems, etc

TreatmentChildren with BMI> 85th centile should receive regular lifestyle counseling

Children with BMI> 95th centile require specialist care

Service development

Children with comorbidity or severe obesity should receive their care in a multidisplinary specialist service

RREGIONALEGIONAL H HEALTHEALTH E EDUCATIONDUCATION

Weight InterventionsWeight Interventions