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بسم الله الرحمن
الرحیم
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Dr Ali Akbar Sayyari professor of pediatric gastroenterology and
nutritionShahid Beheshti
University of medial science
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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
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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
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0
2
4
6
8
10
12
14
16
1976-80 1988-94 1999-00
Male
Female
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0
2
4
6
8
10
12
14
16
1971-74 1976-80 1988-94 1999-00
Males
Females
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0
2
4
6
8
10
12
14
16
1971-74 1976-80 1988-94 1999-00
Males
Females
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Prevalence of overweight and obesity in children
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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
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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
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The etiology of obesity includes both
genetic and environmental factors
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Dietary factors Psychosocial stressors Genetic Factors behavioral factors Exercise style Culture Disorders/ endocrine/
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Energy Energy IntakeIntake
EnergyEnergyExpenditureExpenditure
High fat, High fat, high-calorie diethigh-calorie diet
GeneticGeneticPredispositionPredisposition
Sedentary Sedentary lifestyle lifestyle
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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
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• 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
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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
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Environmental factors (lifestyle) and cultural or socio-economic conditions
Psychological factors Metabolic factors Drugs (high dose glucocorticoids) Secondary to a variety of
neuroendocrine disorders
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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
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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
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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
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Assessment of the obese
child and adolescent
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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
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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.
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BMI/ Age percentileInterpretation
< 5thUnder weight
5-85th Normal
85-95th Overweight
>95thobese
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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.
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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
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•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
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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
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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
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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
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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
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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
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چربي و قند
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1.Increase physical activity2.Incidental activity3.Lifestyle activity4.Exercise programs5.Active transport (walking,
cycling)
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Decreased sedentary behaviorReduce time spent watching
television, playing computer games, using other electronic mediaEncourage alternatives to
motorized transport
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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
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Community- Based prevention programs
School-based prevention programs
Classroom curriculum intervention
School food service intervention
Physical education intervention
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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
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چربي و قند
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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.
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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
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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
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RREGIONALEGIONAL H HEALTHEALTH E EDUCATIONDUCATION
Weight InterventionsWeight Interventions