KLINIýKI I LABORATORIJSKI NALAZI KOD ADOLESCENATA U ...scindeks-clanci.ceon.rs/data/pdf/1452-0923/2012/1452-09231246106L.pdf · metaboliþkog sindroma. Gojazna deca imaju pove üan

106 MEDICINSKI GLASNIK / str. 106-116

Snežana Lešovi *

KLINI KI I LABORATORIJSKI NALAZI KOD ADOLESCENATA U PROGRAMU „ IGOTICA” OD 2008. DO 2012. GODINE

UVOD: Gojaznost postaje sve zna ajniji problem javnog zdravlja zbog drasti nog porasta njene u estalosti, ne samo u odrasloj ve i u de joj i adolescentnoj dobi, što direktno i indirektno uti e na morbiditet, o eki-vano trajanje života i mortalitet stanovništva. Kao odgovor na epidemiju gojaznosti u Srbiji je 2008. godine formiran Centar za prevenciju, le enje i rehabilitaciju gojaznosti kod dece adolescenata i Program „ igotica“ u Specijalnoj bolnici „Zlatibor“. Karakteristika Programa „ igotica“ je multidisciplinarni pristup le enju gojazne dece, koji podrazumeva speci nu edukaciju, dijetetske intervencije sa smanjenjem ukupnog dnevnog kalorijskog unosa, zi ku aktivnost, klini ku kontrolu i psiho-lošku podršku, promenu ponašanja i stila života.

CILJ: Utvrditi komplikacije gojaznosti i metaboli ke faktore rizika u adolescenata u esnika Programa „ igotica”.

METOD RADA: Antropometrijski, klini ki i biohemijski parametri analizirani su kod 1000 adolescenata (468 devoj ica i 532 de aka), pro-se nog uzrasta 15,30 godina (od 12. do 18. godine) sa dijagnostikovanom primarnom gojaznoš u. Istraživanje je sprovedeno u Centru za prevenciju i le nje gojaznosti kod dece i adolescenata, Specijalna bolnica „ igota“ u periodu od 27.07.2008. do 01.01.2012. godine. Hospitalizacija traje 21 dan. Kriterijum za gojaznost je indeks telesne mase (ITM) > +2 SD. Pored klini kog pregleda, meren je krvni pritisak. Nivo triglicerida, uku-pnog, HDL i LDL holesterola, mokra ne kiseline i glikemija odre ivani su drugog dana hospitalizacije posle 12 h gladovanja.

REZULTATI: Abdominalnu gojaznost de nisanu OS>P90 imaju svi is-pitanici (100%). Hipertenziju ima 28% adolescenata. Akantoza nigrikans

* Prim. Dr Snežana Lešovi Mr Sc pedijatar, Specijalna bolnica za bolesti štitaste žlezde i bolesti metabolizma Zlatibor, e-mail: [email protected]

107KLINI KI I LABORATORIJSKI NALAZI KOD ADOLESCENATA U PROGRAMU „ IGOTICA”...

prisutna je kod 51,4% adolescenata. Vrednosti triglicerida su povišene kod 7,8% ispitanika, snižene vrednosti HDL h ima 22,9% ispitanika, a povišene vrednosti holesterola ima 5,8% ispitanika. Dva faktora rizika za metaboli ki sidrom ima 27,6%, a metaboli ki sindrom 18,3% ispitanika. Poreme aj prometa še era u organizmu ima 8,9% ispitanika. Tri ispi-tanika imaju dijbetes tipa 2 (0,3%). Orotpedske komplikacije ima 82% ispitanika. Sindrom policisti nih jajnika ima 12% adolescentkinja.

ZAKLJU AK: U velikog broja gojaznih adolescenata prisutne su komplikacije, što ukazuje na ozbiljnost problema gojaznosti i potrebu za e kasnijim preventivnim programima. Kratkoro ni efekti programa

igotica ohrabruju, a e kasnost multidisciplinarnog le enja gojaznih adolescenata proceni e teku e istraživanje koje razmatra održivost postignutih rezultata.

Klju ne re i: gojaznost, adolescenti, metaboli ki faktori rizika, insulinska rezistencija, indeks telesne mase (ITM), Program igotica

UVOD

Gojaznost kod dece predstavlja jedan od najve ih javno-zdravstvenih problema u 21. veku, sa naro ito alarmantnim kretanjem u nekim delovima sveta. Razli ite studije u Evropi procenjuju da je 10–30% dece uzrasta od 7. do 11. godine i 8–25% adoles-cenata od 14 do 17. godine prekomerno uhranjeno. Svetska zdravstvena organizacija je 1948. godine prekomernu uhranjenost proglasila za bolest, a procene SZO ukazuju da e do 2025. godine 50% svetskog stanovništva biti gojazno. Savremena saznanja ukazuju na porast incidencije gojaznosti kod dece i adolescenata, a posebno brinu podaci da gojazna deca ostvaruju sve teži stepen gojaznosti i da je do 85% gojaznih adolescenata gojazno i u odrasloj dobi (1).

Nasle e, porodi no okruženje, socio-ekonomske i kulturološke prilike i sva-kodnevne navike uti u na pojavu gojaznosti, pri emu se isti e njihova me usobna interakcija (2). Zanimanje koje zaslužuje gojaznost kod dece posebno je opravdano zbog mogu nosti prevencije komplikacija gojaznosti, ije je le enje zahtevno, mu-kotrpno i esto ne tako uspešno (3). Programi za prevenciju gojaznosti dobijaju na zna aju zbog ograni enih mogu nosti njenog medikamentoznog i posebno hirurškog le enja u de joj dobi (4, 5).

Gojaznost kod dece povezana je sa pove anim rizikom nastanka brojnih metabo-li kih komplikacija kao što su insulinska rezistencija, poreme ena tolerancija glukoze i dijabetes tipa 2. Povišeni ITM (indeks telesne mase) u detinjstvu glavni je generator metaboli kog sindroma. Gojazna deca imaju pove an rizik za nastanak ortopedskih, respiratornih bolesti i psiholoških problema (4). Pored brojnih komplikacija, gojaznost je uzrok velikog ekonomskog optere enja kroz smanjenje produktivnosti i prihoda i na nju otpada 7–12% svih troškova za zdravstvenu zaštitu u zapadnim zemljama (6).


Prevalencija gojaznosti u Srbiji za decu uzrasta do pet godina iznosi 19% prema podacima kancelarije UNICEF-a iz 2005. godine. Prema proceni za 2007. godinu, prekomerna uhranjenost i gojaznost nalazi se u 18% adolescenata, što je u odnosu na u estalost u 2000. godini porast od skoro 50%. Usled kontinuiranog porasta broja gojazne dece u Srbiji, a u svrhu prevencije gojaznosti i promena navika u ishrani i stila življenja, Udruženje pedijatara Srbije je, u saradnji sa Specijalnom bolnicom „Zlatibor” koja ima dugogodišnje iskustvo u le enju i rehabilitaciji gojaznosti kod odraslih, izradilo u julu 2007. godine Projekat “Prevencija i le enje gojaznosti kod dece i adolescenata u Srbiji”. Republi ki zavod za zdravstveno osiguranje uz pokro-viteljstvo Ministarstva zdravlja odobrilo je u prole e 2008. godine le enje i rehabili-taciju gojaznoj deci uzasta od 12 do 18 godina u trajanju od 21 dan jedanput godišnje i osnivanje Centra za prevenciju, le enje i rehabilitaciju prekomerno uhranjene i gojazne dece i adolescenata u kompleksu Specijalne bolnice „Zlatibor”. Odlukom Republi kog zavoda za zdravstveno osiguranje od maja 2012. le enje gojazne dece u Centru traje 10 dana.

U Centru se obavljaju dijagnosti ka ispitivanja i le enje u kome u estvuju: pe-dijatar endokrinolog, specijalista zikalne medicine, psiholog, nutricionista, profesori zi kog vaspitanja i medicinske sestre. Jednom u 3 meseca profesori pedijatri-endo-

krinolozi iz Beograda i Niša obavljaju konsultacije i vrše vizite u Centru. Uz stru ni nadzor pacijenti dobijaju plan ishrane i zi kih aktivnosti zavisno od uzrasta, zdrav-stvenog stanja i kondicije, a po potrebi u le enje se uvodi i medikamentozna terapija. Neposredan cilj le enja je posti i dugoro nu- trajnu redukciju telesne mase.

Le enje u Programu igotica zahteva multidisciplinarni pristup koji podrazume-va speci nu edukaciju, dijetetske intervencije sa smanjenjem ukupnog kalorijskog unosa, zi ku aktivnost, klini ku i psihološku potporu i promenu u ponašanju i stilu života.

Klini kim pregledom na prijemu identi kuju se pacijenti sa primarnom i sekun-darnom gojaznoš u i prisutnim komplikacijama gojaznosti, planiraju se dijagnosti ke procedure, planira se ishrana i zi ka aktivnost individualno za svako gojazno dete. Pri otpustu svako dete dobija savete, uputstva i preporuke za dalje pra enje kod nadležnog pedijatra.

Osnovni princip ishrane za gojaznu decu i njihove porodice je uzimanje uravno-teženih obroka, koji obezbe uju nutritivne potrebe organizma koji se razvija i raste. Restrikcija kalorijskog unosa u dece je individualizovana i pomno pra ena da se ne bi kompromitovao normalan rast i razvoj (7, 8). Ukupna dnevna koli ina hrane ras-pore ena je u 5 obroka (doru ak, ru ak, ve era i 2 užine). Sva jela su pripremljena u kuhinji Specijalne bolnice „Zlatibor” pod nadzorom iskusnih kuvara i nutricioniste. Jela se pripremaju u skladu sa osnovnim principima i uputstvima o zna aju pravilne ishrane u prevenciji gojaznosti, a na osnovu inicijalnih dnevnih kalorijskih potreba i zi ke aktivnosti dece. Predavanja nutricioniste i radionice posve ene su pravilnom

izboru namirnica, spremanju obroka, proceni nutritivne i kalorijske vrednosti obroka,


a pri otpustu deca i roditelji dobijaju pisana uputstva i preporuke za ishranu gojazne dece i adolescenata.

Program igotica sadrži šest vrsta zi kih aktivnosti, predavanja i ciljne progra-me društveno-zabavnih aktivnosti. Na osnovu testa za procenu anaerobnih sposobnosti i zdravstvenog stanja planira se program aktivnosti. Planirane zi ke aktivnosti su: šetnje, brzi hod u prirodi, trim stazi ili na kardio- tnes trenažerima; vežbe obliko-vanja, ja anja pojedinih miši nih grupa bez rekvizita i sa rekvizitima (terapeutska lopta, elasti ne trake…), vežbe u vodi, trenažno plivanje, terenske igre, aktivnosti na otvorenom i sportske igre. Fizi ka aktivnost je svakodnevna, raznovrsna, zabavna i prilago ena gojaznoj deci. Fizi ka aktivnost uz hipokalorijsku ishranu doprinosi re-dukciji telesne mase, poboljšava zi ku sposobnost, pomaže u održavanju inicijalno smanjene telesne mase i deca su spremna da se uklju e u standardni program nastave zi kog vaspitanja i motivisana su da unaprede zdravlje. (9, 10).

Program psihološke obrade podrazumeva intervju sa psihologom, upitnik za samoprocenu i psihološku pomo , 6 radionica i podršku u razumevanju i rešavanju problema gojaznosti. Terapijski program koji uklju uje izmenu ponašanja daje znatno bolje rezultate i jedino se promenom životnog stila može posti i dugoro an uspeh. Zato je za uspešan i dugoro an efekat terapije kod dece potreban psihološki pristup usmeren na promenu stavova, uverenja i ponašanja vezanih za ishranu i zi ku ak-tivnost (11).

Predavanja i radionice pedijatra, nutricioniste, psihologa i profesora zi kog vaspitanja, uz razmenu iskustava gojazne dece, doprinose usvajanju novih znanja i stavova u pogledu zna aja pravilne ishrane (izbor zdravih navika u izboru namirnica, smanjenju obroka), zi ke aktivnosti, poboljšanju interpersonalnih odnosa i rešavanju emocionalnih problema kod gojaznih adolescenata.

Cilj rada

Utvrditi prisustvo komplikacija gojaznosti i metaboli ke faktore rizika u ado-lescenata u esnika Programa „ igotica”.

Metod rada

Izvršena je prospektivna analiza 1000 gojaznih adolescenata (468 devoj ica i 532 de aka) prose nog uzrasta 15,3 godine, u esnika Programa „ igotica“, kod kojih je dijagnostikovana primarna gojaznost. Gojazna deca uzrasta od 12 do 18 godina hospitalizovana su 21 dan u Specijalnoj bolnici „ igota“ radi le enja gojaznosti, edu-kacije i rehabilitacije u periodu od 27. 07. 2008. do 01.01.2012. godine. Iz ispitivanja su isklju eni adolescenti sa dijagnozom sekundarne gojaznosti, sa medikamentoznom


terapijom, nemotivisani i adolescenti sa hospitalizacijom kra om od 21 dan. Klini ko pra enje gojaznih adolescenata uklju uje inicijalni pregled, anketu o ishrani i stepenu zi ke aktivnosti, antropometrijsko merenje, EKG, nakon ega sledi upoznavanje sa

osnovnim principima le enja i kontinuirani nadzor pacijenta. Telesna masa, ITM, % masti dobijeni su upotrebom Tanita vage za odre ivanje

telesne kompozicije metodom impedance. Dete pri merenju treba da bude u donjem rublju. Merenje je ujutru pre doru ka i posle pražnjenja creva i bešike. Dobijena vrednost se o itava do najbližih 0,1 kilograma i izražava u kilogramima (na jednu decimalu), a od nje se odbije težina rublja.

Indeks telesne mase (ITM) dobija se kada se vrednost telesne mase izražene u kilogramima podeli kvadratom vrednosti telesne visine izražene u metrima. Dobijeni rezultati su izraženi koz odstupanja broja standardni devijacija (SD) od referentnih vrednosti za odre eni uzrast i pol, predstavljeni kao z-scor i preporu eni od SZO (National Center for Health Statistics – NCHS) WHO Growth Reference. Shodno preporukama, vrednosti z-skora koje ozna avaju prekomernu uhranjenost su u rasponu od +2 SD do +3 SD, a ve e od +3 SD ukazuju na gojaznost (12). Visina tela meri se antropometrom sa postoljem. Pri merenju dete treba da bude boso i gologlavo, le ima naslonjeno na šipku antropometra, sa tako podignutom glavom da donja ivica orbite i tragus budu u istoj horizontalnoj ravni. Horizontalni kliza antropometra se pri merenju spušta do temena, a vrednost visine tela o itava se do najbližih 0,5 cm, i izražava se centimetrima (na jednu decimalu).

Obimi (struk, kuk, nadlaktica i natkolenica) se mere plasti nim nerastegljivim metrom. Vrednosti se o itavaju do najbližih 0,1 centimetra i izražavaju se u centimetri-ma. Krvni pritisak je meren tri puta u sede em položaju na desnoj ruci, odgovaraju om manžetnom. Nivo triglicerida, ukupnog, HDL i LDL holesterola, mokra ne kiseline, kao i glikemija su odre ivani drugog dana hospitalizacije posle 12 h gladovanja. Vrsta i trajanje svake aktivnosti Programa igotica su svakodnevno kontrolisane. Za postavljanje dijagnoze metaboli kog sindroma koriš eni su IDF kriterijumi (Interna-tional Diabetes Federation).

Rezultati

Od 27.07.2008. do 01.10.2012. godine u Centru je hospitalizovano 1900 pacije-nata. Odre en je uzorak od 1000 adolescenata sa primarnom gojaznoš u, prose nog uzrasta 15,30±1,45. Hospitalizacija je trajala 21 dan.

Abdominalnu gojaznost de nisanu OS>P90 imaju svi ispitanici (100%). Krvni pritisak je povišen kod 290 ispitanika (29%). Sistolna hipertenzija je registrovana kod 180 adolescenata (18,00 %), dijastolna kod 95 (9,50%), a sistolna i dijastolna kod 91 (9,1%) adolescenata. Klini kim pregledom registrovano je prisustvo akantoze kod 514 adolescenata (51,4%): kod 265 devoj ica (26,50 %) i 249 de aka (24,9 %)


(gra kon 1). U 51,4% gojazne dece akantoza je prisutna na vratu, pazušnim jamama, preponama i re e na eksornim površinama kolena i lakta.

26,50 %

24,90%

48.60%

DEVOJ ICE

DE ACI

OSTALI

Gra kon br 1. Akantoza nigrikans kod u esnika Programa igotica

Vrednosti triglicerida (>17 mmol/l) su poviše kod 78 ispitanika (7,8%), snižene vrednosti HDL h (<1,00 mmol/l) ima 229 ispitanika (22,9%) i povišene vrednosti holesterola ima 58 adolescenata (5,8%). Poreme aji u regulaciji glukoze su otkrive-ni kod 95 (9,5%) ispitanika, od ega je 61 (6,1%) imao pove anu glikemiju našte. Dijabetes tipa 2 je otkriven kod 3 adolescenta (0,3%).

Kriterijume za dijagnozu metaboli kog sindroma ispunjava 185 ispitanika (18,5%). Dva faktora rizika za metaboli ki sindrom ima 282 ispitanika (28,2%). Jedan faktor rizika (OS>p90) za metaboli ki sindrom imaju svi ispitanici. 39% (390) ado-lescenata ima povišen nivo mokra ne kiseline, a mikroalbuminurija nije odre ena kod svih ispitanika. Ortopedske komplikacije ima 82% ispitanika. Sindrom policisti nih jajnika ima 12% adolescentkinja.

Diskusija

Alarmantno širenje epidemije gojaznosti kod dece i adolescenata, kao i odsustvo proverenih i e kasnih mera i programa prevencije gojaznosti ukazuju na opravdanost formiranja Centra za prevenciju, le enje i rehabilitaciju gojaznosti kod dece adoles-cenata i Programa igotica u Specijalnoj bolnici „ igota“. U Centar se upu uju pre-komerno uhranjena i gojazna deca uzrasta od 12 do 18 godina iz školskih dispanzera i pedijatrijskih odeljenja širom Srbije.

Urbanizacija, industrijalizacija, globalizacija tržišta i ekonomski razvoj uticali su na nagle promene stila života i ishrane („nutriciona tranzicija“). Pove ano konzu-miranja hrane velike energetske gustine i velika potrošnja masti, naro ito zasi enih i nedovoljan unos kompleksnih ugljenih hidrata, povr a i vo a uz sedentarni na in


života i manji energetski rashod, zna ajno su doprineli porastu gojaznosti i u našoj sredini.

Krvni pritisak je povišen kod 290 ispitanika (29%). Udruženost hipertenzije i gojaznosti je davno prime ena. U obe bolesti sre u se sli ni poreme aji regulacije krvnog pritiska koji mogu da pokrenu ili održavaju hiperetnziju. Deca sa hiperten-zijom mogu imati poreme aj glukozne tolerancije, preprandijalnu i postprandijalnu hiperinsulinemiju ili insulinsku rezistenciju. Insulin deluje stimulativno na aktivaciju simpati kog nervnog sistema, renin-angiotenzin-aldosteron sistema i pospešuje re-apsorpciju natrijuma u proksimalnim tubulima bubrega (13). Mnoge epidemiološke studije potvr uju izrazitu korelaciju izme u gojaznosti i arterijske hipertenzije u dece (14, 15). Istraživanje u Kanadi 2012. ukazuje da gojazni de aci imaju za 7,6 mm Hg, ve i krvni pritisak u odnosu na normalno uhranjene vršnjake. Gojazna deca uz nedo-voljnu zi ku aktivnost i pozitivnu porodi nu anamnezu za hipertenziju su u riziku za hipertenziju. Rane itervencije u le enju gojazne dece smanji e broj gojazne dece sa hipertenzijom, a u budu nosti i rizik za kardiovaskularnu bolest (16).

Klini kim pregledom registrovano je prisustvo akantoze na vratu, pazušnim jamama, preponama i re e na eksornim površinama kolena i lakta kod 514 adoles-cenata (51,4%). Akantoza je kožna lezija koja se karakteriše hiperpigmentacijom i hiperkeratozom na pregibnim površinama, a pra ena je neravnom i naboranom kožom (17). Patološke promene prisutne su u epidermisu a odlikuje ih papilomatoza, hiper-keratoza i pove ani broj melanocita (18). Akantoza se nalazi u klini kim stanjima udruženim sa smanjenim delovanjem insulina na elijskom nivou, uzrokovano genskim defektom, insulinskom rezistencijom indukovanom antireceptornim antitelima naj-eš e, ali i patogenetski slabije objašnjenim stanjima insulinske rezistencije prisutne

u gojaznih (19, 20).

Akantoza nigrikans je važan prediktor insulinske resistencije u gojaznih adoles-cenata. Rano identi kovanje dece sa akantozom (skrining?), njihovo pra enje i multi-disciplinarno le enje gojaznosti je neophodno za prevenciju komplikacija, pre svega dijabetesa tipa 2 u dece. Ostale promene registrovane na koži gojaznih adolescenata


su strije, akne, gljivi ne infekcije kože, intertriginozne promene, hiperpigmentacije i hirzutizam.

Gojaznost je jedan od glavnih faktora rizika za razvoj kardiovaskularne bolesti u odrasloj dobi. Neželjeni uticaj gojaznosti ve se u de joj dobi ogleda u promenama u lipidogramu. Vrednosti triglicerida (>17 mmol/l) su povišene kod 78 ispitanika (7,8%), snižene vrednosti HDL h (<1,00 mmol/l) ima 229 ispitanika (22,9%) i povišene vred-nosti holesterola ima 58 adolescenta ( 5,8%). Istraživanje National Health and Nutri-tion Examination Survey (NHANES), od 1999. do 2006, ukazuje da je prevalencija dislipidemije u gojazne dece od 12. do 19. godine iznosila 20.3%. Ve ina komplikacija gojaznosti identneti kuje se u odraslih pacijenata ali deo njih se uo ava ve u dece. Podaci Bogalusa studije pokazuju da gotovo 20 % gojazne dece ima najmanje jedan faktor rizika za pojavu kardiovaskularne bolesti (hiperholesterolemija, hiperinsuli-nemija, hipertrigliceridemija ili hipertenzija) vezanih i za ranu pojavu ateroskleroze. Insulinska rezistencija je naj eš i metaboli ki poreme aj u gojazne dece (21).

Porast u estalosti gojaznosti u populaciji dece i adolescenata povezana je sa ve im rizikom za nastanak dijabetesa tipa 2. Poreme aji u regulaciji glukoze su otkriveni kod 95 (95%) ispitanika. Dijabetes tipa 2 je otkriven kod 3 adolescenta (0,3%). Prisutan poreme aj u regulaciji glukoze ukazuje na rizik za nastanak te bolesti. Gojaznost i insulinska rezistencija kod dece stvara predispoziciju za vaskularne komplikacije u kasnijem životu. Izrazita debljina ve u uzrastu od 9. do 11. godine dovodi do smanjenja elasti nosti karotidnih arterija, a debljina u adolescenciji do zadebljanja intime i medije karotidnih arterija u mladih odraslih osoba (22). Bogalusa studija je pokazala da prevalencija broznih plakova u aorti i koronarnim arterijama raste sa dobi i pozitivno korelira sa BMI z-scorom, koncentracijom triglicerida i holesterola i krvnim pritiskom.

Povišeni ITM u detinjstvu glavni je generator metaboli kog sindroma, koga odlikuju: abdominalna gojaznost, intolerancija glukoze, rezistencija na insulin, dislipidemija (niski HDL holesterol i hipertrigliceridemija), hipertenzija, hroni na in amacija i protromboti no stanje. Metaboli ki sindrom pove ava rizik nastanka dijabetesa i kardiovaskularnog mortaliteta. Oko 24–51% gojazne dece od 12 do 19 godina ima metaboli ki sindrom. Prevalencija metaboli kog sindroma je znatno niža u adolescenata normalne telesne mase (1–3%) u odnosu na gojazne u SAD.

Kriterijume za dijagnozu metaboli kog sindroma ispunjava 18,3% naših ispi-tanika. Dva faktora rizika za metaboli ki sindrom ima 28,2%. Jedan faktor rizika (OS>p90) za metaboli ki sindrom imaju svi ispitanici. Akumulacija abdominalne masti povezana je sa insulinskom rezistencijom, dok osetljivost na insulin slabije korelira s nakupljenom femoralnom i glutealnom supkutanom masti. Akumulacija visceral-ne masti pra ena je rezistencijom masnog tkiva na delovanje insulina i pove anom osetljivoš u na kateholamine. Ovi pacijenti imaju veliki rizik za kardiovaskularnu bolest i dijabetes tipa 2 u odraslom dobu (23, 24). Od kada su utvr eni faktori rizika za nastanak metaboli kog sindroma u dece, ukazala se potreba za skriningom gojazne


dece koja imaju dva ili više faktora rizika i blagovremenim le enjem i spre io razvoj komplikacija.

39% adolescenata ima povišen nivo mokra ne kiseline, a mikroalbuminurija nije odre ena kod svih ispitanika. Gojaznost je rizi an faktor za nastanak hroni nog ošte enja bubrega. Prvi znak ošte enja bubrega je mikroalbuminurija. Ošte enje bu-brega nastaje zbog hemodinamskih i hormonskih promena u gojaznih i sekundarno uz dijabetes tipa 2 i hipertenziju (25).

Pored nabrojanih komplikacija gojaznosti, kod naših ispitanika prisutne su ste-atoza jetre, steatohepatitis, ovarijalni hiperandrogenizam u devojaka i ginekomastija u de aka, holecistitis, holelitiasa, pankreatitis, apneja u snu, stres inkontinencija. Or-topedske komplikacije i tegobe od strane koštano-zglobnog sistema su prisutne kod gojaznih adolesenata. Anamnesti ki podaci ukazuju na este povrede i frakture naših gojaznih adolescenata, a naj eš e se žale na bol u kukovima, kolenima i stopalima. 82% gojazna adolescenta ima jednu od promena na koštano-zglobnom sitemu: defor-mitet ki menog stuba, varus kolena ili ravne tabane. Tri pacijenta su imala epi ziolizu glave butne kosti, a dva Blountovu bolest. Ortopedske komplikacije je potrebno što pre prepoznati u gojazne dece i podsticati ih da se što pre uklju e u alternativne vidove zi ke aktivnosti (bicklizam, plivanje...) (26).

Poreme aj menstrualnog ciklusa uz insulinsku rezistenciju, akne, hirzutizam i akantozu nigrikans, što karakteriše sindrom policisti nih jajnika ima 56 (12%) naših gojaznih adolescentkinja.

Psihološki problemi i naj eš e psihološke posledice gojaznosti: anksioznost, ra-zne fobije, depresivnost, agresivnost, zloupotreba duvana kod naših ispitanika name u da je u procesu l enja neophodna i psihološka pomo i podrška (27).

Potreba za prevencijom gojaznosti proizlazi iz dramati nog porasta njene u esta-losti, ograni enih mogu nosti le enja i direktnog i indirektnog uticaja na razvoj niza hroni nih bolesti koje se javljaju uz gojaznost u sve mla oj životnoj dobi. Gojaznost je udružena sa zna ajnim zdravstvenim problemima u pedijatrijskoj populaciji i važan je faktor rizika morbiditeta i mortaliteta u odrasloj dobi. Stoga pronalaženje na ina koji bi smanjili rastu u prevalenciju njenih sekvela u dece i odraslih predstavlja iza-zov. Prevenciju debljine trebalo bi po eti u ranom detinjstvu, fokusiranjem na zdravu ishranu i zi ku aktivnost (28).

Efekti programa igotica ohrabruju i ukazuju da je multidisciplinarni pristup doveo do zna ajne redukcije telesne mase, normalizovanja krvnog pritiska i metabo-li kih faktora rizika, pove anja aerobnih sposobnosti i samopouzdanja kod gojaznih adolescenata.


Zaklju ak

U velikog broja gojaznih adolescenata prisutne su komplikacije gojaznosti, što ukazuje na ozbiljnost problema gojaznosti i potrebu za e kasnijim preventivnim pro-gramima. Multidisciplinarni pristup le enju programa igotica dovodi do zna ajne redukcije telesne mase, poboljšanja metaboli kih faktora rizika, aerobnih sposobnosti i samopouzdanja adolescenata. E kasnost programa igotica i multidisciplinarnog le enja gojaznih adolescenata proceni e i teku e istraživanje koje razmatra održivost postignutih rezultata.

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Sen Y, Kandemir N, Alikasifoglu A, Gone N, Ozon A. Prevalence and risik factors of 13. metabolic syndrome in obese children and adolescents the role of role of the severity of obesity. Eu J Pediatr (Epub, ahead of print), 2008.Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to 14. cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 1999, 103: 1175–1182.Sorof J, Daniels S. Obesity hypertension in children: a problem of epidemic proportions. 15. Hypertension 2002, 40: 441–447.Yipu Shi, Margaret de Groh and Howard Morrison. Increasing blood pressure and its 16. associated factors, in Canadian children and adolescents from the Canadian Health Me-asures Surve Shi et al. BMC Public Health 2012, 12: 388.Schwartz RA. Acanthosis nigricans. J Am Acad Dermatol 1994;31: 1-19.17. Rogers DL. Acanthosis nigricans. Semin Dermatol 1991;10: 160-3.18. Torley D, Bellus GA, Munro CS. Genes, growth factors, and acanthosis nigricans. Br J 19. Dermatol 2002;147: 1096-101.Eberting CL, Javor E, Gorden P, Turner ML, Cowen EW. Insulin resistance, acanthosis 20. nigricans, and hypertriglyceridemia. J Am Acad Dermatol 2005;52: 341-4.Gerald S. Berenson, MD, Wendy A. Wattigney, MS, Richard E. Tracy, MD, PhD, William 21. P. Newman III, MD, Sathanur R. Srinivasan, PhD, Larry S. Webber, PhD, Edward R. Dalferes Jr., BS, Jack P. Strong, MD. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (the Bogalusa Heart Study) . The American Journal of Cardiology, Volume 70, Issue 9, 1 October 1992, Pages 851–858.Baker JL, Olsen Lina W, Sorensen TIA. Childhood body-mass index and the risik of 22. coronary heart disease in adulthood. N Engl J Med 2007; 357: 2329-37.Klein S. Romijn JA. Obesity. U Kronenberg: Williams Textbook of Endocrinology, 11 th 23. ed. Saunders, Philadelphia, 2008; 1563-80.Haung T, Nansel TR, Belshem AR, Morrison JA. Speeci city, and Predictive Values of 24. Pediatric Metabolic Syndrome Componentis in Relation to Adult Metabolic Syndrome: The Princeton LRC Follow-up Study. J Pediatr 2008;152: 185-90.Morales E, Vlaero A, Leon M. et al. Bene ticial effects of weight loss in overweight 25. patients with chronic proteinuric nephropathies. Am J Kidney Dis 2003;41: 319-27. 26. Erica D. Taylor, Kelly R. Theim, Margaret C. Mirch, Samareh Ghorbani, Marian Ta-nofsky-Kraff, Diane C. Adler-Wailes, at all. Orthopedic Complications of Overweight in Children and Adolescents Pediatrics June 2006;117:6 2167-2174; Dawn K. Wilson. New Perspectives on Health disparities and Obesity Interventions in 27. Youth. J Pediatr. Psychol. 2009;34: 231-44.Bani evi M. Zdravkovi D. Miti D. ur i V. Medicinski pravilnik Centra za prevenciju 28. i le enje gojaznosti kod dece i adolescenata. Zlatibor: Specijalna bolnica za bolesti štitaste žlezde i bolesti metabolizma, 2008.

117CLINICAL AND LABORATORY FINDINGS IN ADOLESCENTS IN ”CIGOTICA” PROGRAMME...

Snežana Lešovi *

CLINICAL AND LABORATORY FINDINGS IN ADOLESCENTS IN ”CIGOTICA” PROGRAMME FROM 2008 TO 2012

INTRODUCTION: Obesity is becoming an increasingly important pu-blic health problem due to a drastic increase in its frequency, not only in adult but also at the pediatric and adolescent age, which directly and indirectly in uences population morbidity, life expectancy and mortality. In response to the obesity epidemic in Serbia in 2008, the Center for the prevention, treatment and rehabilitation of obesity in children and adolescents was formed as well as “CIGOTICA” Programme at the Spe-cial Hospital “Zlatibor”. The characteristics of programs “CIGOTICA” Programme is a multidisciplinary approach to the treatment of obese children, which includes speci c training, dietary intervention with the reduction of total daily caloric intake, physical activity, clinical control and psychological support, change in behaviour and lifestyle.

OBJECTIVE: To identify the complications of obesity and metabolic risk factors in adolescents participating in CIGOTICA Programme.

METHOD: Anthropometric, clinical and biochemical parameters were analyzed in 1,000 adolescents (468 girls and 532 boys), of average 15.30 years of age (range 12 to 18) with primary obesity. The research was conducted at the Center for the Prevention and treatment of obesity in children and adolescents at the Special Hospital “Cigota” from 27 July, 2008 to 1January, 2012. Hospitalization lasts 21 days. The criterion for obesity is the body mass index (BMI)> +2 SD. In addition to clinical examination, blood pressure was measured. Triglycerides, total, HDL and LDL cholesterol, uric acid and glucose were measured on the second day of hospitalization after 12 hours of fasting.

* Prim. Dr. Snežana Lešovi M.Sci, Special Hospital for pediatric thyroid disorders and metabolic diseases Zlatibor, e-mail: @ lsnez eunet. rs


RESULTS: Abdominal obesity de ned as OS> P90 was diagnosed in all examinees (100%). 28% of adolescents had hypertension. Acanthosis nigricans was present in 51.4% of adolescents. Triglyceride values were high in 7.8% of patients, lower levels of HDL h were observed in 22.9% of the examinees, and high cholesterol was present in 5.8% of patients. Two risk factors for metabolic syndrome were observed in 27.6%, and metabolic syndrome was present in 18.3% of patients. 8.9% examinees had a glucose disorder (0.3%). Orthopedic complications were observed in 82% of the examinees. Polycyistic ovary syndrome were observed in 12% of adolescents.

CONCLUSION: Complications occur in a large number of obese adolescents, which indicates the seriousness of the problem of obesity and the need for more effective prevention programmes. Short-term effects of Cigotica programme are encouraging, and the effectiveness of the multidisciplinary approach to obesity treatment will be evaluated by the current research which analyses sustainability of the achieved results.

Key words: obesity, adolescents, metabolic risk factors, insulin resi-stance, body mass index (BMI), CIGOTICA Programme

Introduction

Obesity in children is one of the biggest public health problems in the 21st cen-tury, with particularly alarming trends in some parts of the world. Various studies in Europe estimate that 10-30% of children aged 7 to 11 and 8-25% of adolescents aged 14 to 17 are overweight. In 1948, the World Health Organization declared obesity as a disease, and it now estimates that by 2025, 50% of the world population will be obese. Contemporary ndings indicate an increase in the incidence of obesity in children and adolescents, with the particularly alarming ndings that say that obese children develop more serious degrees of obesity and that up to 85% of obese adolescents are obese in adulthood (1).

Heredity, family environment, socio-economic and cultural conditions and daily habits in uence the occurrence of obesity, and emphasize their mutual interactions (2). Concern about obesity in children is especially justi ed by the possibility of pre-vention of complications due to obesity, whose treatment is demanding, dif cult, and often not so successful (3). Programmes to prevent obesity are becoming increasingly important because of the limited possibilities for its pharmacological and surgical treatment especially at the pediatric age (4.5).

Obesity in children is associated with an increased risk of a number of metabolic complications such as insulin resistance, impaired glucose tolerance and type 2 diabe-tes. Elevated BMI (body mass index) in childhood is a major generator of metabolic


syndrome. Obese children are at increased risk of orthopedic, respiratory illnesses and psychological problems (4). In addition to numerous complications, obesity is a cause of great economic loading through the reduction in productivity and income, and it accounts for 7-12% of all health care costs in Western countries (6).

The prevalence of obesity in Serbia in children up to ve years of age is 19% according to the UNICEF of ce from 2005. According to the estimates for 2007, overweight and obesity are present in 18% of adolescents, and compared to the inci-dence in 2000, this shows an increase of almost 50%. Due to the continuous growth in the number of obese children in Serbia, and in order to prevent obesity and ensure changes in dietary habits and lifestyle, the Association of Pediatricians of Serbia, in cooperation with the Special Hospital “Zlatibor” that has years of experience in the treatment and rehabilitation of obesity in adults, in July 2007 prepared the project “Prevention and treatment of obesity in children and adolescents in Serbia.” In the spring of 2008, the Republic Institute for Health Insurance under the auspices of the Ministry of Health approved the treatment and rehabilitation of obese children aged 12 to 18 for the period of 21 days once a year and the establishment of the Center for the Prevention, Treatment and Rehabilitation of overweight and obese children and adolescents in the complex of the Hospital “Zlatibor”. Upon the decision of the Re-public Institute for Health Insurance from May 2012, the treatment of obese children at the Center lasts for 10 days.

The Center performs diagnostic tests and treatment, with the participation of: a pediatric endocrinologist, a specialist in physical medicine, psychologists, nutriti-onists, physical education teachers and nurses. Once in three months, professors of pediatrics – endocrinologists from Belgrade and Nis visit the Centre to do consulting. Under professional supervision, patients receive a plan of eating and physical activity depending on their age, health and tness, and if necessary, medication treatment is also included in the therapy. The immediate goal of the treatment is to achieve a long-lasting reduction in body-weight.

The treatment in CIGOTICA Programme requires a multidisciplinary approach that includes speci c training, dietary intervention with a reduction in total calorie intake, physical activity, clinical and psychological support and changes in behavior and lifestyle.Upon admission, clinical examination identi es patients with primary and secondary obesity and complications, diagnostic procedures are planned, a diet and exercises are planned individually for each obese child. When leaving hospital, each child receives advice, guidance and recommendations for the supervision of a competent pediatrician.

The basic principle of nutrition for obese children and their families is taking balanced meals, which provide for the nutritive needs of a growing and developing body. Restriction of caloric intake in children is individualized and carefully moni-tored so as not to compromise normal growth and development (7.8). The total daily amount of food is distributed in 5 meals (breakfast, lunch, dinner, and 2 snacks). All


dishes are prepared in the kitchen of the Hospital “Zlatibor” under the supervision of experienced chefs and nutritionists. Meals are prepared in accordance with the basic principles and guidelines on the importance of proper nutrition in the prevention of obesity, based on initial daily caloric requirements and physical activity of children. Nutritionists’ lectures and workshops are dedicated to the right choice of food, meal preparation, assessment of nutritional and caloric value of a meal, and upon release, children and parents receive written instructions and recommendations for the nutrition of obese children and adolescents.

CIGOTICA programme contains six types of physical activities, lectures and target programmes of social and entertainment activities. Health program activi-ties are planned on the basis of the anaerobic capacity test. The planned physical activities are: walking, fast walking in the countryside, on the running track or in the cardio- tness gyms, shaping exercises, exercises to strengthen certain muscle groups without props and accessories (therapeutic balls, elastic bands ...), exercises in water, swimming practice, eld games, outdoor activities and sports games. Physical activity is organised on a daily basis, it is diverse, fun and tailored to obese children. Together with a hypocaloric diet, physical activity contributes to the reduction in weight, improvement of physical tness, children are ready to engage in the standard programme of physical education, they are motivated to improve their health, and the greatest role is in maintaining the initially reduced body weight (9, 10).

Psychological treatment in the programme includes an interview with a psyc-hologist, and a self-assessment questionnaire for psychological help, 6 workshops and assistance in understanding and solving the problem of obesity. Therapy pro-gramme that includes behavior modi cation gives much better results, and only a change of lifestyle can achieve long-term success. Therefore, for successful and long-term effects of the therapy in children, a psychological approach aimed at changing attitudes, beliefs and behaviors related to nutrition and physical activity is needed (11).

Lectures, workshops of pediatricians, nutritionists, psychologists, and physical education teachers together with obese children sharing their experiences, contribute to the adoption of new knowledge and attitudes towards the importance of proper nutrition (healthy eating choice in the selection of food, reducing meals), physical activity, improvement of interpersonal relationships and resolution of emotional problems in obese adolescents.

Objective

To determine the presence of complications of obesity and metabolic risk factors in adolescents participating in CIGOTICA programme.


Method

A prospective analysis was performed in 1,000 obese adolescents (468 girls and 532 boys), of the average age of 15.3, participants in “CIGOTICA” programme, who were diagnosed with primary obesity. Obese children between the ages of 12 and 18 were hospitalized for 21 days in the special hospital “ i-gota” for obesity treatment, education and rehabilitation in the period from 27 July, 2008 to 1 January, 2012. Adolescents diagnosed with secondary obesity, with medication therapy, unmotivated and adolescents who were hospitalised for less than 21 days were excluded from the research. Clinical monitoring of obese teenagers includes an initial overview, a survey on the diet and physical activity level, anthropometric measurements, ECG followed by an introduction to the basic principles of treatment and continuous monitoring of the patient.Body weight index BMI, fat % were obtained using a Tanita scale to determine body composition by impedance. While measured, a child should be in their underwear. Measuring is performed in the morning before breakfast and after emptying the bowel and bladder. The obtained value is read to the nearest 0.1 kg and is expressed in kilograms (one decimal place), and the weight of underwear is subtracted from it.

Body mass index (BMI) is obtained when the value of body weight in ki-lograms is divided by the square value of body height expressed in meters. The obtained results are expressed as the number of standard deviations through deviation (SD) of the reference values for a given age presented as Z-score and recommended by the WHO (National Center for Health Statistics-NCHS) WHO Growth Reference. According to recommendations, z-score values that indicate overweight and obesity are in the range of +2 to +3 SD and greater than +3 SD (12). Body height is measured by anthropometre with a stand. While measured, a child should be barefoot and bareheaded, his back to the bar of the anthropometre, with his head elevated so that the bottom edge of the orbit and tragus are in the same horizontal plane. The horizontal slider of the anthropometre in the measu-rement goes down to the scalp, and the height value is read to the nearest 0.5 cm, and is expressed in centimetres (to one decimal place). Circumferences (waist, hip, upper arm and thigh) are measured with a non-elastic plastic tape measure. The values are read to the nearest 0.1 centimeter and expressed in centimeters. Blood pressure is measured three times in a sitting position on the right arm, with an appropriate cuff. Triglycerides, total, HDL and LDL cholesterol, uric acid, and glucose are measured on the second day of hospitalization after 12 hours of fasting. The type and duration of each activity within IGOTICA programme were controlled on a daily basis. For the diagnosis of metabolic syndrome, IDF criteria (International Diabetes Federation) were used.


Results

From 27July, 2008 to 1January, 2012, 1,900 patients were hospita-lized at the Center. A sample of 1,000 adolescents with primary obesity, average age 15.30 ± 1.45 was determined. Hospitalization lasted 21 days. Abdominal obesity de ned as OS> P90 was observed in all patients (100%). Blood pressure was elevated in 290 patients (29%). Systolic hypertension was registered in 180 adolescents (18.00%), diastolic in 95 (9.50%), and systolic and diastolic in 91 (9.1%) adolescents. Clinical examination showed the presence of acanthosis in 514 adolescents: 265 girls (26.50%) and 249 boys (24.9%). In 51.4% of obese childre,n acanthosis was present in the neck, armpits, groin, and rarely on the exor surfaces of the knees and elbows.

26,50 %

24,90%

48.60%

DEVOJ ICE

DE ACI

OSTALI

Figure1. Akanthosis nigricans in the participants of CIGOTICA programme

Levels of triglycerides (> 17 mmol / l) were elevated in 78 subjects (7.8%), lower levels of HDL h (<1.00 mmol / l) were observed in 229 patients (22.9%) and high cholesterol was present in 58 adolescents (5.8%). Disorders in the regulation of glucose were detected in 95 (9.5%) patients, of which 61 (6.1%) had increased fasting glucose. Type 2 diabetes was detected in 3 adolescents (0.3%).

The criteria for the metabolic syndrome were met by 185 subjects (18.5%). Two risk factors for metabolic syndrome were observed in 282 patients (28.2%). One risk factor (OS> p90) for the metabolic syndrome was present in all patients. 39% (390) of adolescents had elevated levels of uric acid and microalbuminuria was not determined in all patients. Orthopedic complications were observed in 82% of the examinees. Polycyistic ovary syndrome were observed in 12% of adolescents.

GYRLS

BOYS

OTHERS


Discussion:

The alarming spread of the epidemic of obesity in children and adolescents, as well as the lack of reliable and effective policies and programs to prevent obesity indicate the need for the establishment of the Centre for the Prevention, Treatment and Rehabilitation of obesity in children and adolescents and CIGOTICA Progra-mme at the Special Hospital “Cigota”. Overweight and obese children aged 12 to 18 from school dispensaries and pediatric departments throughout Serbia are sent to the Centre.

Urbanization, industrialization, globalization of markets and economic growth have in uenced the rapid change of lifestyle and diet (“nutritional transition”). Increased consumption of food with high energy density and high consumption of fat, especially saturated fat, and consumption of complex carbohydrates, vegetables and fruits along with sedentary life and lower energy expenditure, have signi cantly contributed to the rise of obesity in our society.

Blood pressure was elevated in 290 patients (29%). The connections between hypertension and obesity were noticed a long time ago. In both diseases, there are similar disorders in blood pressure that can trigger or maintain hypertension. Children with hypertension may have a disorder of glucose tolerance, preprandial or postpran-dial hyperinsulinemia or insulin resistance. Insulin stimulates the activation of the sympathetic nervous system, renin-angiotensin-aldosterone system and increases the re-absorption of sodium in the proximal renal tubules (13). Many epidemiological studies showed a distinct correlation between obesity and hypertension in children (14, 15). A research in Canada in 2012, suggests that obese boys have by 7.6 mmHg higher blood pressure compared to their peers with normal weight. Obese children who do insuf cient physical activity, and have a positive family history of hyper-tension are at risk of hypertension. Early interventions in the treatment of obese children will reduce the number of obese children with hypertension, and the risk of cardiovascular diseases in the future (16).

Clinical examination showed the presence of acanthosis in the neck, armpits, groin, and rarely on the exor surfaces of knees and elbows in 514 adolescents (51.4%). Acanthosis is a skin lesion that is characterized by hyperpigmentation and hyperkeratosis on the folding surfaces, followed by a rough and wrinkled skin (17). Pathological changes are present in the epidermis and are characterized by papi-llomatosis, hyperkeratosis, and increased number of melanocytes (18). Acanthosis is present in the clinical conditions associated with decreased insulin action at the cellular level, caused by genetic defects, insulin resistance induced most often by antireceptory antibodies, as well as by the pathogenetically insuf ciently explained states of insulin resistance present in obese patients(19,20).


Acanthosis nigricans is an important predictor of insulin resistance in obese adolescents. Early identi cation of children with acanthosis (screening?), their mo-nitoring and multidisciplinary treatment of obesity is essential for the prevention of complications, especially type 2 diabetes in children. Other changes registered in the skin of obese adolescents are Sirmium, acne, fungal infections of the skin, intertrigi-nose changes, hyperpigmentation and hirsutism.

Obesity is a major risk factor for cardiovascular disease in adulthood. Undesirable effects of obesity are re ected at an early age in the changes in the lipid pro le. Levels of triglycerides (> 17 mmol / l) were high in 78 subjects (7.8%), lower levels of HDL h (<1.00 mmol / l) were observed in 229 patients (22.9%) and high cholesterol was present in 58 adolescents (5.8%). The research of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006, suggested that the prevalence of dyslipidemia in children aged 12 to 19 was 20.3%. Most of the complications of obesity are identi ed in adult patients, but some of them are already evident in chil-dren. The data from Bogalusa study showed that nearly 20% of obese children had at least one risk factor for cardiovascular diseases (hypercholesterolemia, hyperinsu-linemia, hypertriglyceridemia, and hypertension) associated with the early onset of atherosclerosis. Insulin resistance is the most common metabolic disorder in obese children (21).

Increased prevalence of obesity in children and adolescents is associated with a higher risk of developing type 2 diabetes mellitus. Disorders in the regulation of glu-cose were detected in 95 (95%) patients. Type 2 diabetes was detected in 3 adolescents (0.3%). A disorder in the regulation of glucose indicates the risk of the disease. Obesity and insulin resistance in children makes them predisposed to vascular complications in later life. Severe obesity at the age of 9-11 leads to the reduction in carotid artery elasticity and obesity in adolescence leads to the thickening of the intima-media carotid arteries in young adults (22). Bogalusa study showed that the prevalence of brous plaques in the aorta and coronary arteries increases with age and positively

correlates with BMI z-score, triglyceride and cholesterol levels and blood pressure.Elevated BMI in childhood is a major generator of metabolic syndrome, which is


characterized by: abdominal obesity, glucose intolerance, insulin resistance, dyslipi-demia (low HDL cholesterol and triglycerides), hypertension, chronic in ammation, and prothrombotic states. Metabolic syndrome increases the risk of diabetes and cardiovascular mortality. Approximately 24-51% of obese children between the age of 12 and 19 have metabolic syndrome. The prevalence of metabolic syndrome is signi cantly lower in normal weight adolescents (1-3%) compared with the obese adolescents in the United States.

The criteria for the metabolic syndrome are met by 18.3% of our respondents. Two risk factors for metabolic syndrome are observed in 28.2% of adolescents. One risk factor (OS> p90) for the metabolic syndrome is present in all patients. The accumulation of abdominal subcutaneous and visceral fat is associated with insulin resistance, and insulin sensitivity correlates less with femoral and gluteal subcutaneous fat. The accumulation of visceral fat is accompanied by resistance to the action of adipose tissue insulin sensitivity and increased catecholamines. These patients are at high risk of cardiovascular diseases and type 2 diabetes in adulthood (23, 24). Ever since risk factors for metabolic syndrome were identi ed, there has been a need for screening obese children who have two or more risk factors, in order to try to prevent the development of complications and start the treatment.

39% of adolescents have elevated levels of uric acid and microalbuminuria is not determined in all patients. Obesity is a risk factor for chronic renal failure. The rst sign of kidney damage is microalbuminuria. Kidney damage is caused primarily

by hemodynamic and hormonal changes in obese children and secondarily, occurs with type 2 diabetes and hypertension (25).

In addition to these complications of obesity, our patients have liver steatosis, steatohepatitis, rapid growth, ovarian hyperandrogenism in girls and gynecomastia in boys, cholecystitis, holelitiasa, pancreatitis, sleep apnea, stress incontinence. Orthopedic complications and problems of the bone and joint system are present in obese adolescents. Anamnestic data indicate frequent injuries and fractures in our obese adolescents, who most often complain of pain in the hips, knees and feet. 82% of obese adolescents have one of the changes in the osteoarticular design trails: spinal deformity, varus knees or at feet. Three patients had epiphyseolysis femoral head, and two of them had Blount disease. It is necessary to identify ort-hopedic complications in obese children as soon as possible and encourage them to get involved as soon as possible in alternative forms of physical activity (trekking, swimming ...). (26).

Menstrual disorders with insulin resistance, acne, hirsutism and akanthosis nigricans are characteristics of the polycystic ovary syndrome, which is also present in 56 (12%) our obese adolescents.

Psychological problems and often psychological consequences of obesity: anxiety, phobias, depression, aggression, abuse of tobacco in our patients indicate the fact that in the treatment psychological help and support are also needed (27).


The need for the prevention of obesity stems from a dramatic increase in its incidence, limited treatment options and the direct and indirect impact on the deve-lopment of a number of chronic diseases that occur with obesity at the young age. Obesity is associated with signi cant health problems in the pediatric population and is an important risk factor for morbidity and mortality in adulthood. Therefore, nding ways to reduce the growing prevalence of its sequels in children and adults is

a challenge. Obesity prevention should begin in early childhood, focusing on healthy eating and physical activity (28).

The effects of CIGOTICA are encouraging and indicate that the multidisciplinary approach has led to a signi cant reduction in body weight, normalization of blood pressure and metabolic risk factors, increased aerobic capacity and self-esteem in obese adolescents.

Conclusion

Complications occur in a large number of obese adolescents, which indicates the seriousness of the problem of obesity and the need for more effective prevention programmes. The multidisciplinary approach in the CIGOTICA programme treatment leads to a signi cant reduction in body weight, improvement in metabolic risk factors, aerobic capacity and self-esteem among adolescents. The effectiveness of CIGOTI-CA and the multidisciplinary treatment of obese adolescents will be evaluated by the current research that examines sustainability of the achieved results.

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