Trudy Voortman, PhDtrudy.voortman@erasmusmc.nl

Childhood obesity: a global and lifecourse perspective

Global perspective

Prevalence of overweight and obesity (weight-for-height ≥ 2SD) among children under age 5 years, 2014, WHO

Life-course perspective – women’s health

1850 1900 1950 2000 2050 2100

104.5

119.8

89.1 96.8

108.9

98.1

time series

forecast mean

95% approx.conf. interval

time series

forecast mean

95% approx.conf. interval

120

110

100

90

80

70

60

50

40

Forecast of record life expectancy

Source: Vaupel

In 2015: Japan 84 (Men 80, women 87)

Top global causes of death

WHO 2015

Causes of death Deaths in Millions

CHD 8.9

Stroke 6.3

COPD 3.2

Low resp. infections 2.7

Lung cancers 1.7

Non-communicable diseasesInfectious diseases

LE=30 ys LE=50 ys LE=70 ys

Demographic & Epidemiologic Transition

Top global causes of death

WHO 2015

Causes of death Deaths in Millions

CHD 8.9

Stroke 6.3

COPD 3.2

Low resp. infections 2.7

Lung cancers 1.7

Top risk factors?

Global risk factors

Malnutrition?

Malnutrition

Malnutrition = inadequate/unbalanced nutrition

• Undernutrition

• Protein-energy malnutrition

• Micronutrient deficiencies

• Overnutrition

Overweight/obesity

2.1 billion adults

~a third of the world population

Marie Ng, et al. Lancet, 2014

Obesity – a worldwide problem

• Overweight and obesity are linked to more deaths worldwide than underweight

Prevalence of overweight and obesity, GBD, 2013

Childhood obesity – a worldwide problem

• 43 million overweight and obese preschoolers (<5 y) in the world

• 35 million live in developing countries

de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92:1257-64.

Consequences of childhood obesity

• In childhood:- Can harm heart, lungs, muscles, bones, kidneys and GI tract- Disturbances in hormones that control blood sugar and puberty- Social and emotional problems

• Risk for later life: overweight children are likely to : - become obese adults, overweight ‘tracks’- develop diabetes and CVD at a younger age

• Developed countries: increases in obesity began in the 1980s; since 2006, the increase has slowed down

• Developing countries: obesity rates continue to rise

Obesity – a worldwide problem – trends

WHO, 2014

World health in transition

• Demographic transition (Warren Thompson, 1929) population ageing

• Epidemiological transition (Abdel Omran, 1971) changes in global disease burden

• Nutrition transition (Barry Popkin, 1993) changes in diet and physical activity

Nutrition transition

The shift in dietary consumption and energy expenditure that coincides with economic, demographic, and epidemiological changes

Pattern 1 – Hunter Gatherer

• Highly active lifestyles• Hunting and foraging for food• Diets rich in fibrous plants and protein from lean wild

animals• Diets low in fat

Pattern 1 – Hunter Gatherer

• Highly active lifestyles• Hunting and foraging for food• Diets rich in fibrous plants and protein from lean wild

animals• Diets low in fat

Pattern 2 – Early Agriculture

• Famine is common• Slowing individuals’ growth• Scarcity • Low variation of the food supply

Pattern 2 – Early Agriculture

• Monoculture: low variation of the food supply• Nutrient deficiencies• Famine is common• Scarcity • Short stature

Pattern 3 – End of Famine

• Famine recedes • Income rises • Nutrition improves: more fruits, vegetables, and animal

protein

Pattern 3 – End of Famine

• Famine recedes • Income rises • Nutrition improves: more fruits, vegetables, and animal

protein

Pattern 4 – Overeating, Obesity-Related Diseases

• Incomes continue to rise• Access to an abundance of high-calorie foods• Diets high in total fat, cholesterol, sugar; and low in

PUFAs and fiber • Increasingly sedentary lifestyle • Increases in obesity • Increase in obesity-related chronic diseases, such as

diabetes and heart disease

Pattern 4 – Overeating, Obesity-Related Diseases

• Incomes continue to rise• Access to an abundance of high-calorie foods• Diets high in total fat, cholesterol, sugar; and low in

PUFAs and fiber • Increasingly sedentary lifestyle • Increases in obesity and related chronic diseases, such as

diabetes and heart disease

Pattern 5 – Behavior Change

• Response to increasing rates of obesity and obesity-related chronic diseases

• Individuals change their behavior• Communities promote behavior changes

Pattern 5 – Behavior Change

• Response to increasing rates of obesity and obesity-related chronic diseases

• Individuals change their behavior• Communities promote behavior changes

Nutrition transition

1. Hunter-gatherer: collecting food, diets high in carbohydrates, low in fat, fat was mainly unsaturated

2. Early agriculture: famine, scarcity, reduced variation of the food supply

3. End of famine: more fruits, vegetables, and animal protein

4. Overeating, obesity-related diseases: diets high in total fat, cholesterol, sugar; and low in PUFAs and fiber; often accompanied by an increasingly sedentary lifestyle

5. Behavior change: to prevent or delay degenerative diseases

Barry Popkin, 1993

Nutrition transition

• Currently, most low- and middle-income countries are rapidly moving from pattern 3 (end of famine) to pattern 4 (processed foods)

Popkin BM. Am J Clin Nutr. 2006; 84:289–98.

Shift from traditional to Western-style diets

Nutrition and epidemiologic transition

• Different stages of transition within:– Countries– Regions– Families– Individuals

Double burden

Double burden in countries

Low-middle income countries battle with:

food insecurity, undernutrition, infectious diseases

AND

obesity, heart disease, hypertension, stroke, and diabetes.

Example: South Africa

• Significant levels of stunting, but declining levels of underweight

• In adults, overweight and obesity are more serious than underweight.

• Rising incidence of CVD, diabetes and cancer, but also of TB and HIV/AIDS.

• Overweight in combination with micronutrient deficiencies (e.g., vitamin A)

• Early-life under nutrition, stunting + adulthood obesity

Double burden within individuals

Double burden within families

• Pregnant women -> children

Risks of undernutrition during pregnancy for the child: LBW, mental retardation, death

But also More NCD later in life (Barker)

Barker, 1995, BMJ

The Dutch Hunger Winter Study

Rooseboom et al. 2001 & 2006

Poor maternal nutrition during pregnancy may lead to increased disease susceptibility in later life

↑ Obesity ↑ Type 2 diabetes↑ Coronary heart disease↑ Kidney disease

Similar effects for overnutrition/ obesity during pregnancy!

Maternal obesity

• The Generation R Study

• Adverse offspring outcomes of maternal obesity during pregnancy:

Fetal outcomes Childhood outcomes Adult outcomes

StillbirthNeonatal deathCongenital anomaliesLGA at birthNeonatal hypoglycemiaReferral to neonatal intensive care unit

ObesityAdverse body compositionHigh blood pressureDyslipidemiaIncreased inflammatory markersImpaired insulin/glucose homoeostasis

ObesityHigh blood pressureDyslipidemiaInsulin resistancePremature mortality

Developmental Origins of Health and Disease (DOHaD)

“The DOHaD concept describes how, during early life

(at conception, and/or during fetal life, infancy, and early childhood),

the environment induces changes in development that have long term

impact on later health and disease risk.”

International Society for Developmental Origins of Health and Disease

Childhood obesity

• 43 million overweight and obese preschoolers (<5 y) in the world• 35 million live in developing countries

• Affects child’s health, quality of life• Tacks to later life

Covered by the MDGs?

de Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 2010;92:1257-64.

WHO

On Jan 25, 2016, the

Commission on Ending

Childhood Obesity

(ECHO) presented its

report to the Director-

General of WHO

Ending Childhood Obesity (ECHO)

Childhood obesity: global and lifecourse perspective

Thank you for your attention!

trudy.voortman@erasmusmc.nl

Gynecologic and ObstetricConsequences of Obesity in

Adolescent Girls:THE FACTS

Leticia Elizondo-Montemayor, M.D.

Director of the Clinical Nutrition and Obesity Research Center.

Introduction

Obesity: most prevalent nutritional problem in children and adolescentsin the US. (Ogden, Carroll, Kit, & al, 2012)

The prevalence of overweight in children and adolescents has increased by more than half, and that of obesity has doubled. (Ogden, Carroll, Kit, & al, 2012)

50 – 77% of obese adolescents will become obese adults. (De Silva, Helmrath, Klish, 2007) (In-Iw, Biro, 2011)

In Mexico, 1 in every 3 children and adolescents is overweight orobese. (Gutierrez, Rivera-Dommarco, Shamah-Levy, & al, 2012)

Obesity rates

OECD estimates based on national health surveys. Leticia Elizondo-Montemayor Tecnológico de Monterrey, México

International Association for theStudy of Obesity, 2013; Bös et al. (2004), Universität Karlsruhe and Ministères de l’Educationnationale et de la Santé forLuxembourg; and KNHANES 2011 for Korea.

Overweight(includingobesity) amongchildrenaged 5-17, 2010 ornearest year

National prevalence of overweight and obesity in infants less than 5 years

old in Mexico, EN88, ENN1999, ENSANUT 2006,

ENSANUT 2012

National prevalence of overweight and obesity in children 5 to 11 years old in Mexico, ENSANUT 2012

National prevalence of overweight and obesity in adolescents of 12-19 years old in Mexico, ENSANUT 2012

Effects of obesity on the life courseof women’s health

Cardiovascular

• Hypertension

• Dyslipidemia

• Atherosclerosis

• Congestive heart failure

• Intima thickening

• Left ventricular hypertrophy

• Peripheral vascular disease

• Pulmonary embolism

Metabolic

• Insulin Resistance

• Glucose Intolerance

• DM type 2

• Metabolic syndrome

• Gout

• Vitamin D deficiency

Pulmonary

• Obstructive sleep spnea

• Hypoventilation syndrome

• Pulmonary hypertension

• Dyspnea

• Asthma exacerbation

Hepatic

• Nonalcoholic fatty liver disease

• Nonalcoholic Steatohepatitis

• Cirrhosis

Genitourinary

• Polycystic ovarian syndrome

• Hyperandrogenism

• Infertility

• Irregular menstruation

• Urinary incontinence

• Impotence

Neurologic

• Embolism

• Idiopatic intracraneal hypertension

• Lower back pain

(Elizondo, Hernández, Zamora, 2011)

Cancer

• Breast

• Colon

• Prostate

• Endometrial

Orthopedic

• Osteoarthritis

• Blount disease

Gastrointestinal

• Cholelitiasis

• GERD

• Hernias

Dermatologic

• Acanthosis nigricans

• Hirsutism

• Stretch marks

• Venous stasis

• Cellulite

• Intertrigo

Renal

• Microalbuminuria

• Terminal renal disease

• Obesity related glomerulopathy

Psychological

• Depression

• Anxiety

• Low self esteem

• Suicide

• Low quality of life

• Years of life lost

Effects of obesity on the life courseof women’s health

(Elizondo, Hernández, Zamora, 2011)

Metabolic and life impact of obesity in girls• Childhood and adolescent adiposity are good predictors of MetS, both in

adolescence and adulthood. (In-Iw, Biro, 2011) (Morrison, Friedman, Wang, & al, 2008)

• Based on the degree of overweight adolescents, younger adults have a tendency to have greater years of life lost than older adults. (De Silva, Helmrath, Klish, 2007)

(Li, Chen, Srinivasan, & al, 2012)(Zeller, Modi, 2006)(Finkelstein, Brown, Wrage, & al, 2010)

Consequences Risk/prevalence

Metabolic Syndrome 27.8% prevalence

Diminished health related quality of life 5.5 times more likely

Years of life lost 5-9 years

Psychological Impact of obesity in adolescence

Low self-esteem

• Twice more likely to have low self-esteem, especially females. (McClure, Tanski, Kingsbury, & al, 2010) (Kelly, Barlow, Rao, & al, 2013)

Depression

• Positive correlation between depressive symptoms and obesity in adolescents, especially the severely obese. (Liem, Sauer, Oldehinkel, & al, 2008) (Anderson, Cohen, Naumova, & al, 2006)

• Depression rates of 30% in severely obese adolescents. (Kelly, Barlow, Rao, & al, 2013) (Zeller, Roehrig, Modi, & al, 2006)

There is also

• Stigmatization

• Altered cognitive performance

• Low self-worth

• Frustration

• Emotional disorders.

Effects of obesity on puberty

Early pubertyHigh BMI was positively correlated with early maturation, starting puberty earlier. (Buyken, Karaolis-Danckert, Remer, 2009) (Wang, 2002)

(Biro, Huang, Morrison, & al, 2010)

Cohort study

10 year length

1,141 girls

9 years of age

Earlier maturation in thosewith higher fat mass,

waist-to-height ratio, ratio of fat mass to fat-free mass

Population based cohort

Danish

135,000

7 year old girls

Large pre-pubertal BMI associated with growth

spurt and peak highvelocity at an earlier age

(Aksglaede, Juul, Olsen, & al, 2009)

Effects of obesity on puberty

Early menarche

(Castillo, Nucci, 2015)

(Lee, Appugliese, Kaciroti, & al, 2007)

Cross-sectional

study

Brazilian

1,671 girls

7-18 years old

Overweight girls presentedwith earlier menarche.

American Longitudinal study

354 girls

36 months

to 12 years old

Larger BMI, as early as 3 yearsold Earlier breast

development and menarche.

Effects of obesity on reproductive function

Risk of infertility

Fertility disorders are stronger when obesity has an early onset during the adolescent years.

(Hartz, Barboriak, Wong, & al, 1979) (Norman, Clark, 1998)

597 anovulatory women VS. 1,695 primiparous controls

Increased risk of infertilitydue to obesity in both groups

3-fold higher risk of infertility

Internet -based prospective cohort study

Danish

Overweight, obese and and women who gained

excess weight since age 17

Reduced fertility

(Grodstein, Goldman, Cramer, 1994) (Wise, Rothman, Mikkelsen, & al, 2010)

Effects of obesity on reproductive function

Obese women submitted to in-vitro fertilization in which exogenous gonadotropins were used:

• Had lower odds of conception than non-obese women. (Gesink, Maclehose, Longnecker, 2007)

• Required longer gonadotropin stimulation and higher amounts than normal weightwomen to produce a similar number of follicles. (Practice Comm of Am- Society for Reprod Medicine, 2008)

Likelihood of clinical pregnancy and live birth with in vitro fertilization were 50% lower in women with BMI over 40. (Shah,

Missmer, Berry, & al, 2011)

Embryos derived from oocytes of obese women are of poorer quality than those from normal-weight women. (Metwally, Cutting, Tripton, & al, 2007)

Influence on assisted reproductive technology (ART)

Disorders of menstruation in adolescets with obesity

Irregular menstruation• Obese women are twice more likely to have irregular

menstruation. (Wei, Schmidt, Dwyer, & al, 2009)

• The same goes for obese adolescents. (Hillman, Miller, Inge, 2011)

(Hillman, Miller, Inge, 2011)

American Cohortstudy

25 severelyobese

adolescents(BMI 51.4)

bariatric surgery

Mean age 17.4 years

High prevalenceof irregular

mensescycles

28% Menorrhagia

32% Oligomenorrhea

Disorders of menstruation in adolescents with obesity

Irregular menstruation

• Oligomenorrhea

• irregular menstrual bleeding

• Amenorrhea

• heavy menstrual bleeding. (Seif, Diamond, Nickkho-Amiry, 2015)

Cross-sectional

Serbian

835 post-menarcheal

girls

Irregular cycles: higher weight, BMI, fat percentage and

larger ovaries.

Predisposingfactor for

polycystic ovarysyndrome.

Prospectivepopulation-

based

Finnish

2,033 subjects

Menstrual irregularity and/orelevated androgenlevels at 16 years.

Associated withsymptoms of PCOS

and infertilityproblems at age 26.

(Radivojevic, Lazovic, Kravic-stevovic, & al, 2014)

(West, Lashen, Bloigu, & al, 2014)

Dysmenorrhea in adolescents with obesity

Negative correlation

Cross-sectional

study

Turkish

800 students

17-32 years old

Dysmenorrhea 1.5 times higher in underweight people than in

overweight/obese.

Cross-sectional

study

Japanese

2,282 females

18-21 years old

Higher prevalence in the underweightgroup (BMI <19.8).

(Ozerdogan, Sayiner, Ayranci, & al, 2009)(Hirata, Kumabe, Inoue, 2002)

Consider these are UNDERWEIGHT, not normal weight adolescents

The effect of obesity on dysmenorrhea is still CONTROVERSIAL

Dysmenorrhea in adolescents with obesity

No association

Cross-sectional

study

Nigerian

1,399 adolescents

Primarydysmenorrhea 85.4%.

BMI and level of adiposity (based

on WC) werenot associated.

Review

15 longitudinal, case-control,

cross-sectionalstudies

Increased risk High stress, family history of

dysmenorrhea.

InconclusiveObesity, diet,

smoking.

(Maruf, Ezenwafor, Moroof, & al, 2013)(Ju, Jones, Mishra, 2014)

Dysmenorrhea in in adolescents with obesity

Positive correlation

American cohort study

Severely obese adolescents

40% withdysmenorrhea.

Australian Longitudinal Studyon Women’s Health

14, 247 women 18-23 years

13 year follow up

Obesity was more common among

those withdysmenorrhea.

Longitudinal study

Australian

9,688 women

22-27 years old

U- shapedassociation

betweendysmenorrhea and

BMI.

(Hillman, Miller, Inge, 2011)

(Ju, Jones, Mishra, 2014)

Sexual behavior in in adolescents with obesity

Less likely to be sexually active. (Ratcliff, Jenkins, Reiter-Purtill, & al, 2011) (Ali, Rizzo, Amialchuk, & al, 2014)

For each point increase in BMI the probability of having a romanticrelationship decreased by 6%. (Halpem, King, Oslak, & al, 2005)

Higher odds ratio for unsafe sexual behavior:(Leech, Dias, 2012; Ratcliff, Jenkins, Reiter-Purtill, & al, 2011; Chang, Davis, Kusonoki, & al, 2015)

• Unprotected sex.

• Sex under the effects of alcohol or drugs.

• Casual sex.

• Numerous partners.

• Lack of contraceptive use.

One study proved no influence of weight sexual behavior or contraceptive use. (Akers, Lynch, Gold, & al, 2009)

Contraception weight gain in obesity

Fear of weight gain

Use hormonal contraceptives less frequently

Depend on less efective forms or no contraception. (Shaw, Edelman, 2013)

Population-based longitudinal study with 900 teens 18 to 19 years oldproved this. (Chang, Davis, Kusunoki, & al, 2015)

Teens who experience weight gain while taking COC attribute it to theCOC and discontinue their use. (Coney, Washenik, Langley, & al, 2001)

(Gallo, López, Grimes, & al, 2014)

Cochrane reviewNo relationship between COC or a combination skin patch

and weight change.

COC related weight gain in adolescents

Contraception weight gain in obesityCOC related weight gain in adolescents

Adolescents using hormonal inyectable contraceptives gain more weight tan COC users. (Beksinska, Smit, Kleinschmidt, & al, 2010)

Placebo-controlled, randomized

trial

700 adolescentswomen >14

years

Low dose COC (20mg EE/100 mg LNG)

did not cause weight gain, because of the low dose.

Longitudinal study

12- 21 yearsold

Using COC for more

than 1 year.

4.2% increase in weight;

12.5% increase in body fat.

(Coney, Washenik, Langley, & al, 2001)(Bonny, Britto, Huang, & al, 2004)

Contraception weight gain in obesityDMPA related weight gain

• Depotmedroxyprogesterone (DMPA) is more associatedwith weight gain than other hormonal contraceptives.

• Those overweight at the start of DMPA were more likelyto gain weight during the first year of use. (Mangan, Larsen, Hudson, 2002)

(Beksinska, Smit, Kleinschmidt, & al, 2010)

Longitudinal study

15-19 yearsold

Use DMPA orNET-EN

gain 6.2kg compared to

2.3kg with COC.

Contraception Failure in obesityCOC effectiveness

• COC and the patch• higher failure rates in obese adolescents. (Greydanus,2009)

• Progestin Long Acting Reversible Contraceptives (LARC) Etonorgestrel implant and levonorgestrel IUD• Safer and more effective.

Retrospective cohort analysis

18-39 years old

1.6 increased risk of COC failure.

Associated with the highest weightquartile among very low dose COC users (<35mcg ethinyl estradiol).

Case control study

Risk of pregnancy 60% higher in women with BMI >27.3.

>70% higher in BMI >32.2 and weight >74kg.

Doubled with weight > 86kg. (Holt, Scholes, Wicklund, & al, 2005)

(Holt, Cushing-Haugen, Daling, 2002)

Contraception Failure in obesity

Emergency contraception effectiveness

• Overweight and obese women taking LNG were 4 times more likely to get pregnant. (Mody, Han, 2014)

Meta-analysis of 2 randomized

controlled trials

comparing UPA vs LNG

>16 yearsold

Obese women are 3 times as likely to get pregnant as those with normal BMI for either method. (Glasier, Cameron,

Blithe, & al, 2011)

Cohort of Europeanwomen,

using COCswith CMA

Increased BMI and weightassociated with higher

rate of failure.

CMA Lipophilic. (Dinger, Cronin,

Möhner, & al, 2009)

Polycystic Ovary Syndrome in obesityObesity increases the risk of PCOS in adolescents. Odds ratio of being obese or extremely obese was 4.0 for adolescents with diagnosedPCOS. (Christensen, Black, Smith, & al, 2013)

50% of adolescents and adults with PCOS are obese. (Messinis, Messini, Anifandis, & al, 2015) (Azziz, Woods, Reyna, & al, 2004)

Overweight and obesity amplify the severity of PCOS and increase the risk of metabolic alterations. (Franks, 2008)

•Girls aged 14 with a high BMI in childhood increased risk of oligomenorrhea and diagnosis of PCOS in young adulthood. (Glueck, Morrison, Daniels, & al, 2011)

Girls with premature puberty (obese) have been linked to PCOS.

Polycystic Ovary Syndrome in obesity

• Metabolic alterations• Overweight and obese girls with PCOS have a 3-fold

increased risk of developing type 2 diabetes. (O’Brien, Emans, 2008) (Palmert, Gordon, Kartashov, & al, 2002)

• PCOS in obese adolescents is associated with MetS.

Study in obese adolescent females

15.4% Elevatedaminotransferase levels,

suggestive of non-alcoholicsteatohepatitis.

43.6% MetS

10.2% Both. (Barfield, Liu, Kessler, & al, 2009)

Study of severely obese, obese, overweight adolescents

37% girls with PCOS hadMetS.

5% with normal weight

Girls with PCOS were4.5 times more likely to

have MetS. (Coviello, Legro, Dunaif, 2006)

Mineralization and Bone density in adolescents with obesity

Positive or no effect

Correlational study

200 adolescents

and children,

4-20 yearsold.

Obesity during childhood and adolescence Increased vertebral bone density, increased whole bodybone dimensions and mass. (Leonard,

Shults, Wilson, & al, 2004)

865 children and

adolescents

Obese children (% body

fat)

Did not have lower BMC compared with leaner

children. (Petit, Beck, Shults, & al, 2005) (Ellis,

Shypailo, Wong, & al, 2003)

Mineralization and Bone density in adolescents with obesity

Negative effect

Obesity impeds acquisition and promotes loss of bone mass. (Mosca, Silva, Goldberg, 2013)

200 female adolescents

Negative correlationsbetween % body fat

and femur and lumbar spine BMD

Excess fat mass can be detrimental to theattainment of bonemass. (Mosca, Goldberg, da

Silva, & al, 2014)

300 adolescents

3-19 years old

Lower bone mass and bone area for theirtotal body weight.

(Goulding, Taylor, Jones, & al, 2000)

Children and young adults, 4-20 years old.

Proximal femur bonestrength in overweight wasadapted to lean mass and

height. Bone strengthadjusts to muscle forces

Fat mass did not havea positive influenceon bone strength

(static load). (Petit, Beck,

Shults, & al, 2005)

In obese teens, as thenumber of cardio-metabolic risk factorsincreased, their BMD decreased. (Pollock, Bernard, Gutin, & al, 2011)

Macromastia in adolescents withobesityAdolescent girls with macromastia

• Overweight 35%

• Obese 35% (Cruz-Korchin,

Korchin, González-Keelan, & al, 2001)

Most frequent complaints

• back pain, shoulder pain, and intertrigo.

• shoulder grooving from bra straps, upper extremity parestesias, headaches and thoracic kyphosis. (Wolfswinkel, Lemaine, Weathers, 2013)

Adolescents <21 withmacromastia reported

• lower HRQOF

• lower self-esteem

• more eating disorders(Cerrato, Webb, Rosen, & al, 2012)

The demand for breastreduction among

adolescent girls has recently increased.

(Larson, Gosain, 2012)

Breast Cancer in obesity

A greater BMI contributes to increasing incidence of breast cancer. (Gewefel, Salhia, 2014) (Porter, 2008)

Birth weight impacts the risk and progression of breast cancer.

• Women born >4kg 2-fold higher risk than those <3kg. (dos Santos, de Stavola, Hard, & al, 2004) (Perks, Holly, 2011)

Adult obese women have increased risk for postmenopausal breast cancerbut not premenopausal. (Neuhoser, Aragaki, Prentice, & al, 2015)

Obese women with a family history of breast cancer have an increased risk of developing postmenopausal breast cancer. (Carpenter, Ross, Paganini-Hill, & al, 2003)

Increased risk

Breast cancer in obesity

Premenopausal breast cancer exhibits an inverse associationwith BMI and body fat in childhood and adolescence. (Harris,

Tamimi, Willett, & al, 2011) (Michels, Terry, Willett, 2006)

Early life adiposity had a protective effect whencorrelating body fatness at young ages and risk of breast cancer. (Baer, Tworoger, Hankinson, & al, 2010)

Once a woman has developed breast cancer, beingoverweight or obese has adverse consequences. (Perks, Holly, 2011)

Decreased risk

Endometrial cancer in obesity5% of endometrial cancer is diagnosed in women

younger than 40 years old. (Creasman, 2014) (Madison, Schottenfeld,

James, & al, 2004)

Earlier onset of puberty and sexual development in obese adolescents is associated with an increase in

hormone-dependent cancers in adulthood.

Obesity is a risk factor for endometrial cancer with a relative risk between 2 to 5-fold. (Brinton, Lacey, Devesa, & al, 2004)

Adolescents with PCOS are particularly vulnerable. (Hardiman, Pillay, Atiomo, 2003)

Endometrial cancer in obesity

Obesity as a risk factor

Japanese case-control studyand American case control

study

Weight gain >35% in early adulthood

trend to developendometrial cancer10 years earlier than

subjects withoutweight change. (Hosono,

Matsuo, Hirose, & al, 2011) (Lu, Risch, Irwin, & al, 2011)

American cohort

76, 569 women

5% increase in weightfrom baseline

(age 25)

greater risk of postmenopausal

endometrial cancer. (Han, Stevens, Truesdale, & al, 2014)

American subcohort study

33, 057 postmenopausalwomen not using

hormones for 17 years.

High BMI at age18 was

associated withendometrial

cancer risk. (Stevens,

Jacobs, Patel, & al, 2014)

Endometrial cancer in obesity

Obesity not as a risk factor

American prospective

study and Koreanretrospective

study

There wasn’t a strongassociation between BMI

at a young age and endometrial hyperplasiaor cancer. (Lee, Kim, Ahn, & al, 2009)

(Dougan, Hankinson, Vivo, & al, 2015)

Pregnancy complications in adolescentswith obesity

Retrospective case-control study

4, 822 females <19 years old

3-fold increased risk for gestational

diabetes mellitus.

1.8-fold increased risk for pregnancy induced

hypertension.

1.7-fold increased riskfor preeclampsia. (Sukalich,

Mingione, Glantz, 2006)

Retrospective cohort

Primiparous adolescents<20 years old

Overweight and obese gained more

weight than recommended.

1.5 to 1.9-fold risk for

preeclampsia. (Harper, Chang, Macones,

2011)

Population based cohortretrospective study

34, 648 overweight and obeseteenagers

11-17 years old.

1.5 times more likely to have

pregnancyrelated

hypertension. (Halloran, Marshall,

Kunovich, & al, 2012)

Obstetric Consequences of Obesity

(Sukalich, Mingione, Glantz, 2006) (Shaw, Wise, Mayo, 2014) (Harper, Chang, Macones, 2011) (Halloran, Marshall, Kunovich, & al, 2012)

Consequences Impact : increased risk

Pre-term delivery >1.2 - 2.7 fold

Pregnancy induced hypertension 1.8 fold

Post-term delivery >1.8 fold

Preeclampsia 1.7 - 1.9 fold

Primary cesarean delivery 1.6 fold

Failure to progress/ cephalopelvicdisproportion

1.6 fold

Labor induction 1.4-fold

Early spontaneous preterm birth 1.2 - 2.7

Large for gestational age infant 2 - 3 fold

Perinatal adverse outcomes in obese adolescents

Obstetric consequences of obesity

Consequences Impact: increased risk

Birth trauma 1.4 - 4 fold

Meconium aspiration syndrome 1.4 - 4 fold

Respiratory distress syndrome 1.4 - 4 fold

Low Apgar scores 1.4 - 4 fold

Premature rupture of membranes 1.4 - 4 fold

Length of stay >5 days 1.4 - 4 fold

Stillbirth 2 - 3 fold

(Sukalich, Mingione, Glantz, 2006)(Shaw, Wise, Mayo, 2014)(Harper, Chang, Macones, 2011) (Halloran, Marshall, Kunovich, & al, 2012)(Warshak, Wolfe, Russell, 2013)

Perinatal adverse outcomes in obese adolescents

Lifestyle factors which affect bodycomposition and obesity

Diet• Fatty foods: higher BMI.

• Sugary drinks lead to higher BMI.

• Bigger portions of food.

• Higher variety of refined foods.

Lack of exercise

• Lessens total energy expenditure and basal energy expenditure.

• Exercise is inversely related to body weight, BMI and degree of obesity.

Sleep deprivation

• Less energy expenditure

• Thermogenesis disturbance

• Increased fatigue

• More time to eat(Elizondo, Hernández, Zamora, 2011)

Take home messagesObese teens have a wide range of psychological, metabolic, gynecological and obstetric consequences

• Psycological and social distress

• Cardio-metaboliccomplications

• Risky sexual behaviour

• Earlier sexual maturation

• Reproductive dysfunction

• Dysmenorrhea

• Disorders of menstruation

• Contraception failure

• PCOS

• Mineralization and bonedensity alterations

• Macromastia

• Increased risk of breastand endometrial cancer

• Pregnancy and obstetriccomplications

• Perinatal complications

• Neonatal complications

Take home messages

• Ask about social behavior, bullying, social isolation, self-esteem, and anxiety during routine consultations.

• Apply a simple depression screening questionnaire.

• Refer to psycologist or psychiatrist if necessary.

Psycologicaland social

distress

• Inform patients and parents about CM risks

• Perform simple anthropometric measurements such as WC, and W/Ht ratio.

• Assess for fasting glucose, HOMA index, lipid profile.

Cardiometabolic

complications

• Gain the patient´s confidence.

• Ask about sexual behaviour, drugs, alcohol and contraceptive use during routine consultations or any.

• Give advice as patient provides information.

Risky sexual behaviour

Take home messages• Early physical examination and clinical history.

The greater the BMI percentile, the sooner.

• Talk to them about uncomfortable physical changes, greater risk of early sexual maturation: give reassurance

• Be ready to talk to the patient and parents aboutclothing issues, and how to handle sports and P.E. class.at school-

Earlier sexual maturation

• Explain to the patient and parents the increased risk of annovulatory cycles and infertility and decreasedeffectivness of ART if obesity continues.

• Assess for fasting glucose, HOMA index, hormonal profile.

Reproductivedysfunction

• The effect in a girl´s daily life of dealing withdysmenorrhea can be quite cumbersome and distressful.

• Provide the necessary care.

• Referral if needed to improve this condition.

Dysmenorrhea

Take home messages

• Patients should be counseled that weight loss mightameliorate the problem, including heavy menstrual bleeding.

• Investigate and consider how it disturbs daily life.

• Advise weight loss through healthy nutrition and physical activity.

Disorders of menstruation

• Emphasize with patients the higher risk they are at.

• Offer safer and more effective methods such as progestin long-acting reversible contraceptives(etonorgestrel implant and LNG IUD).

ContraceptionFailure

• Thorough screening to identify patients at risk, provideopportune diagnosis, and offer the needed care, evenbefore they undergo puberty.

• Screen for cardiometabolic abnormalities: glucose, HOMA, lipids

PCOS

Lifestyle factors which improve body composition and obesity

Diet• Balanced hypocaloric diet.

• Weight loss or maintainance.

• Avoid fatty foods, sugared drinks and sweets.

• Smaller portions of food.

• Higher variety of fruits and vegetables.

Physical Activity and Screen Time

• As recommended by tha AAP

Alcohol• Limit alcohol consumption to reduce caloric intake

Sleep Balance

• Children 8-9 hours

• Adolscents 7-8 hours(Elizondo, Hernández, Zamora, 2011)

Take home messages

Guidelines for treatment of Obesity according to AHA

Children 2-4 years oldwith obesity

Reduce BMI to achieve a weight gain rate of <1kg/2cm of linear growth

Children >4 years old withoverweight (BMI 85-95%) Children >4 years old withobesity (BMI >= 95%), no comorbidities

Reduce BMI to <85th percentile to mantain thepresent BMI;

or weight maintenance through linear growth.

Children > 4 years oldwith obesity (BMI >= 95 percentile), withcomorbidities

Individual approach based on the severity of comorbidities.When weight loss is necessary, it should be progressive and slow. If weight loss is big or quick, there will be a slowing-down of growth that will not be recovered further on.

Adolescents with obesitythat have completedlinear growth

More aggressive weight loss, similar to the one foradults.

Take home messages

(Daniels, Arnett, Eckel, & al, 2005)

Guidelines for treatment of Obesity according to AAP

2-5 years old 6-11 years old 12-18 years old

BMI 85-94th percentileMaintain weight up to a BMI <85th percentile ordiminish weight gain(deflection of BMI curve)

BMI 85-94th percentileMaintain weight up to a BMI <85th percentile ordiminish weight gain(deflection of BMI curve)

BMI 85-94th percentileMaintain weight up to a BMI <85th percentile ordiminish weight gain(deflection of BMI curve)

BMI >= 95th percentileMaintain weight up to a BMI <85th percentile; ifthere is weight loss withhealthy diet it should notbe over 500g/per month

BMI >= 95th percentileMaintain weight up to a BMI <85th percentile orgradual weight loss of 500g/per month

BMI >= 95th percentileWeight loss up to a BMI< 85th percentile, not over1kg per week

BMI >21 kg/m2 (rare)Gradual weight loss, notover 500g/ per month

BMI >= 99th percentileWeight loss, an average of 1kg per week

BMI >= 99th percentileWeight loss, an average of 1kg per week

Adapted from Spear BA et al. Recommendations for Treatment of Child and Adolescent Overweight and Obesity. Pediatrics. American Academy of Pediatrics,2007;120;S254-S288

Take home messages

Exercise recommendations in obesity

According to the AAP and the American College of Sports Medicine, adolescents and children should have:

• 60 minutes of physical activity, daily.

• Less than 2 hours per day of screen time (TV, videogames, computer). (Council on Sports Medicine and Fitness, 2006)

The activity should be enjoyable in the long run (Cycling, skating, jumping the rope, dancing, hiking).

Resistence training is not recommended in prepuberal children that haven’t achieved physical and bone maturity.

(Elizondo, Hernández, Zamora, 2011)

Take home messages

Thank you very much.God bless you !

Leticia Elizondo-Montemayorlelizond@itesm.mx

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