1. Mansoura Faculty of Medicine.
Two Intimate Epidemics: Peripubertal Obesity and Polycystic Ovarian Syndrome BY
Professor
Mohammad Emam
OB & GYN Dept.
Mansoura Faculty of Medicine.
Egypt
2007

2. Definitions Obesity is:
excessive storage of triglycerides in adipose cells. (Adipocytes)
Peripubertal obesity( PPO): comprises childhood and adolescent obesity .

3. Definitions Obese= Above 95th percentile for age . For children,
overweight = BMI 85th to 95th percentile for age
Obese= Above 95th percentile for age .
For adolescent and adults,
BMI > 25 = overweight
BMI > 30 = obese,
BMI > 40 = morbidly obese

5. Definition PCOS ( After 2003)
Two of the following three features are present, after exclusion of other etiologies :
(i) Oligomenorrhoea and or Anovulation
(ii) Hyperandrogenism and/or hyperandrogenemia.
(iii) Polycystic ovaries (sonar).

6. RATIONALE
Peripubertal obesity :
Is associated with medical and psychosocial co-morbidities that are both immediate and long-term.
PCOS:
Is one of the co-morbidities and sequelae of Peripubertal obesity .
An emerging epidemic especially in developing countries.
Prevention of Peripubertal obesity is the first line for prevention of PCOS.

7. Objective:
To illustrate the link between two current epidemics , Peripubertal obesity and PCOS.
To pinpoint the role of gynecologists regarding these two epidemics.

8. Peripubertal obesity Prevalence
In USA :
doubled in 6-12 year .
tripled in adolescents.
15% of 6-19 year are obese.
In different countries :
Range from ( 10% to 25%).

9. Childhood Obesity Epidemic
(title appears) The airwaves have been filled of late with two public health pronouncements that are increasingly linked by cause and effect. The first is that physical activity has a profound positive physiological effect on the body. The second is that childhood obesity is growing in epidemic proportions.
(rest of slide appears) That childhood obesity is on the rise is undeniable. The rates have been advancing steadily for the past 35 years with obesity growing from 4% to 13% in 6 to 11 years olds and from 5% to 14% in 12 to 19 year olds. In just two decades, the number of obese children has doubled. 1.
Source: National Center for Health Statistics, 1999 National Health and Nutrition Examination Survey.

11. MORE THAN 1 IN 4 CHILDREN IS OVERWEIGHT or OBESE!!

12. Peripubertal obesity -A true epidemic
Obesity is now 4X more common than malnutrition in developing countries.
Obesity would surpass tobacco as leading cause of death.

13. Peripubertal obesity -A true Epidemic
The current epidemic is due to interactions between genetic ,epigenetic and environmental factors :
Increased sedentary life
Decrease in physical activity.
Increased energy intake

14. Causes of Childhood Obesity
Genetics
Neuroendocrine
Cultural
Childhood obesity
Behavioral
Socioeconomic

15. Obesity Is Caused by Long-Term Positive Energy Balance
Fat Stores

16. Peripubertal obesity Energy Out Energy In Weight gain:
Weight gain happens when you consume more energy (calories from food and drinks) then you actually expend through daily activities and exercise.
Our society has become more dependant upon the car for transportation, we watch more TV, and spend tons of time using other media including computers and video games. At the same time, our portion sizes have gotten larger, and foods that are rich in calories have become easier to access and are cheaper (Lancet, 02)

17. Snacking as a food trend has increased in children over the past two decades.

18. Swollen Food
Over the last 2 decades, almost every food portion has swollen.
For many of us, the little paper bag on the right was our introduction to fast food french fries. Many remember when cardboard boxes first came out for the jumbo orders. Now, the bag, like the 12 ounce soda, is an historical oddity.
210 Calories
2.4 ounces
610 Calories
6.9 ounces

19. Soft Drinks
Become part of the daily diet for many school age children.
Leads to a higher daily energy intake and reduced intakes of some essential nutrients

20. TV and Computer ( Sedentary behavior)
Talk
Create
Talk
Snack
More
Buy
More
Relate
Run
Eat
More
Sit
More
Imagine
Play
Read

22. Some Interesting Results
TV & computer= Main culprit for energy imbalance.
Healthy Kids Watch Less TV.
Sedentary children are more likely to be obese.

23. Consequences of Peripubertal obesity later in life
Psychosocial
Poor self-esteem
Depression
Eating disorders
Pulmonary
Sleep Apnea
Asthma
Exercise Intolerance
Gastrointestinal
Gallstones
Steatohepatitis
Renal
Glomerulosclerosis
Musculoskeletal
Slipped capital femoral epiphysis
Blount’s disease
Forearm fracture
Flat feet
Neurological
Pseudotumor cerebri
Cardiovascular
Dyslipidemia (hypercholesterolemia
and (hypertriglyceridemia)
Hypertension
Coagulopathy
Chronic inflammation
Endothelial dysfunction
Endocrine
Type 2
Precocious puberty
Polycystic ovary syndrome (girl)
Hypogonadism (boys)
Obesity impacts almost every aspect of health, starting with mental health and extending to every system in the body. This slide illustrates some of that impact.
Perhaps most importantly, CLICK mental health suffers: our culture, our media teach our children that they are ugly or weak or ridiculous if they are fat. We laugh at fat people. The child loses self-esteem and becomes depressed. Some stop eating, or binge and purge, in an effort to be thin, to have control.
CLICK
Breathing suffers. In Charles Dickens’ The Pickwick Papers, Fat Joe was a boy who could hardly stay awake. Today, we give the name Pickwickian Syndrome to sleep apnea and daytime somnolence is an obese patient. The mainstay of treatment is weight loss. Asthmatic children who are obese in puberty are 3 times more likely to carry there symptoms into and through adulthood. If one loses weight by exercising, but can’t breathe enough to exercise because of the effort of lifting the chest wall, what happens? How do you escape?
The gastrointestinal tract is an obvious place to find health impact of weight. Overweight is historically one of the cardinal risks for gallstones. Steatohepatitis refers to accumulation of fats in the liver, and can lead to cirrhosis, This, too, improves with weight loss.
In the kidney, obesity is a risk factor for the development of focal segmental glomerulosclerosis. This term refers to the circumscribed loss of individual microscopic filtering units in the kidney, in the same way that a tornado can devastate one block but leave surrounding homes untouched.
Bones have to carry the child’s mass. Obesity increases the load on the femur and the risk that the head of the thigh bone with be pushed off the bone, resulting in pain and deformity. Blount’s disease, or tibia vara, is a permanent bowing of the legs thought to result from compression of the inside or medial part of the growth plate of the shin bone. The outside or lateral part of the shinbone grows faster, resulting in an apparent bowing. It may affect one or both sides. This is painful, and permanent. In a fall, an obese child is more likely to break the radius and ulna because of their weight. Obesity is also thought to be a risk factor for overpronation, or fallen arches.
In the brain, obesity is a risk for a form of chronic headache called Psuedotumor cerebri which notoriously strikes obese women.
The big guns in today’s world: the cardiovascular and endocrine constellation known as the metabolic syndrome. Diabetes, hypertension, dysfunction of the blood vessel lining (or endothelium) and obesity all serve as evidence of insulin resistance. This combination carries a four- to eight-fold risk of heart attack. This is the epidemic that will kill our children. It is preventable, with regular exercise and a balanced diet.

24. Sequelae Specific to Children ( Disease of Diseases)
Metabolic Syndrome.
Hypertension
Fatty Liver .
Liability for PCOS at adolescence.
Early Sexual Maturation.
Asthma
Sleep apnea

25. Sequelae Specific to Children … cont
Persistence of Obesity at Adulthood:
Overweight adolescents have a 70% chance of becoming overweight adults.
Increases to 80% if one or both parents are obese.
Obese 6 year old has a 25% chance of becoming obese adult
Obese 12 year old has a 75% chance of becoming a obese adult.

27. PCOS : An Epidemic
About 20% of reproductive age women demonstrate the ultrasound picture of polycystic ovaries.
About % have clinical or biochemical signs of Anovulation and androgen excess.
PCOS, starts in adolescence But Unfortunately not always diagnosed at that age ,

28. PCOS : An Epidemic
Caused by Complex interaction of genetic ,epigenetic and environmental factors.
An epidemic in developing countries
( ED & PCOS !!!!).

29. Link between Peripubertal obesity & PCOS
IR & ghrelin & Leptin & Fat, steroid

30. Prevalence Of Insulin Resistance Syndrome In PCOS
Affects 2/3 of the PCOS women

31. Prevalence Of Insulin Resistance Syndrome In Childhood obesity
Prevalence about 28% (Cook et al, 2003 & de Ferranti et al., 2004)

32. The Central Player ( Insulin Resistance )
Pregnancy
Aging
Drugs
Lifestyle
Insulin
Resistance
Genetics
obesity
Increased lipid storage
PCOS
Hyperinsulinemia
Altered lipoprotein &
cholesterol metabolism
Altered steroid
hormone metabolism

33. IR : The central paradox
The high ovarian response to insulin.
Opposed by the whole body resistance.

35. LEPTIN
Leptin (leptos = thin) is 167 AA peptide secreted by adipocytes and circulates in blood .
Blood levels proportional to total fat mass.
Exerts a specific action on steroidogenesis and follicular maturation in ovary.
Effects: - appetite inhibition effects on GH-RH and GnRH

36. GHRELIN (orexigenic effects)
A peptide 28 AA peptide .
Secreted by gastric mucosa on an empty stomach.
Fasting   GHRELIN level.
GHRELIN level in most obese are lower than in non obese.
 APPETITE   FOOD INTAKE
  FAT UTILIZATION
IN OBESITY, GHRELIN level .
OVERPRODUCTION  OBESITY

37. GHRELIN & Leptin antagonism
The satiety effect of leptin is abolished by co-injection of ghrelin  leptin / ghrelin antagonism.

38. Role of Gynecologist
Management of PCOS should start by early intervention in hi-risk peripubertal kids by prevention of obesity.
Prevention of peripubertal obesity:
Primary prevention is vital.
secondary prevention:
Effective treatment programs for children and adolescent who are already overweight.

39. approach For prevention
Cooperation between :
Medical (pediatric)
Dietetics
Physical activity
Psychological / socialogical

40. Primary Prevention Achieving equilibrium of the energy balance.
Energy input =
Energy loss..
FOOD INTAKE
ENERGY EXPENDITURE

41. Secondary Prevention (Obesity Treatment Pyramid)
Diet
Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery

42. Secondary prevention Life- style modifications: Improve IR
Diet modification
Weight loss
Exercise
Psychosocial support.
Improve IR
( Metformin)

43. Conclusions
We are facing two current epidemics which affect a large scale of population and also affect their reproductive future .
Childhood Obesity is a Public Health Perspective

44. Recommendations:
We recommend cooperation of multi-faceted, large-scale interventions for Prevention of peripubertal obesity :
Dietary modification.
Increased physical activity.
Decreased sedentary activity.
Behavior modification.

45. OB& GYN, Mansoura Faculty of Medicine
Thank you
Prof. Mohammad Emam
OB& GYN, Mansoura Faculty of Medicine
EGYPT
Telfax & .