Two Intimate Epidemics: Peripubertal Obesity and Polycystic Ovarian Syndrome

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Two Intimate Epidemics Peripubertal Obesity
and Polycystic Ovarian Syndrome

• BY
• Professor
• Mohammad Emam
• OB GYN Dept.
• Mansoura Faculty of Medicine.
• Egypt
• 2007

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Definitions

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

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Definitions

• For children,
• overweight BMI 85th to 95th percentile for
  age
• Obese Above 95th percentile for age .
• For adolescent and adults,
• BMI gt 25 overweight
• BMI gt 30 obese,
• BMI gt 40 morbidly obese

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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).

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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.

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Objective

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

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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).

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Childhood Obesity Epidemic
Source National Center for Health Statistics,
1999 National Health and Nutrition Examination
Survey.
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• MORE THAN 1 IN 4 CHILDREN IS OVERWEIGHT or OBESE!!

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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.

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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

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Causes of Childhood Obesity
Genetics
Cultural
Neuroendocrine
Childhood obesity
Behavioral
Socioeconomic
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Obesity Is Caused by Long-Term Positive Energy
Balance
FatStores
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Peripubertal obesity
Weight gain
Energy Out
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• Snacking as a food trend has increased in
  children over the past two decades.

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Swollen Food

• Over the last 2 decades, almost every food
  portion has swollen.

610 Calories 6.9 ounces
210 Calories 2.4 ounces
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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

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TV and Computer ( Sedentary behavior)
Talk
Buy More
Snack More
Eat More
Sit More
Imagine
Play
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Some Interesting Results

• TV computer Main culprit for energy imbalance.
• Healthy Kids Watch Less TV.
• Sedentary children are more likely to be obese.

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Consequences of Peripubertal obesity later in
life
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Sequelae Specific to Children( Disease of
Diseases)

• Metabolic Syndrome.
• Hypertension
• Fatty Liver .
• Liability for PCOS at adolescence.
• Early Sexual Maturation.
• Asthma
• Sleep apnea

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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.

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PCOS An Epidemic

• About 20 of reproductive age women demonstrate
  the ultrasound picture of polycystic ovaries.
• About 5- 10 have clinical or biochemical
  signs of Anovulation and androgen excess.
• PCOS, starts in adolescence But Unfortunately
  not always diagnosed at that age ,

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PCOS An Epidemic

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

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Link between Peripubertal obesity PCOS
PCOS
Peripubertal obesity
IR ghrelin Leptin Fat, steroid
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Prevalence Of Insulin Resistance Syndrome In PCOS

• Affects 2/3 of the PCOS women

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Prevalence Of Insulin Resistance Syndrome In
Childhood obesity

• Prevalence about 28 (Cook et al, 2003 de
  Ferranti et al., 2004)

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

• The high ovarian response to insulin.
• Opposed by the whole body resistance.

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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

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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

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GHRELIN Leptin antagonism

• The satiety effect of leptin is abolished by
  co-injection of ghrelin ? leptin / ghrelin
  antagonism.

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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.

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approach For prevention

• Cooperation between
• Medical (pediatric)
• Dietetics
• Physical activity
• Psychological / socialogical

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Primary Prevention

• Achieving equilibrium of the energy balance.
• Energy input
• Energy loss..

FOODINTAKE
ENERGYEXPENDITURE
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Secondary Prevention (Obesity Treatment Pyramid)
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Secondary prevention

• Life- style modifications
• Diet modification
• Weight loss
• Exercise
• Psychosocial support.
• Improve IR
• ( Metformin)

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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

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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.

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Thank you
Prof. Mohammad Emam
OB GYN, Mansoura Faculty of Medicine EGYPT
Telfax 0020502319922 0020502312299 Email.
mae335_at_hotmail.com