1 University of Alexandria High Institute of Public Health Department of Nutrition



Under supervision of




1. Introduction …………………………………………...……….. 03 2. Normal nutritional requirements …………………………… 03 3. Role of physical activity and good eating habits ………… 05 4. Definition of obesity ………………………………………….. 07 5. Body Mass Index (BMI) for age …..………………………….. 08 6. Causes of obesity ………………………………………….. 11

7. Complications of obesity ……….…………………………….. 14 8. Treatment of obesity …………………………………………… 16 9. Complications of treatment .………………………………… 19 10. References ………….…………………………………………… 21


Adolescence:is the period of life beginning with the appearance of
secondary sex characteristics and ending with the cessation of somatic .growth, occur between the ages of 12 and 21years old It is a period of physiological,psychological,and cognitive transformation .during which a child becomes a young adult

-:Stages of adolescence
Early : ages 12-14 years Middle : ages 15-17 Late : ages 18-21 Teens gain 40% to 50%of adult weight during adolescence. The majority of weight gain occurs with increase in linear height Males gain twice as much lean tissue as females, resulting in differentiation in percent body fat and lean body mass. Difference in lean body mass and body fat mass affect energy and nutrient needs throughout adolescence and .differentiate needs of females from those of males

Normal nutritional requirements:Micronutrient needs of youth are elevated during adolescence to support physical growth and development. Vitamins and minerals involved in bone, .RBCs, RNA,DNA, body mass Nutritional needs vary from individual to individual but basic nutritional requirements are clearly defined. The caloric requirements for adolescents are affected by biologic age, opposed to chronologic age. The RDA recommends 2700-2800 k calories for males aged 11-18 and 2100 2200 for females aged 11-18. These calories must be a proper mix of proteins, carbohydrates, fats, vitamins and minerals. Caloric needs are related to growth rate, basal metabolic rate and physical activity. Basal metabolic rate is the amount of energy required for the involuntary work of the brain, heart, muscles and digestive organs. Proteins are consist of more than 20 amino acids. Complete proteins are usually found in animal foods such as meats, eggs and milk. Incomplete proteins are usually found in vegetable proteins, such as beans and nuts.


Protein is needed for adequate cell growth. Too much protein can contribute to obesity. Carbohydrates include all starches and sugars. The sugars are fructose, found in honey, fruits and vegetables; lactose, found in milk; maltose, found in digested starches and sucrose which is commonly known as table sugar. Starches are found in potatoes, , beans, nuts and cereal grains. Carbohydrates supply energy to the body. Fats provide a good way to store energy, and are classified as saturated and unsaturated, the difference being that unsaturated fats are liquid at room temperature. Saturated fats, contained in animal foods, contribute to high cholesterol levels. Vitamins are needed for energy release and tissue building. Vitamins have specific functions. There is an increased need for vitamins during adolescence. Important vitamins include A, C, D, E, K, Thiamin, Riboflavin, Niacin B1, Folic Acid, B6, Vitamin B12 and Biotin. A well balanced diet usually supplies all necessary vitamins. Vitamin A, found in green and yellow leafy vegetables; folic, found in dark green leafy vegetables and citrus fruits; and B6 which is found in whole grain cereals, seeds, legumes and potatoes, are found to be insufficient in most adolescents.9 Minerals are necessary for muscle contraction, heartbeat control, bone and teeth formation and cell maintenance. Macrominerals are required in sufficient amounts and microminerals, or trace minerals, necessary for good health, are needed in small amounts. The examples of macrominerals and their sources are: calcium—milk and dairy products phosphorus—milk, peas, beef, pork, tuna and peanuts magnesium—seafood, nuts, meats, wheat bran potassium—oranges, tomatoes, bananas


The examples of microminerals and their sources are: Iron—seafood, iodized salt, eggs, green vegetables, dry beans and nuts. Copper—shellfish, organ meats, raisins Zinc—seafood, nuts, meat, eggs Chromium—meats and whole grains Manganese—nuts, legumes, whole grains Selenium—grains and onions (www.yale-edu/ynhti/curriculum/units)

What Role does Physical Activity and Good Eating Habits Play in Obesity?
For adolescents who are overweight, the goals should be to maintain a healthy weight, begin to practice good eating habits, and get more physical activity on a daily basis. Physical activity and exercise help burn calories. The amount of calories burned depends on the type, duration, and intensity of the activity. They need a total of 60 minutes of physical activity per day, but this does not have to be done all at one time. Short more 10 or 5 minute bouts of activity throughout the day are just as good.17

Types of physical activities:

1. Riding bikes 2. Playing an outdoor sport such as; soccer, baseball, or tennis. 3. Taking a walk 4. Dancing

5. Skating


6. Join school or community sports teams 8. Park the car at the end of the parking lot 9. Take the stairs instead of the elevator 10. Walk around with a quick brisk pace The foods you eat not only affect the increase of body weight it also can affect the way blood flows through your heart and arteries. A diet high in fat and cholesterol can gradually causes build-up in your arteries. That build-up slows down the blood flow and blocks small arteries. Along with physical activity, it is very important for children to learn and practice good eating habits.

Some of the good eating habits :

1. Eat fast food less often 2. Eat breakfast everyday 3. Eat more fruits and vegetables 4. Avoid inactive pastimes 5. Limit television time 6. Get up and move during commercials 7. Substitute fruit for candy and chocolate 8. Eat low- fat fruits and snacks


What is Obesity?
The problem of childhood obesity in the United States has grown considerably in recent years. Between 16 and 33 percent of children and adolescents are obese. Obesity is among the easiest medical conditions to recognize but most difficult to treat. Unhealthy weight gain due to poor diet and lack of exercise is responsible for over 300,000 deaths each year. The annual cost to society for obesity is estimated at nearly $100 billion. Overweight children are much more likely .to become overweight adults Prevalence of overweight and obesity .And 6.2%, respectively, among the Egyptian adolescents 12.1 5 % of never-married males age 10-19 and 6% of never-married females' age 10-19 in Egypt may be classified obese, i.e., their BMI values were at or above the 95th percentile on the age and sexspecific BMI growth charts. The BMI values for an additional 15 % of males and 19% of females fall between the 85th and 95th percentiles, indicating that they were classified as at risk of becoming overweight. The proportions of both males and females classified in the overweight and at risk of overweight categories were higher among urban than rural residents. These proportions also increased with mother’s education status and with the wealth quintile. For example, 31% of never-married females in the highest wealth quintile were overweight or at risk of being overweight compared to 17% of never-married females in the lowest wealth quintile. www.measuredhs.com/pubs/pdf/FR220/FR220.pdf EDS 2008 An obese person has accumulated so much body fat that it might have a negative effect on their health. If a person's bodyweight is at least 20% higher than it should be, he or she is considered obese


What is Body Mass Index (BMI)?
The BMI is a statistical measurement derived from your height and weight. Although it is considered to be a useful way to estimate healthy body weight, it does not measure the percentage of body fat. The BMI measurement can sometimes be misleading - a muscleman may have a high BMI but have much less fat than an unfit person whose BMI is lower. However, in general, the BMI measurement can be a useful indicator for the 'average person'. The following charts of BMI for Boys and Girls according to the ages

2 to 20 years: Boys & Girls Body mass index-for-age percentiles
Top of Form



Why do Teens become obese?
Teens become obese for several reasons, including:


1- Consuming too many calories. Teens are eating much more than they used to. This used to be the case just in developed nations - however, the trend has spread worldwide. Despite billions of dollars being spent on public awareness campaigns that attempt to encourage people to eat healthily, the majority of us continue to overeat. In 1980 14% of the adult population of the USA was obese; by 2000 the figure reached 31% (The Obesity Society). In the USA, the consumption of calories increased from 1,542 per day for women in 1971 to 1,877 per day in 2004. The figures for men were 2,450 in 1971 and 2,618 in 2004. Most people would expect this increase in calories to consist of fat - not so! Most of the increased food consumption has consisted of carbohydrates (sugars). Increased consumption of sweetened drinks has contributed significantly to the raised carbohydrate intake of most young American adults over the last three decades. The consumption of fast-foods has tripled over the same period. 2- Leading a sedentary lifestyle. With the arrival of televisions, computers, video games, remote controls, washing machines, dish washers and other modern devices, the majority of people are leading a much more sedentary lifestyle compared to their parents and grandparents. Some decades ago shopping consisted of walking down the road to the high street where one could find the bakers, banks, etc. As large out-of-town supermarkets and shopping malls started to appear, people moved from using their feet to driving their cars to get their provisions. In some countries, such as the USA, dependence on the car has become so strong that many people will drive even if their destination is only halfa-mile away. The less you move around the fewer calories you burn. However, this is not only a question of calories. Physical activity has an effect on how your hormones work, and hormones have an effect on how your body deals with food. Several studies have shown that physical activity has a beneficial effect on your insulin levels - keeping them stable. Unstable insulin levels are closely associated with weight gain. 3- Not sleeping enough. If you do not sleep enough your risk of becoming obese doubles, according to research carried out at Warwick Medical School at the University of Warwick. The risk applies to both adults and children.


Professor Francesco Cappuccio and team reviewed evidence in over 28,000 children and 15,000 young adults. Their evidence clearly showed that sleep deprivation significantly increased obesity risk in both groups. Professor Cappuccio said, "The 'epidemic' of obesity is paralleled by a 'silent epidemic' of reduced sleep duration with short sleep duration linked to increased risk of obesity both in adults and in children. These trends are detectable in adults as well as in children as young as 5 years." Professor Cappuccio explains that sleep deprivation may lead to obesity through increased appetite as a result of hormonal changes. If you do not sleep enough you produce Ghrelin, a hormone that stimulates appetite. Lack of sleep also results in your body producing less Leptin, a hormone that suppresses appetite. 4- Endocrine problems, such as some foods that interfere with lipid metabolism. A team from the University of Barcelona (UB) led by Dr Juan Carlos Laguna published a study in the journal Hepatology that provides clues to the molecular mechanism through which fructose (a type of sugar) in beverages may alter lipid energy metabolism and cause fatty liver and metabolic syndrome. Fructose is mainly metabolized in the liver, the target organ of the metabolic alterations caused by the consumption of this sugar. In this study, rats receiving fructose-containing beverages presented a pathology similar to metabolic syndrome, which in the short term causes lipid accumulation (hypertriglyceridemia) and fatty liver, and eventually leads to hypertension, resistance to insulin, diabetes and obesity. Poorly balanced diets and the lack of physical exercise are key factors in the increase of obesity and other metabolic diseases in modern societies. In epidemiological studies in humans, the effect of the intake of fructosesweetened beverages also seems to be more intense in women. (From "New Data On Fructose-Sweetened Beverages And Hepatic Metabolism"). Although there appears to be a consensus on the negative effects of fructose-sweetened beverages there is still some debate over the effects of fructose versus high fructose corn syrup - two studies of note are: "AMA Finds High Fructose Syrup Unlikely To Be More Harmful To Health Than Other Caloric Sweeteners" and "Fructose Sweetened Drinks Increase Non fasting Triglycerides In Obese Adults".


5- Lower rates of smoking (smoking suppresses appetite). According to the National Institutes of Health (NIH) "Not everyone gains weight when they stop smoking. Among people who do, the average weight gain is between 6 and 8 pounds. Roughly 10 percent of people who stop smoking gain a large amount of weight - 30 pounds or more." 6- Medications that make patients put on weight., some medications cause weight gain. "Clinically significant weight gain is associated with some commonly prescribed medicines. There is wide inter individual variation in response and variation of the degree of weight gain within drug classes. Where possible, alternative therapy should be selected, especially for individuals predisposed to overweight and obesity
e.g. Steroids –some psychiatric medications

N.B If one parent is obese, there is a 50 percent chance that the children will also be obese. However, when both parents are obese, the children have an 80 percent chance of being obese. Although certain medical disorders can cause obesity, less than 1 percent of all obesity is caused by medical problems. 7. Others stressful life events or changes (separations, divorce, moves, deaths, abuse) • family and peer problems • low self-esteem • depression or other emotional problems

1. Blood (fat) lipid abnormalities: The primary

dyslipidemia related to obesity is characterized by increased


triglycerides, decreased HDL levels, and abnormal LDL composition. (Howard BV, Ruotolo G, Robbins DC.) 2. Cancer, including cancer of the uterus, cervix, ovaries, breast, colon, rectum and prostate
3. Respiratory problems: Obesity can also cause respiratory

problems. Breathing is difficult as the lungs are decreased in size and the chest wall becomes very heavy and difficult to lift. (Medical College of Wisconsin) 4. Gallbladder disease Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is then delivered into the bile causing it to become supersaturated. Some evidence suggests that specific dietary factors (saturated fats and refined sugars) are the primary culprit in these cases (University of Maryland Medical Center) 5. Gynecological problems, such as infertility and irregular periods Heart disease: Obesity is associated with an excess occurrence of cardiovascular disease morbidity and mortality. (Department of Preventive Medicine, University of Tennessee
6. 7. High blood pressure: There are multiple reasons why

obesity causes hypertension, but it seems that excess adipose (fat) tissue secretes substances that are acted on by the kidneys, resulting in hypertension. Moreover, with obesity there are generally higher amounts of insulin produced. Excess insulin elevates blood pressure. 8.Metabolic syndrome 9.Nonalcoholic fatty liver disease 10.0steoarthritis :it an important risk factor for osteoarthritis in most joints, especially at the knee joint (the most important site for osteoarthritis). Obesity confers a nine times increased risk in knee joint osteoarthritis in women. Osteoarthritis risk is also linked to obesity for other joints. A recent study indicated that obesity is a strong determinant of thumb base osteoarthritis in both sexes. Data suggest that metabolic and mechanical factors mediate

15 11 skin probs, such as impaired wound healing 12. sleep apnea 13. Stroke 14. type 2 DM

Quality of life
When you're obese, your overall quality of life may be lower, too. You may not be able to get around or to perform normal daily activities as well as you'd like. You may have trouble participating in family activities. You may avoid public places... Other issues that may affect your quality of life include:
    

Depression Disability Physical discomfort Sexual problems Shame (www.mayoclinic.com)

Treatments for obesity
Obesity treatments have two objectives: 1. 2. To achieve a healthy weight. To maintain that healthy weight.


Treatment of adolescent obesity is controversial and difficult. Many topics need to be addressed in the initial evaluation, such as:
o o o o o

diet history culturally accepted food types level of physical activity presence of behavior disorders family dysfunction

Particular attention to capacity and readiness to change is recommended as part of the evaluation. If a patient has not started to contemplate the implications of a behavior change, then attempts to prepare for change by the clinician may actually result in a negative experience for both the patient and family. A successful obesity regimen has been described as one that prevents increased weight gain, causes a 5% to 10% reduction in initial body weight, and establishes long-term maintenance once weight loss goals are achieved. Interventions: Increasing physical activity  Decreased television watching time  Encourage participation in physical education classes Introduction of daily activities such as using stairs, etc. o Dietary interventions  Reduction of dietary fat is essential, through diets such as the "stoplight" diet, which limits high-fat and high-calorie foods by grouping into usable categories that allow the patient to make food choices regarding the meal plan.  Introduction of a ketogenic diet, which has been shown to obtain rapid weight loss in highly motivated patients. The diet consists of 80-100 g of protein, 25 g of fat, 25 g of carbohydrate, totaling 700 calories per day. This is a temporary diet for at-risk patients, and controversy remains regarding the long-term efficacy of this plan.  Dietary glycemic index diet. The glycemic index describes the degree to which blood glucose rises after a meal. Refined, starchy foods, like bread, cereal and potatoes and concentrated sugars have a high glycemic index, whereas most vegetables, legumes and fruits have a low GI. Studies have shown that after a high GI index meal, blood glucose and insulin levels generally rose higher than after the low-GI meal. A few hours after the high GI meal, blood glucose and fatty acids decreased to relatively low levels an epinephrine rose markedly. These



metabolic changes are associated with increased hunger, and subjects were found to eat 80% more calories after the high GI meal versus the low GI meal. Thus, a low GI diet may help decrease hunger and promote weight loss. o Drugs  The use of drugs in adolescent patients is not recommended at this time, however, several new drugs are under investigation.  Sibutramine (Meridia) is a serotonin and noradrenalin reuptake inhibitor that has been shown to increase energy expenditure and satiety in clinical trials  Orlistat (Xenical) reduces the absorption of fat from the GI tract by blocking pancreatic lipases. Use of this drug has been shown to reduce weight, improve LDL cholesterol and circulating insulin levels.  A novel approach to drug therapy may be leptin and leptin receptors. Leptin is a circulating hormone produced primarily in adipose tissue that induces profound changes in hunger and energy homeostasis, presumably through interaction with receptors in the hypothalamus. Clinical trials with leptin administration are currently under way. Surgery

Weight loss surgery (bariatric surgery)
Weight loss surgery (WLS) is also known as Bariatric Surgery. It comes from the Greek work baros, which means weight. WLS is a development of cancer/ulcer operations that consisted of removing part of a patient's stomach or small intestine. Those cancer/ulcer patients subsequently lost weight after surgery. Doctors decided the procedure might be beneficial for morbidly obese patients. In 2008 about 220,000 bariatric operations were carried out in the USA (American Society for Bariatric Surgery). As obesity levels in America and many other parts of the world grow, so does the number of bariatric procedures. About 15 million people in the U.S. have morbid obesity; only 1% of the clinically eligible population is being treated for morbid obesity through bariatric surgery. According to the American Society for Bariatric Surgery, the average female surgery patient weighs about 300 pounds. The American Society for Bariatric and Metabolic Surgery says that Bariatric surgery can improve or resolve more than 30 obesity-related conditions, including type 2 diabetes, heart disease, sleep apnea, hypertension and high cholesterol .


Basically, bariatric surgery alters your stomach or small intestine so that you are unable to consume much food in one sitting. This reduces the total number of calories you consume each day, thus helping to lose weight.

There are two types of bariatric surgeries:
• Restrictive

procedures - These make your stomach smaller. The surgeon may use a gastric band, staples, or both. After the operation the patient cannot consume more than about one cup of food during each sitting, significantly reducing his food intake. Over time, some patients' stomachs may stretch and they are gradually able to consume larger quantities. • Malabsorptive procedures - Parts of the digestive system, especially the first part of the small intestine (duodenum) or the mid-section (jejunum), are bypassed. Doctors may also reduce the size of the stomach. This procedure is generally more effective than restrictive procedures. However, the patient has a higher risk of experiencing vitamin/mineral deficiencies because overall absorption is reduced Although effective, ileojejunal bypass surgery has major medical risks, including fatal intraoperative complications, wound dehiscence, pain, diarrhea, electrolyte disturbances, and nephrolithiasis.  New laparascopic techniques may prove to have fewer complications, however, little research has been done to assess the longterm effects of gastric bypass in adolescent patients. Surgery should only be considered in patients who are extremely obese patients who are suffering major complications and in whom conventional treatment has failed. o . Team approaches that involve the pediatric subspecialties are appropriate for children and adolescents that are at risk. The physician makes evaluation to rule out underlying endocrine, metabolic, or genetic conditions. The nutritionist obtains a detailed diet history, identifies problem areas such as skipped meals and excessive fruit juice or soda consumption, and works with the family to set realistic goals for dietary change. The behavioral medicine specialist assesses the adolescent
 o

level of motivation, relevant family dynamics, and any obstacles to effective lifestyle modification.

Complications of Treatment


Development of an eating disorder, other psychological problems and gallbladder disease are potentially preventable complications. Gallbladder disease can result from rapid weight loss over a relatively short period of time, and this risk can be minimized by keeping weight loss at rates less than 1.5 kg/wk. The challenges of an adolescent health care provider are to raise the awareness of the importance of obesity among patients and families, identify high-risk individuals early and offer treatment or referrals as necessary. Culturally sensitive counseling promoting a balanced diet, increased physical activity, and decreased television watching time should be widely available to adolescents and their families. The best treatment for obesity in adolescents is one which provides realistic goals. When setting these goals, it is important to consider many factors, including age, motivation, emotional stability, hereditary body build, extent of overweight or obesity, attitudes towards food, home life and physiologic state. A realistic goal for weight loss is slow, averaging 1 to 2 lbs. per week. The importance of a balanced diet must be emphasized. There needs to be a proper mix from all food groups. It is important to eat at least three meals a day, choose foods that have fewer calories, eat smaller portions, cut the intake of fats, alcohol, sugars and limit starches. Fat intake should be 30% (or less) of the total daily calories, carbohydrates 58% and proteins 12%. Calorie levels for obese adolescents should be approximately 1500—1800 k calories. Suggested food substitutions should be provided. A structured physical activity program must be combined with dieting. Exercise is important in weight reduction and maintenance. Besides providing a positive emotional outlet and a general sense of well being, exercise is a way to have a more attractive body. Walking up the stairs instead of using an elevator, walking rather than driving or taking the bus are some routine activities that can increase physical activity by changing regular patterns. Obese teenagers generally do not like gym classes in school. Motivational techniques must be utilized by educators and parents to promote student participation in such physical activities. Swimming is considered to be an ideal first exercise for overweight children. Playing ball (softball, kickball) is also a good activity. Gymnastics provide an opportunity to develop flexibility and strength. Exercise promotes the development of socialization skills, provides time away from food, decreases appetite, increases absorption of calories and improves physical and mental health. Consistency and continuity in diet and exercise must be stressed.


To achieve weight loss adolescents must want to lose weight and must have adequate support. Diet and exercise should promote a change in behavior, attitudes and life-style, through behavior modification programs. These programs encourage changing the place, times and location of consumption of food

. Some recommended suggestions for modifying eating behavior are:, do not read or watch TV while eating, take only the amount you intend to eat to the table, do not feel you must finish everything on your plate if you feel you’ve had enough, do not take second portions, measure portions, drink a glass of water before each meal, eat three meals a day and reward yourself realistically. Alternative techniques for combating stress, boredom and fatigue, rather than eating food are encouraged while maintaining a food diary. This diary should include information about time spent eating, hunger rating, mood, circumstances, food consumed and quantity. Through constant monitoring of the food diary, eating behavior can be changed. With adolescents a multidisciplinary approach must be used when dealing with obesity. The nurturing and care levels associated with childhood must be continued throughout adolescence.


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