Invited lecture by Dr Sujoy Dasgupta in a Webinar by Food, Drugs and Medicosurgical Equipment Committee of FOGSI (Federation of Obstetric and Gynaecological Societies of India) on “Adolescent Nutrition: Challenges and Way Forward” held in November, 2021.

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Consultant: Reproductive Medicine, Genome Fertility Centre,
Kolkata
• Managing Committee Member, Bengal Obstetric & Gynaecological Society
(BOGS)- 2019-20
• Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS-
2019-20
• Member, Endocrinology Committee, FOGSI
• Member, Food & Drug Committee, FOGSI
• Convener, Spectrum MRCOG Course, Kolkata
• Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress,
London, 2019
Obesity in Adolescent-
Right Time to Intervene

2. Who are adolescents?
• A period of human growth and development
that occurs after childhood and before adulthood
• Includes those persons between 10 and 19 years
of age (WHO 2014).
1. early adolescence (10-14 years)
2. late adolescence (15-19 years)
• India has the largest adolescent population in
the world, 253 million, and every fifth person is
between 10 to 19 years.

4. What is obesity?
• “a condition of abnormal or excessive fat
accumulation in adipose tissue, to the extent
that health may be impaired.” (WHO)

5. Body Mass Index (BMI)

6. Limitation of BMI

7. Obesity in Indian population
• Frank obesity not as high as in the West
• Asian are especially prone to ‘adiposity’ (fat
content in the body) and its consequences.
• South Asians have at least 3 to 5% higher body
fat for the same BMI as compared to
Caucasians.
• The fat is typically located ‘centrally’ (i.e.
waist, trunk) and around visceral organs –
metabolically more dangerous than peripheral
fat.

8. Danger of Obesity

10. Understanding obesity and its impact on
female reproductive function is important
because future generations, namely, the
children of obese women, ultimately will
be affected.

14. Indian Scenario

17. Phases of evolution in obesity
• Role of Intrauterine growth pattern
• Relationship between birth weight & Future BMI.
• Insulin resistance, LBW & obesity (“Thin Fat
baby”)
• Consistently protective role of breast feeding .
• Early menarche predisposes to obesity
• 80% obese adolescents will become obese adults

18. Obesity and reproductive problems
• Precocious puberty
• Delayed puberty
• PCOS (Type II)
• Hypothalamic amenorrhoea (Type I)
• Menstrual irregularities
• Heavy menstrual bleeding

19. Obesity & PCOS
• Obesity leading to insulin resistance is one of the
major root cause for PCOS
• Obesity associated PCOS results in Type 2
Diabetes in long term.
• Obesity which occurs in 30-75% of women with
PCOS increases the magnitude of hormonal and
metabolic dysfunction in these women.

20. Decrease sex hormone
Binding globulin
Increase in insulin
Like growth factor 1
Thecal cell hyperplasia
In ovary
Increase in androgen activity
Increase in LH
Hyperinsulenemia
Insulin Resistance
Excess Body Fat
Anovulation
BMJ 1998;317(7154):329

21. PCOS with Obesity
• Anovulation
• Menstrual irregularities
• Insulin Resistance, IGT, Type II DM
• Metabolic Syndrome
• Cardiovascular Events
• Obstructive Sleep Apnoea (OSA)
• Non-alcoholic fatty liver (NAFD)
• Endometrial Cancer
• Pregnancy Complications

22. Obesity → PCOS?
• Fasting → ↑Ghrelin and Adiponectin → ↓GnRH Pulse
generator
• Teleologically, this mechanism helps conserve energy
during times of famine, while encouraging reproduction
when food is more readily available.
• High caloric intake→ ↑leptin→ ↓neuropeptide Y (NPY) →
↑proopiomelanocortin (POMC) → ↑hypothalamic GnRH
pulse generator → ↑ gonadotropin levels, mainly LH.
• Both insulin and leptin also act peripherally on the ovaries,
where leptin potentiates insulin-induced theca cell
proliferation and intra-ovarian androgen production.
• leading to PCO/PCOS phenotypes.

23. Khairy M, Rajkhowa M. Effect of obesity on assisted reproductive treatment
outcomes and its management: A literature review. The Obstetrician &
Gynaecologist 2017;19:47–54.
• A minority of morbidly obese patients have
mutations in the leptin or leptin receptor
genes leading to a complete lack of response to
leptin with phenotypic features of obesity
and hypogonadotrophic hypogonadism.

24. Management of obesity in
adolescents
1. Lifestyle changes- diet and exercise
2. Drugs- CNS acting and non-CNS acting
3. Bariatric surgery
4. Screening, early detection and management
of metabolic complications

26. Lifestyle Intervention
• The main principle of dietary modification is a low caloric
intake with a recommended daily caloric intake of 600
kcal less than caloric requirement to maintain a stable
body weight.
• Very low-calorie diets (<800 kcal/day) should not be used
routinely and if used in cases of emergency, the diet
should be nutritionally complete and followed for a
maximum of 12 weeks.
• The importance of a multidisciplinary approach to
lifestyle interventions aimed at combating obesity has
recently been re-emphasised, as no single intervention
seems to be effective for long-term control.

27. Specific Dietary Advice
• Base your meals on starchy foods such as potatoes, bread, rice and
pasta, choosing wholegrain if possible. These foods are satisfying without
containing too many calories.
• Eat at least 5 portions of different fruit and vegetables every day rather
than foods that are higher in fat and calories. Potatoes do not count towards
your five-a-day target.
• Eat a low-fat diet and don’t increase the number of calories you eat.
• Avoid drinks that are high in added sugars, other foods such as sweets,
cakes and biscuits that have a high fat or sugar content and fried food.
• Eat fibre-rich foods such as oats, beans, lentils, grains and seeds, as
well as wholegrain bread, brown rice and wholemeal pasta.
• Eat some protein every day; choose lean meat, and try to eat two
portions of fish a week. Lentils, beans and tofu are also a good source of
protein.
• Always take breakfast.

31. Snacks what you like

33. Paradigm shift

34. Target of Weight Control
• SMART (Specific Measurable, Achievable, Realistic and
Timely)
• The weight-loss target should be set realistically at no more
than 0.5–1 kg/week and should be agreed individually
• A minimum of 150 min/week of moderate intensity physical
activity or 75 min/week of vigorous intensities on 2 non-
consecutive days/week
• A minimum of 250 min/week of moderate intensity
activities or 150 min/week of vigorous intensity on 2 non-
consecutive days/ week
• Activity be performed in at least 10-minute bouts or around
1000 steps, aiming to achieve at least 30 minutes daily on
most days.
• Minimised sedentary, screen or sitting time.

35. Benefits of Weight Loss
5% weight loss results in improvement of endocrine parameters, such
as decrease in free testosterone, lower fasting insulin levels and
increased frequency of ovulation.
In addition, weight loss causes a significant reduction in central fat
deposits (11%) and serum luteinizing hormone levels with return of
normal menstrual cycles in four out of five women.
J Hum Reprod Sci. 2010 May-Aug; 3(2): 62–67.

36. 5,2,1,0 Rule
• 5 or more fruits & vegetables
• 2 hours or less recreational screen time
• 1 hour or more of physical activity
• 0 sugary drinks, more water & low fat milk

38. CNS Acting Drugs
• appetite suppressants -sibutramine
• cannabinoid receptor antagonists-
rimonabant
• have been withdrawn from the market in the
UK due to concerns over cardiovascular
effects (hypertension, palpitation) for the
former class and neuro-psychiatric effects
including depression and suicidal risks of
the latter class

39. Orlistat
• Non CNS Acting (Locally acting), lipase inhibitors
• Decrease Dietary Fat Absorption - (GI Tract)
• The recommended dose is 120 mg taken immediately before,
during, or up to 1 hour after each meal (maximum 120 mg
TDS).
• Common side effects include flatulence, oily leakage from
the rectum with steatorrhoea and fecal urgency.
• Prolonged administration can lead to malabsorption, and
vitamin deficiency syndromes.
• Orlistat should, therefore, be used for longer than 12 weeks
only if weight loss exceeds 5% of the initial bodyweight and
after counselling patients about the potential risks and
benefits.
Khairy M, Rajkhowa M. Effect of obesity on assisted reproductive treatment outcomes and its
management: A literature review. The Obstetrician & Gynaecologist 2017;19:47–54.

40. Metformin
• There is currently no evidence that the use of insulin-sensitising agents
confers any long-term benefit.
• Metformin has been shown to have beneficial short-term effects on insulin
resistance and other cardiovascular risk markers in women with PCOS
without type II diabetes.
• Women with a BMI of >37 kg/m2 may not respond well to the standard
dose of metformin therapy.
• lifestyle intervention was superior to metformin in improving
cardiometabolic risk factors and progression to type II diabetes
• Metformin can be considered in women with PCOS who are already
undergoing lifestyle treatment and do not have improvement in impaired
glucose tolerance and in those women with impaired glucose tolerance
• Should NOT be regarded as therapy solely for WEIGHT-LOSS

42. Bariatric Surgery
• BMI ≥ 40 kg/m2
• BMI 35-40 kg/m2 with other comorbidities, where
nonsurgical management has proven unsuccessful
• National Institute for Health and Care Excellence (NICE).
Obesity: Guidance on the prevention of overweight and
obesity in adults and children. NICE clinical guideline 43.
Manchester; NICE: 2006 [https://www.nice.org.uk/
guidance/cg43/resources/guidance-obesity-pdf]. Accessed
2015 Jul 27.

43. Lumsden MA, Hor K. Impact of obesity on the health of women in midlife. The
Obstetrician & Gynaecologist 2015;17:201–8.

44. Take Home Messages
• Obesity in adolescent- growing problems
• Incorporate physical activity into the school
day
• Participate in local or state activity that
promote activity & healthy eating.
• Collaborate with parents, nutritionist &
teachers.
• Educate, educate & educate children as well as
parents on evils of obesity.

45. Thank You