Nutrition Problems in lndonesia
1. lron Deficiency
Malnutrition:
l. Undernutrition
2. Overnutrition ----+ Obesity
lndonesia
Double Burden
2. Vitamin A Deficiency
3. lodine lleficiency
4. Malnutrition
Obesity:
lncreased of body weight caused by an
excess accumulation of body fat
Over weight
lncrcased of body weight caused by an increase
of lean body mass without excess accumulation
of fat
 Pre adipocarte diffrentiation
Etiology of Obesity
16 Weeks: Multi Factorial and complex
Diffrenthtion of embryonic cell which
contain lipoprotein lipase
30 weeks
Fat depooitlon doesn't commence

3th trimester
Rapid accumulation of fat
Total body fat in full term infant 400 gr (16% BW)
- 80% synthezise
- 20% FFA transPlacentallY
- hypertrophyl hYPerPlasia
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Enviroment J***ou
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Positif energy balanced
storcd as adipose tissue obes.tyand rerevision
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Ghildren ;

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Excessive energy intake
lnadequate exercise (scdentary life style)
low metabolic rab to body composition and mass
increased insulin sensitivity
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 Timing of Solid Food lntroduction and
Risk of Obesity The Role of maternal Obesaty in Early Pregnancy
in Preschool-Aged Ghildren
prevalence of childhood obesity:
847 infants
t. 67% br€astfed, 33% formula-fed. 2 yeas 9,5o/o
2. 3 years, 75 childrcn (9%) were obese' 3 years 14,8o/o
3.1. BF , OR 1,t (95% Cl 0,3 -4,4)
3.2. Formula lnfant 4 years 14,8o/o
lntroduction of solid foods < 4 months + 30,3% if the children had
6 times than BF, OR 6.3 (95% Cl 2.3- 6.91 obese mother.

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Genetic
- oen mutatlon: leotin2
' propiomrilanocortin (POilC),
brohormone convertase (PCSKt)
ieseptor melanocortin 4 lMC4Rl
+ (130 obese 42 mutasi,2003)

-90 gen lain (2003):

ohrelln.
Feroxldome prollferation-activated rcceptor gamma,
uncoupling protein Syndrome (-)
beta3-adrenoreceptor
Non endocrine
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Rapidly lncrease
Obesity and syndrorne

Jakarta 1:
Syndrome Signs 6 - 18 years: 6,7%
Boy:3,1%
P€der-Willi short sbhrre, $afl hands and f€et, almond€haped Girl i 10,2 %
ete, mund fa@. hypogonadim, d4 delay

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o€teodF ophy hyf @lemh (p6sudop€Ettypottf oid'M) 3 Elementery Schools:
Middb - High oconomic levol >10%
[aurene{r@1 .elinilb fillMtoss, polydadily. sfiorl #ure, dw- Loweconomic level 3-5%
Btrder'Bliedl d€lay
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Over Weight (BWA) The probabllities of obesity in adulthood

according toAge BMt 95 th

Girls Obese

3 to 5 years 2Ao/"1o39.9o/"
fuskesdas 2010r 6 to 'll year€ to 59.906
il0olo
12 to 20 years 600/o
No diftence :

economic ad educatioral level, Boys Obeee

rural - mmicipal
low(13.7%) md high rconomic 3 to tl years 20o/o
('t4.U/.) level
5to ll.5 years 20% to 39.906
11.5 to 16 years 18o/o to 59.94/o
17 to 20 years 60%

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Persiitenc6 of obesity: Persi$tence of obo$ity: childhood into adulthood
preschool to elementary school Bllll, in childhood +obesity in adulthood,
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Overweight and obesity in childhood and adolescencel'2'3

- associated with adverse socioeconomic outcomes
- increased health risks and moBidities
- lncrcased mortality rates in adulthood

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Obesity in childhood and

adolescent is important

ln the future) the next generation

of every nation
i

lmmediate and longterm health problemsr23 Diabetes Prevalence Parallels

Obesity - Diabesity

Nleu Bodlxeighl (kgs)

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ilenstrual lrregularity
Depression and social stigmatization.
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lnsulin Resistence Obesity and the metabolic symdrome

Obstructlnesleepapnea in ehildhood and adolescent
and in usA adult and children
Adol$c. T2DM in USA
il
am
Severely obese ---..--+ 50 %
6 tu
lp Increasing of each half unit on BMI
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the risk of metab syndr 1
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 {. ldentification:
| '-,+
iHow to assess obesity to measure body fatt : I

What we have to do I

underwater weight measurcments

1. ldentification dual energy x-ray absorptiometry
2. Assessment magneting resonance imaging
3. Prevention ( No health risk): computed tomography
4. lntervention for Treatment (Health Risk) stable botoo methods

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Easily in clinicall epidemiologieal setting Skinfold thickness

Overgrowth
Fattylobesity) '""'""'
1. Skinfold thickness
2. Bioelectric impedance analysirs: Triceps,
- acceptable for clinical, public health purposes
Subscapular
appropriate standards and available ??
Supra iliac
3, W,L-H : - > 90th percentile on NCHS growth chart
- or W > 120% of the median (A,H,Sex) Not recomnrended for routine clinical use:
4. Bil: Ut (kg), H2 (rn2) lack of available data reff.
useful standard rEasure of adiposity
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 Waist Circumfercnce BMI

{, doesnt diredly nreasurcd body fat

2. eyaluate as prcdictor adlposity in child, adoles,
a bctter€timate for adipose tissue
3. predlcts r*Fks i pr€6nu future medical complication
more efflcient for predicting ingulin resistence,
blood pressure Childrcn+ -bloodpreseupt
serum cholosterol - liplds2 and lnsulin3 levele
--'-"'+ foradoleecent

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- lncomplete information lbffiAftf ill.d Pd{ tui'l* ddF€tuuh ffitu hslhd
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'lacl epesiflc guidelines for clinical use

BMI Galculation - Slrr!8' 9*r'r g*, t3tt'r$

si6bSrBlFdS

example
o BMI=Wt(kg)IHta(m2)

EX: Boy AI 3 yearc

Wt=20k9;Ht=90cm
BMI=20/(0,9)2=19,99

Boy A, 38 monb, W A, kg, Ht gl cm

BMI for age ( for ehildren & teens)
BM|-for-age percentile
shows how your child's weight compares to that of
other children of the same age and sex.

For example,
a BMI-for-age pere,entile of >95% means that the
child's weight is greater than that of >95o/o of other
children of the same age and sex.

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2. Assessment:
sH Medical Risk : Child gro',vth, Family history
Behavior Risk: sedentary, physical activity
Attitudes : concern to motivation

3. Prevention ( No health risk):

rarset Behavior:
:|"ff IrfH::'"'
ParenU Family counseling
UKK NPM : =< 2 yeaFWHO 2005
CDC No refidata <2 years MowsEd 6ckFdcode. ExFfrCdb R@m&tus R€dbg bohydon,
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>2 years CDC 2000 20:Sl&- S 192

WHO No roff data >2 years

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Treatment Obese child Dietary lntervention

t;*
+
(Health Risk) BMI
.$i:J
Acute treatment phase 6 - t2 y
2-7yeaE >= TYears l{ot less than {2OO kellrlav
\ >=95 tlr
{
"u-6^ 85- <94 th mixed, effective for weight management
j
Ot
-95
.t 2. Traffic light diet
comorbHtty green, low denslty energy, fiee consumption
*" *. T^T
Yes No
yelloq moderate deneity energy, modsrato consumption
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rcd, high density energy, very limited consumpfion
6 - ,12 years
bs m.hh@ b$ mdll&ffi b provide nutrifion with the lowest enersy intate
900 - 1200 ( l50O) kcauday
3. Food cuide Pyramide
Pdirtr2mln:r2@

Energy proportion
lnfanb S 2 year€ child >2 vears
Carbohydrate S5-S5% 55_60"/
Protein i1-2go/o IO-ZA;j
Fat 35- 50% <3v/o

RDA Age(Y) Energy (CaUKg)

0- 1 110_120
1_3 ,l00
4-6 90

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- 14
t0
ff$
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S0
3;t
,t0€s
E=8,9keX110

11- 18 40d, 40
Calorie = ideal body weight (Kg) X RDA

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Medical Bariatric $urgery

1. Sibutramine Morbid Obesity
- >=16y Malabsorptive, R€trictive and combination
- Behavioral
__+Weight, Recommondedt
sideeffect V L Physical mature
long-tefm safety ?? 2. BMI >= 50, >40 kg/mz+ s;gn16xnt comorbidity
3, Failure to 6 mo conventional treat, (weight loss prognm)
2. Orlistat 4, Be capable of lffe style changes after surgery
effective 5. Experience and capable to long term tollow up care
side effect abd. crarnp Limited data {risks and benefits)
flatus + discharge ..-..+ Conservative approach

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1. Obeelty b chronic dis...+ Metabolic syndrome

2. Earty pr€vcntion, treatm€nt -.-..r best response

3. Management:
3.1. Diet modification
THAl,lK YOU
3,2. lncrease of physical activity
3.3. Behavioral changes
3.4. Medications
3.5. $urgery

'1.
lnvolvlng all family naembers

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