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G E N E R A L   I N T R O D U C T I O N     Adipose   tissue   expanding   in   the   obese   state   synthesizes   and   secretes   metabolites   and   signaling   proteins   like   leptin,   adiponectin,   and   tumor   necrosis   factor-­‐alpha.   These   factors   are   known   to   alter   insulin   secretion   and   sensitivity   and   even   cause   insulin  resistance8.  The  most  important  consequences  of  insulin  resistance  in  chil-­‐ dren  include  increased  incidence  of  type  2  diabetes,  atherogenic  dyslipidemia  and   arterial  hypertension,  which  lead  to  increased  cardiovascular  risk.  In  case  of  female   pediatric   patients   a   higher   incidence   of   polycystic   ovary   syndrome   (PCOS)   is   ob-­‐ served9.  Besides,  there  are  numerous  medical  comorbidities  associated  with  obesi-­‐ ty  in  childhood.  Nonalcoholic  fatty  liver  disease  (NAFLD)  is  increasingly  prevalent   in  pediatric  age  individuals,  in  parallel  with  increasing  obesity,  and  can  lead  to  liver   inflammation,  fibrosis  and  even  cirrhosis10.     Not  only  severe  physical  consequences  of  obesity  can  be  seen,  but  also  psychosocial   problems  are  obvious  like  stigmatization  and  discrimination11.  Obese  children  have   more  problems  with  playing  sports  with  their  peers  and  may  suffer  from  bullying12.   They   may   also   develop   a   low   self-­‐esteem   and   a   poor   body   image.   It   is   generally   agreed   that   being   obese,   or   even   being   overweight,   is   a   highly   stigmatized   condi-­‐ tion.   There   is   a   considerable   discussion   in   the   literature   on   the   stigma   of   obesity   and  the  way  that  obese  people  are  treated  in  western  society,  from  childhood  teas-­‐ ing  and  bullying13,  avoidance  by  others14,  and  misplaced  humour15.  Obese  children   are  at  risk  to  become  isolated,  miss  the  connection  with  peers  and  may  drop  out  of   society.       There  are  a  couple  of  predictive  risk  factors  to  develop  obesity.  In  general,  children   with  a  BMI  ≥  95th  percentile  have  a  high  risk  for  adult  obesity16.  Also  an  early  age  of   adiposity   rebound   (the   moment   of   increase   of   the   BMI)   is   an   important   predictor   for   obesity   in   adolesence17.   Exposure   to   maternal   obesity,   with   or   without   gesta-­‐ tional   diabetes,   having   a   high   birth   weight18,   but   also   low   birth   weight,   together   with  catch-­‐up  growth,  is  associated  with  a  significant  risk  of  adult  obesity.  Studies   including  randomized  controlled  trials  consistently  show  that  higher  protein  intake   during  infancy  is  associated  with  the  development  of  obesity.  Lack  of  breastfeeding   was   also   associated   with   obesity   in   many   observational   studies19.   The   hypothesis   that   breastfeeding   could   have   a   protective   effect   against   obesity   is   supported   by   epidemiological  evidence,  but  literature  data  are  still  controversial.  If  this  hypothe-­‐ sis  is  confirmed,  it  will  represent  one  more  advantage  of  breastfeeding,  as  well  as  a   new  "weapon"  to  fight  obesity.  The  potentially  implicated  mechanisms  still  have  to   be   clarified.   Breastfeeding   involves   several   aspects,   such   as   the   amount   of   food   intake,   composition   of   the   food,   time   of   introduction   of   solid   foods   and   develop-­‐ ment   of   regulatory   eating   mechanisms.   Also   behavioral   aspects   related   to   the   mother-­‐child  relationship  and  formations  of  eating  habits  are  important  aspects  of   breastfeeding20.       13  


Proefschrift binnenwerk Manon Ernst_DEF.indd
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