Adolescence Issue 08
Adolescent Domestic Violence in India – Need for Public Health Action! Adolescent domestic violence occurs in all countries, irrespective of social, economic, religious or cultural group, India being no exception. Studies of the incidence of physical and sexual violence in the lives of adolescents suggest that this form of violence need to be viewed as a serious public health problem today.
Issue 08 | Pages 20 ADOLESCENCE Adolescent Health Committee FOGSI Address for correspondence : Olyai Hospital, Hospital Road, Gwalior- 474009 (MP) India. Phone : (91) -(751)- (2320616) http://www.youtube.com/watch?v=NsR0H0ril20 Adolescent Health Committee FOGSI ADOLESCENCE Message from Message from President FOGSI 2013... Secretary General's Desk... Dr. Hema Divakar President FOGSI 2013 Dear FOGSIANS, Greetings for all times in future ! Coming together in FOGSI is the beginning of the Mission and we remain together to accomplish our Vision for making a positive difference to Womens Healthcare in India When we reflect on the varied health senarios in our country and acknowledge and accept that there are many "Indias" within "the India" and the diversities between INDIA and BHARAT pose a challenge to health equity issues - what is available in the tertiarry centers in metros is quite different from what is available at the primary health centers in rural parts.One has to figure how one can offer the best - but at a low/ reasonable cost and see that it reaches ALL the women of India and makes an impact on health indices of our Nation. We need to study the "impact" of preventive healthcare on reducing the burden of many of the morbidities and mortality. We always seem to think that it is someone else's job ! ICOG Chairperson... Dr. Nozer Sheriar Secretary General FOGSI Dear Colleagues and Friends, ‘Whether you think you can, or that you can't, you are usually right.’ - Henry Ford The adolescent health activities of FOGSI have of course been very effectively managed by the Adolescent Health Committee under the stewardship of a series of very dynamic chairpersons. The committee has striven for greater heights under Dr. Roza Olyai with regular publications, advocacy and national and international recognition. As the Website Coordinator, I have seen the great response of netizens to the six issues of the Adolescence Newsletter in our publications section. I wish Roza and the committee my very best and thank them on behalf of FOGSI for doing this very important work so sincerely. Keep up the good work! We need to "innovate" and see what works for us. We need to "implement" in novel ways - educating the masses on their right to "safe mother hood" and empowering frontline health workers to offer care in the community Dr. Nozer Sheriar Secretary General FOGSI President FOGSI 2012 Adolescents girls worries me! They have just entered the sea - some wading at knee deep water, some at dangerous thigh deep level with their under-feet sands tending to get swept away with every returning wave, but - but they must sail to mid sea and port at will. Along with this, their luxurious hairs are also slowly filling up with twinkling fireflies reminiscent of their fanciful stars. Then they are inescapably surrounded by the strongest live aphrodisiacs-the boys.And they must look exquisite. I am glad that FOGSI has found a leader like Dr. Roza Olyai, Chairperson Adolescent Health Committee FOGSI, to deal with this complex issue and in such broad scale. Her continued efforts will surely help those tender eager souls to cruise the ever turmoiling with joy and resolve and help them to transform their timid shy fireflies into real stars in human skydom . Dr. A K Debdas Chairman, ICOG Message from Chairperson (2013-15) Let us be contributory to the wellbeing of women in India. Dr. Jayamkannan Chairperson Adolescent Health Committee FOGSI (2013-15) Emeritus professor, Tamil Nadu MGR medical university Member PMNCH WHO programme Web coordinator FOGSI Member antiviolence cell FOGSI Dr. P. K. Shah Professor, Dept. of Obstetric & Gynecology Seth G.S.M.C. & K.E.M. Hospital Mumbai. Let us target the adolescents and DELIVER A HEALTHY FUTURE !. Best wishes and warm regards It gives me immense pleasure to write a few words for the Magazine on “Adolescence”. President FOGSI 2013 Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood (age of maturity), but largely characterized as beginning and ending with the teenage stage. Adolescence is usually accompanied by an increased independence allowed by the parents or legal guardians and less supervision, contrary to the preadolescence stage. FOGSI Office Bearers 2013 Dr. Hema Divakar President Dr. Ashwini Bhalerao Gandhi Vice President West Zone Dr. Alpesh Gandhi Vice President West Zone Dr. Jayant Rath Vice President East Zone Dr. Maninder Ahuja Vice President North Zone Dr. S. Shantha Kumari Vice President South Zone Dr. P. K. Shah Immediate Past President Dr. Nozer Sheriar Secretary General Dr. H.D. Pai Deputy Secretary General Dr. Jaydeep Tank Treasurer Dr. Madhuri Patel Jt. Treasurer Adolescent Health Committee of FOGSI is playing vital role in imprinting knowledge to these Adolescent girls by organizing interactive workshops, seminars at the schools. It is our responsibility to share the feelings of these adolescents and their parents. In the concept of 'Maternal Health' the adolescent age is also included. I must congratulate to Dr. Roza Olyai, Chairperson – Adolescent Health Committee in bringing out the most useful informative and educative Magazine on adolescence. I am sure this Magazine will be a good, useful informative guide to adolescent girls, parents and doctors. I wish Dr. Roza and her team very successful & eventful tenure as Chairperson of the Committee. With regards Yours sincerely, Chairperson (2009-12)... Dr. Roza Olyai M.S. MICOG, FICOG, FICMCH National Chairperson Adolescent Health Committee FOGSI (2009-12) Member Board of Governing Council Indian College of Obst. & Gyn.(ICOG 2012-15) Vice President Elect FOGSI (2014) Convener Adolescent Friendly Health Centers India Director Olyai Hospital,Gwalior-MP Email: email@example.com Dr. A.K. Debdas Chairman ICOG Message from My sincere appeal to all FOGSIan's. Let's do our bit as "Change Makers". Let us help in shifting the focus to "preventing illness and promoting wellness". Dr. Hema Divakar Message from Message from Adolescents constitute 22.8% of population of India as on 1st march 2010. They are not only in large numbers but are the citizens and workers of tomorrow. Most Adolescents in India are out of school, malnourished, get married early, working in vulnerable situations, and are sexually active, exposed to tobacco or alcohol abuse. We have to impart Sexual & Reproductive health education services like : contraception, pregnancy testing and option, MTP, STD/HIV screening counseling and treatment, prenatal & postpartum care, well baby care, nutritional services, growth & development monitoring. Dear Friends, It gives me great pleasure to share with you the eight issue of the news magazine of the Adolescent Health Committee FOGSI. Am very happy to welcome Dr. Hema Divakar President FOGSI (2013) with her team & Dr. Jayamkannan as the newly elected Chairperson of the Adolescent Health Committee for 2013-15. Am sure the committee will reach its greater heights under their able leadership & I will be very happy to continue my support of activities during their tenure. The Committee was able to have 24 successful workshops in 2012 for “Comprehensive Adolescent Health care” which was a great success & we are thankful to Dr. P.K.Shah President FOGSI (2012) for giving us this opportunity. Young Women's club is a subsidiary club of the Adolescent Friendly Health Centers a National Project of the Adolescent Health Committee FOGSI which was established since 2010 & hopefully will spread in more cities in 2013. FIGO Congress in Rome witnessed a wonderful moment for India & details of the events is shared in this issue. In this issue we have also covered important topics such as Teenage Pregnancy, Obesity in Adolescents, Delayed Puberty, Preconception care in India Present and future. We have also included other interesting topics such as Adolescent domestic violence in India & HPV vaccine for boys. One of our major project is “Challenges for the youth today & tomorrow”. we were able to cover more girls in the coming months through various school/ college health talks, sharing with them the informative booklets which our committee has prepared. Am very grateful to Emcure Pharma, specialy Mr. Arun Khanna, the COO of Emcure Pharma for his personal interest in supporting the activities of the Adolescent Health Committee FOGSI & helping to spread the message across the country through this magazine for the betterment of the youth. To achieve all these we need, friendly health workers who are knowledgeable, presentable, with good communication skill to maintain confidentiality and be non-judgmental! Your suggestions & feedback will be of great help, kindly share your articles & achievements with us. Do visit our website & share it with the adolescent girls. Through our Adolescent Health committee FOGSI let us all strive to do our best and train more professional health workers. Wish you all a happy reading! The footsteps which are well designed by my predecessors will go a long way in helping me to shape our future workforce of my country. Dr. Jayamkannan Dr. Roza Olyai Dr. P. K. Shah President, FOGSI 2012 1 2 Adolescent Health Committee FOGSI ADOLESCENCE From the Vice Presidents' Desk... First of all congratulations to Dr.Roza Olyai Chairperson of Adolescent health committee of FOGSI and Vice President Elect 2014 for actively coming out with 8th Adolescent health Newsletter. Woman's health is a continuous journey from fetal life to menopause. But adolescent is one phase which is the window of future health of woman. They say "coming events cast their shadows before", so that is what adolescent have to learn how to remain healthy not only in their teen years but beyond that in their middle age and beyond. If they are taught to properly inculcate exercise and healthy diet into their life style, rest all pieces would fall into place .All PCOS and Obesity patients have to be followed up and counseled properly to remain in touch. Dr. Maninder Ahuja Vice President North Zone Excellent work is what Dr. Roza Olyai is doing! So Best of luck Dr.Roza Olayi and to all the literate and forward moving women of India! India plays role model for “Adolescent Sexual Reproductive Health Care” during the XX FIGO World Congress of Gynecology and Obstetrics- ROME 2012 Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI had been nominated by FIGO to speak during the FIGO World Congress which was held in Rome between 7th and 12th October 2012. She represented FIGO during the WHO session on Addressing adolescents in the context of preconception care-What is currently being done in this area in high, middle and low income countries with special emphasis on the work currently being done in India by her. Samples of the CD, book materials & the Adolescence Magazine published by her since 2009 was shared amongst the delegates during the session, was well appreciated by everyone. Adolescent Health Committee FOGSI will be collaborating with other countries towards ARSH. Dr. Roza Olyai was also invited to participate in the workshop organized by the FIGO working Committee on Women's Sexual and Reproductive Rights. This interactive workshop was to understand as to how FIGO proposes to "Integrate the teaching of Human Rights and Women's Health in to educational and clinical practice". There were few other selective participants from all over the world representing their respective countries. FIGO plans in coming months to have such more workshops country wise to spread the message. Adolescent Gynecology is an important subspecialty as it has long term implications.The management of reproductive health in adolescent girls and young women involves understanding, friendly approach and use of newer drugs, methodology as well as technologies whenever possible. Adolescent health has been the main focus of activities in FOGSI in the year 1998 with year of the adolescent girls and 2006 with year of the youth. As the past Chairperson the Adolescent Health Committee of FOGSI (2004-08), I had opportunity to organize various projects like Growing Up, Smart Diet for Teens, Gynecological Manual on Adolescent Girls & Young Women, FOGSI – WHO – Govt. of India orientation programmes on Adolescent friendly health services etc. Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI(2009-12) carried forward many more activities adding new dimentions to the Committee activity. I congratulate Dr. Olyai for successfully completing her tenure and also welcome Dr. Jayam Kanan as the incoming chairperson of this committee from 2013 to 2015! Dr. Ashwini Bhalerao Gandhi Vice President West Zone Adolescence is a phase of rapid growth and development during which physical, sexual and emotional changes occur. Although adolescents are generally considered to be healthy yet the problems of adolescents are multi- dimensional in nature and require holistic approach. I am happy to see that Adolescent Health committee of FOGSI is doing excellent efforts to bring awareness among the health care providers and also for school health education. I must congratulate Dr. Roza Olyai for her visionary leadership and untired efforts for it. You truly deserve the best committee, FOGSI- 2012 award for your committee. Dr. Alpesh Gandhi Vice President West Zone Once again congratulation & keep it up! XX FIGO World Congress of Gynecology and Obstetrics- ROME 2012 One of the most crucial phases in the life cycle of a woman is adolescence – the period of transition from childhood to an adult. Girls aged between 15-19 constitute about 10% of our population and are most vulnerable to various problems, because of several emotional, physical and psychological changes taking place in the body during these years. These girls have the utmost need for sound and safe advice but lack of information and services is a major impediment. Establishment of adolescent friendly clinics and more number of school health programmes would go a long way in sensitizing young girls about anaemia, obesity, PCOS, sexual hygiene, contraception, STDS and a myriad of other problems that they may encounter in the coming years. Dr. Roza Olyai and her team have been doing commendable work in this field since the last few years. I am sure the 8th issue of “ADOLESCENCE” is going to be as interesting and informative as the earlier ones. Dr. Jayant Rath Vice President East Zone Dear Dr. Roza Olyai, It is a great pleasure to see such wonderful work being done by you as chairperson of Adolescent Committee of FOGSI. I congratulate you and your team for bring out the 8th issue of Adolescent magazine. This magazine will give us FOGSIANS an insight in the management of adolescent patients. Our speciality is witnessing rapid and critical advances in the recent past and there is a need that these be brought to practice especially because of the vulnerability of adolescent e group of patients. I acknowledge that there is an urgent need to create and develop facilities. Dr. S.Shanthakumari Vice President South Zone 3 There is also a necessity in working together for the development of sub specialities which are emerging now in our profession. I wish you all the best. 4 TEENAGE PREGNANCY - What is the Solution? Dr. Mario A. Bernardino AOFOG Chair on Population Dynamics, PHILIPPINES Teenage pregnancy is a pregnancy under the age of 20. Why is it important to understand teenage pregnancy? Is it an effect or a cause? It may be both an effect and a cause of reproductive health problems that a woman encounters which may escalate to a national and even a global concern. Understanding its nature will make us aware of its impact or magnitude and perhaps appropriate solutions may be created to address it. What is the burden of the condition globally? The prevalence is the number of pregnancies per 1,000 females between the age of 15 and 19 using the end of pregnancy as cut-off. Topping the list are the subSaharan African countries with 143 per 1,000 females. In South Korea, it is 2.4 per 1,000. The United States has one of the highest rates in the developed countries but it has declined and the 2010 data is 34.3 birth per 1,000. In the 2001 UNICEF report on developed nations, more than two-thirds of the teens had sexual intercourse. In the Indian subcontinent, early marriage is a common practice that leads to adolescent pregnancy in contrast to highly industrialized countries. It is projected that there will be more teenage pregnancies and more complications of pregnancy and childbirth as contrasted to some Western European countries with low teenage pregnancies because of good education and contraception. What is the impact of teenage pregnancy on health? There are higher preterm and low-birth weight infants from teenage pregnancy. Studies have shown that they receive less prenatal care, or if ever they have prenatal care, it starts only on the third trimester. Often times they have no health insurance and have no access to quality medical care. Often times they carry their pregnancy with some nutritional deficiency due to their eating habits like they do from fad dieting to fast food eating. Adolescent risk behavior is a factor that adds to complications of pregnancy particularly infections such as HIV and other sexually transmitted infections. An underdeveloped pelvis in an adolescent can lead to difficult labors and deliveries and may increase the likelihood of Cesarean section. Other possible complications of adolescent pregnancies are eclampsia, obstetric fistula, infant and maternal mortality. There are other social consequences of teenage pregnancy. On the part of the mother, their education will likely be disrupted by the pregnancy, childbirth and rearing. They end up dropping out from school and losing career opportunities. In developing or underdeveloped country, they contribute to increasing poverty and become additional burdens to government welfare services. On the part of the child (especially the premature and the low-birth weight infants) they will likely have delayed abilities in terms of intellectual, language and socioemotional capabilities. Developmental disabilities and behavioral issues are increased in children of adolescent mothers. Some teenage mothers tend to be more affectionate to their child as compensation but some also show anger to their children. Follow up of the children of teenage pregnancy showed poor performance later in school. The effect on the family and siblings of the teenage mother is that they tend to emphasize less on education and employment but more on accepting the adolescent's sexual behavior, early parenting and marriage and they are become more tolerant to non-marital and early birth. 5 ADOLESCENCE There are cultures that practice early marriage and value fertility and pregnancy as a gift from God. In some cultures also, peer and social pressure come into play as a reason to have sex during teenage. Drugs and alcohol use are risky behaviors that have been associated with sex and eventual pregnancy. No access to contraception or information has led to unwanted pregnancy in this age group. Studies on the age of the male partner have shown that the older the male partner is, the higher the likelihood that pregnancy will be desired rather than unwanted. The younger the male partner is or belonging to the teenage group, the likelihood of not wanting to have the pregnancy. Some teenage pregnancies have been associated with sexual abuse or violence in the relationship. Another strong association is poverty, which is related for different complicated reasons. Realizing the impact of the problem, one is compelled to think of possible solutions to the problem. Foremost is adequate adolescent education. Adolescent education is to be learned not only by the adolescent but also by the source of this education particularly the parents and teachers in intermediate and secondary level education. Timing of learning is important because knowledge will make us anticipate concerns related to teenage pregnancy and other associated concerns. Other than the source and timing, it must be delivered or learned effectively. Learning must be strategically delivered to our young population at home and in school. So it must be part of the school curriculum. The most important part of adolescent education is the content, which encompasses the knowledge and the attitudes towards such knowledge. For example, there is a proposed adolescent and reproductive module for high school students as a guide for teachers and guidance counselors. The module includes an Overview of Adolescent Reproductive Health; Sexuality, Gender and Ethics; Adolescence changes and Difference; Promoting Reproductive Health; Reproductive Rights and Responsibilities; and Life Skills. Adolescent education is the key towards a better understanding in approaching a healthy reproductive life. It is a key not only in preventing teenage pregnancy or other risk-taking behavior but other aspects such as sexuality, gender sensitivity or prevention of violence against women and children and others which lead to a better healthy reproductive life. References: 1. UNICEF. (2001). A League Table of Teenage Births in Rich Nations PDF (888 KB). Retrieved July 7, 2006. 2. Treffers PE (2003). "Teenage pregnancy, a worldwide problem" (in Dutch; Flemish). Ned Tijdschr Geneeskd 147 (47): 2320–5. PMID 14669537 3. Locoh, Therese. (2000). "Early Marriage And Motherhood In SubSaharan Africa." WIN News.'.' Retrieved July 7, 2006. 4. Scholl TO, Hediger ML, Belsky DH (1994). "Prenatal care and maternal health during adolescent pregnancy: A review and meta-analysis". J Adolesc Health 15 (6): 444–56. doi:10.1016/1054139X(94)90491-K. PMID 7811676 5. Gutierrez Y, King JC (1993). "Nutrition during teenage pregnancy". Pediatr Ann 22 (2): 99–108. PMID 8493060 6. East, Patricia L. (1996). "Do Adolescent Pregnancy and Childbearing Affect Younger Siblings?". Family Planning Perspectives 28 (4) 7. Macleod, C. (1999). "The 'causes' of teenage pregnancy: Review of South African research—Part 2". South African Journal of Psychology 29 (1). 8. Guttmacher Institute. (2005). Sex and Relationships. Retrieved August 8, 2006 9. Allen, Colin. (May 22, 2003). "Peer Pressure and Teen Sex." Psychology Today.'.' Retrieved July 14, 2006 10. Saewyc, E.M., Lara Leanne Magee, L.M., Pettingell, S.E., (2004) Teenage pregnancy and associated risk behaviors among sexually abused adolescents, Perspectives on Sexual and Reproductive Health, May–June, Findarticles.com. Retrieved on 2011-12-03. What are the causes of teenage pregnancy? The following are the causes or have some association with teenage pregnancy : 1) Early marriage (cultural) and traditional gender roles, 2) Peer and social pressure, 3) drug and alcohol use, 4) Lack of contraception, 5) Age discrepancy in relationship, 6) Sexual abuse, 7) Violence in a relationship, and 8) Poverty. Adolescent Health Committee FOGSI 11. Reyes, M., Aguiling-Panagalangan E, Aguiling-Dalisay G, De Guzman L, Ogena N, Acosta ML, Sangalang A, Alejo E: Adolescent Reproductive Health Module for HighSchool Students, A guide for Teachers and Guidance Counselors. ReproCen, UP College of Medicine Adolescent Domestic Violence in India – Need for Public Health Action! Dr. Geetha Balsarkar Professor, Dept. of Obstetric & gynecology Seth G.S.Medical college, Nowrosjee Wadia maternity Hospital, Parel, Mumbai Adolescent domestic violence occurs in all countries, irrespective of social, economic, religious or cultural group, India being no exception. Studies of the incidence of physical and sexual violence in the lives of adolescents suggest that this form of violence need to be viewed as a serious public health problem today. State agencies in U.S.A reported approximately 211,000 confirmed cases of adolescent physical abuse and 128,000 cases of sexual abuse in 1992. At least 1,200 children died as a result of maltreatment. It has been estimated that about 1 in 5 female older children and 1 in 10 male children may experience sexual molestation (Regier & Cowdry, 1995). In India the burden ranged from 18 percent to 45 percent in certain states in one study in 2012.( Charlette SL, Nongkynrih B, Gupta SK, 2012) More than half of the school going adolescent facing domestic violence show clinical levels of anxiety or posttraumatic stress disorder (Graham-Bermann, 1994). As service providers to this sensitive group, we have to be aware of the existence of this problem. Without treatment, these adolescents are at significant risk for delinquency, substance abuse, school drop-out, and difficulties in their own relationships. Adolescent children may exhibit a range of reactions to exposure to violence in their home usually by elder siblings or parents or guardians. They may also be a witness to violence of mother or siblings. Self-blame which is most common can precipitate feelings of guilt, worry, and anxiety. It is important to consider that all adolescents do not have the ability to adequately express their feelings verbally. Consequently, the manifestations of these emotions are often behavioral. Adolescents may become withdrawn, non-verbal, and exhibit regressed behaviors. Eating and sleeping difficulty, concentration problems, generalized anxiety, and physical complaints (e.g., headaches) are all common. A loss of interest in social activities, low self-concept, withdrawal or avoidance of peer relations, rebelliousness and oppositional-defiant behavior should be picked up early by the health service provider. It is also common to observe temper tantrums, irritability, frequent fighting at school or between siblings, lashing out at objects, treating pets cruelly or abusively, threatening of peers or siblings with violence and attempts to gain attention through hitting, kicking, or choking peers and/or family members. Incidentally, girls are more likely to exhibit withdrawal and unfortunately, run the risk of being "missed" as a child in need of support. Researchers discover a strong association between teenage violence and domestic violence later on in life. Adolescents who engaged in violent behavior at a relatively steady rate through their teenage years and those whose violence began in their mid teens and increased over the years are significantly more likely to engage in domestic violence in their mid 20s than other young adults. Four patterns of youth violence taken by teens between the ages of 13 and 18can are classified as. • Non-offenders, (60 percent), do not engage in violent behavior in adolescence. • Desisters (15 percent) engaged in violence early on but stopped by age 16. • Chronic offenders (16 percent) began violent behavior early and it persisted at a moderate level up to age 18. • Late increasers (9 percent) became involved with violence in mid adolescence with the behavior increasing up to age 18. Individuals from the last two groups are significantly more likely than non-offenders to have committed moderately severe forms of domestic violence when they were 24 years old. Being diagnosed with a major episode of depression or receiving financial help from organizations were significantly related to committing domestic violence, as were having a partner who used drugs heavily, sold drugs, had a history of violence toward others, had an arrest record or was unemployed. Disorganized neighborhoods like slums where attitudes toward drug sales and violence were favorable also increased a person's likelihood of committing domestic violence. It may be possible to prevent some forms of domestic violence by acting early to address youth violence. The earlier we begin prevention programs the better, because youth violence appears to be a precursor to other problems including domestic violence. So how do we trace such individuals and tackle them? For some adolescents, direct questions about home life when they come with physical problems may be difficult to answer, especially if the individual has been "warned" or threatened by a family member to refrain from "talking to strangers" about events that have taken place in the family. We have to watch out for tell tale signs like bruises, black eye, etc. Referrals to the appropriate school personnel with whom they have confidentiality is the first step in assisting the child or teen in need of support. Although the circumstances surrounding each case may vary, suspicion of child abuse is required to be reported to the local child protection agency by teachers and other school personnel. In some cases, a contact with the local police department may also be necessary. If the child does express a desire to talk about his problems, we have to provide them with an opportunity to express their thoughts and feelings. In addition to talking, they may be also encouraged to write in a journal, draw, or paint; these are all viable means for facilitating expression in younger children. Adolescents are typically more abstract in their thinking and generally have better developed verbal abilities than younger children. It could be helpful for adults who work with teenagers to encourage them to talk about their concerns without insisting on this expression. Listening in a warm, non-judgmental, and genuine manner is often comforting for victims and may be an important first step in their seeking further support. When appropriate, individual and/or group counseling should be considered at school if the individual is amenable. Referrals for counseling (e.g., family counseling) outside of the school should be made to the family as well. Providing a list of names and phone numbers to contact in case of a serious crisis can be helpful. The public health sector can foster an environment for primary prevention by sharing knowledge and raising awareness about the various issues related to adolescent domestic violence. Health providers need to be sensitive to the needs of the victims of domestic violence. Support groups should be mobilized for developing a society free of adolescent domestic violence. 6 Adolescent Health Committee FOGSI ADOLESCENCE HPV Vaccine for Boys Delayed Puberty Prof. Subhash Chandra Biswas Prof. & Head, Dept. of Obst & Gynae, BMC, Burdwan, WB. National Correspondent Editor, JOGI; Editorial Advisor, AJMS Dr. Krishna Kavita Ramavath MD, FICOG 2805, Veronia Dr, #103, PalmBeach Gardens Florida, USA 33410 Most of you who are reading this article may wonder should boys be routinely vaccinated with HPV, when this vaccine was originally promoted as a way to prevent cervical cancer in women? A few of you who knew about the sexual transmission of HPV, may even think if boys are the culprits of HPV why not just vaccinate them and leave the girls. So here are some good reasons which go in favor of routine recommendation for boys and young men: One reason is that boys and young men get anal and genital warts, and they certainly are emotionally devastating and disfiguring, though not fatal. They are cause of great morbidity. The second reason is that anal and genital cancers in boys and young men are very destructive. They are caused by one of the types of HPV infection that can be prevented by the HPV vaccine The third reason is that girls get HPV from boys which lead to Cervical cancer. So it is the health care providers responsibility to protect girls from getting the disease through creating awareness. So with these certainly very compelling reasons to make the HPV vaccine a routine recommendation for boys and young men, The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) has recommended the routine use of the human papillomavirus quadrivalent vaccine (HPV4) in boys aged 11 to 12 years. Among the AAP's updated recommendations are that: • Girls aged 11 to 12 years should be routinely immunized using 3 doses of the HPV4 or HPV2 vaccine, administered intramuscularly at 0, 1 to 2, and 6 months. • Girls and women aged from 13 to 26 years who have not been previously immunized or who have not completed their vaccinations should finish the series. • Boys aged 11 to 12 years should be routinely immunized with HPV4, using the same schedule as for girls. • Boys and men aged from 13 to 21 years who have not already been immunized or who have not completed their vaccines should finish the series. • Men aged from 22 to 26 years who have not already been immunized or who have not finished the full series may be administered the recommended vaccine. • Special efforts should be made to target use of the vaccine in gay or bisexual men up to 26 years of age who have not previously received the vaccine. • "ACIP recommends routine vaccination of males aged 11-12 years with 3 doses of HPV4. The vaccination series can be started beginning at age 9 years." People infected with HIV should be vaccinated or complete their series of vaccinations. • The Human papillomavirus (HPV) is the most common sexually transmitted infection in the world. It is estimated that about 50 percent of sexually active men and women will have HPV at some point in their lives. (CDC 2007) The vaccine is not recommended during pregnancy, nor should it be administered to individuals with a known immediate hypersensitivity to yeast. The organization also says that administration of the vaccine should not alter physicians' recommendations regarding use of barrier methods for preventing HPV and other sexually transmitted diseases. In 90 percent of cases, one's own immune system clears HPV naturally within two years. But, sometimes (and for unknown reasons), HPV infections are not cleared and can cause cervical, anal, vulvar and vaginal cancers as well as genital warts. There are over 30 types of HPV, but two strains (16 and 18) cause 80 percent of all cervical cancers and two other strains (6 and 11) cause approximately 90 percent of all genital warts Today HPV vaccination is positively viewed by the younger generation who are willing to get vaccinated. Since the rates of anal cancer are on increasing trend, it is hoped that the vaccine will reverse the trend. Research says that the benefits of the vaccine clearly outweigh the risks. Bibliography: 1. The new guideline would be the same as for girls, with the exception that the guideline for boys specifies use of only the quadrivalent vaccine. Steven Fox ,Medscape Medical News -HPV Vaccine Recommended for Boys in New AAP Guidelines. 2. CDC-HPV vaccine information for clinicians-Fact ( Sep 15th 2011)firstname.lastname@example.org The committee also recommended that boys aged 13 to 21 years who had not already received the HPV4 vaccine should also be vaccinated. 3. Emma Hitt- Medscape Medical News –ACIP Recommends HPV Vaccine for 11-12 –year old Boys. Data from clinical trials shows that the vaccine is highly effective in males, and that the vaccine is most effective when given before exposure to the virus 4. Harriet Hall under Cancer, Vaccines -Science based Medicine –nov-2011 5. Paul A. Offit, MD- Should the HPV Vaccine Be Recommended for Boys and Young Men?-Medscape OB/GYN and Womens health 6. William Smith-Opening :STD awareness month with a success story- HPV and Cervical Cancer: RH Reality check-April 3,2012 Internationally there are two vaccines available that protect against HPV. HPV4 (Gardasil, Merck) was approved in 2006 for administration to 9- to 26-year-old females and offers protection against HPV types 16 and 18, as well as against nononcogenic HPV types 6 and 11, which cause most genital warts. The other, bivalent vaccine (HPV2; Cervarix, GlaxoSmithKline) protects against the oncogenic HPV types 16 and 18 that cause 80% of cervical cancers. This vaccine was approved in 2009 for administration to females aged 10 to 25 years The American Academy of Pediatrics (AAP) has published new guidelines for the use of the HPV vaccine and, for the first time, has specifically recommended use of the vaccine in adolescent boys as well as girls. 7 Quadrivalent HPV vaccine (HPV4, Gardasil, Merck) is the only vaccine approved for use in boys. Introduction Puberty represents a period of significant growth, hormonal changes & attainment of reproductive capacity. Developmental changes during puberty in girls occur over a period of 3 - 5 years, usually between 8 and 13.5 years of age. The period is clinically characterized by accelerated linear growth, the development of breasts (thelarche) & pubic hair (adrenarche) and the eventual onset of menstruation (menarche) which occurs between the ages of 10 & 16 years. In INDIAN perspective it is essential to make the people aware of the knowledge of puberty, particularly when it should be called delayed. Not very infrequently we find in the clinics or out-patient departments the anxious parents with their adolescent daughters attend the doctors not at the proper age they need to do so. Menarche, being the easily identifiable event is used as the only marker of pubertal development by them. The occurrence of these events is consecutive to the stimulation of the hypothalamic-pituitary-ovarian axis, which leads to sex-steroid secretions acting on specific receptors. With the onset of pulsatile GnRH secretions, there is increase in the amplitude of GH pulses released by the pituitary. Sex steroids have been shown to stimulate skeletal growth directly & thus augment the role of GH in promoting somatic growth & development. Increased concentrations of GH exert some effects on circulating insulin which directly stimulate protein anabolism. Insulin also acts as a regulator of IGF-1 through its effects on IGFBP-1. Insulin also has regulatory effects on free sex steroids through SHBG. Finally, there is acquisition of fertility, as well as profound psychological modifications. Although several genes involved in the hypothalamic-pituitarygonadal maturation cascade have been characterized, many genes influencing puberty onset remain undetermined. Identification of the Ob gene product and the role of leptin in reproduction have highlighted the influence of nutritional factors, as illustrated by the frequent association of delayed puberty with systemic diseases and/or with a negative energetic balance. Definition Delayed puberty is defined as the absence of onset of puberty by more than 2 standard deviations later than the average age i,e,> 14 years in girls. It is the absent or incomplete sexual maturation by the age at which 95% of children of the same sex has started pubertal development. Delayed puberty may be idiopathic or familial. It may result from an inactive hypothalamic - pituitary axis (hypogonadotropic hypogonadism) or from primary gonadal failure (hypergonadotropic hypogonadism) or due to a number of general conditions resulting in undernutrition. Causes of Delayed Pubertal Abnormalities Hypergonadotropic Hypogonadsim • Turner's syndrome, gonadal dysgenesis &POF • Chemotherapy, local radiotherapy, oophorectomy • Polyglandular autoimune syndromes 43.0% Hypogonadotropic Hypogonadism 20.0% Reversible • Physiologic delay • Weight loss/anorexia • Primary hypothyroidism • Congenital adrenal hyperplasia • Cushing syndrome • Prolactinoma Irreversible • GnRH deficiency • Hypopituitarism • Congenital CNS defects • Other pituitary adenomas • Craniopharyngioma • Malignant Pituitary tumor General 11.0% • Constitutional delay of growth and puberty • Malabsorption (e.g. coeliac disease, inflammatory bowel disease) • Underweight (due to severe dieting/anorexia nervosa, over exercise) • Other chronic disease (asthma, cystic fibrosis, renal failure) Eugonadism • • • • 26.0% Mullerian agenesis Imperforate hymen Androgen insensitivity syndrome Inappropriate positive feedback Evaluation of Delayed Pubertal Development Detailed discussion of each individual cause is beyond the scope of this chapter. Physician should keep it in mind & follow the systematic approach to clinch the diagnosis. The initial evaluation of delayed puberty begins with careful history taking, thorough physical examination, and appropriate investigations. There are three indications that pubertal delay may be due to an abnormal cause: lateness, discordance of growth & specific disorder. Although no recommended age of evaluation cleanly separates pathologic from physiologic delay, but a delay of no breast development by 13 years, or no menarche by 3 years after breast development (or by 16 years of age) warrants evaluation. A delay of two SD in the population studied has been proposed as a standard. The second indicator is discordance of development. In most children, puberty proceeds as a predictable series of changes in specific order. In children with ordinary constitutional delay, all aspects of physical maturation typically remain concordant but a delay by a few years than the average. If some aspects of physical development are delayed, and others are not, it is likely that something is wrong. The third indicator is the presence of clues to specific disorders of the reproductive syndrome e,g, Turner syndrome, Kallmann syndrome. The history taking along with careful evaluation of the previous growth pattern should determine whether pubertal development has not yet started or stopped after initiation. Children who are healthy but have a slower rate of physical development than average have constitutional delay in growth and adolescence. Rates of skeletal & sexual maturation are closely linked. These children have a history of stature shorter than their agematched peers throughout childhood, but their height is appropriate for bone age, and skeletal development is delayed more than 2.5 SD. They usually are thin and often have a family history of delayed puberty. Children with a combination of a family tendency in older siblings and parents toward short stature and constitutional delay are the most likely to seek evaluation early being motivated by the peer group. Other important factors in history include dietary and exercise habits, previous serious illnesses and medications that might delay the onset or slow the pace of pubertal growth. 8 Adolescent Health Committee FOGSI ADOLESCENCE An adolescent with an underlying metabolic disorder, such as inflammatory bowel disease or hypothyroidism may present with delayed puberty as her first complaint .Neurologic symptoms such as headache, visual disturbances, anosmia, dyskinesia,seizures,and mental retardation suggest a CNS disease or disorder. Anosmia suggests strongly a genetic cause associated with various forms of Kallmann syndrome. The physicians like pediatric endocrinologists with the most training and experience should be involved with evaluating delayed puberty. A complete medical history, review of systems, growth pattern, and physical examination will reveal most of the systemic diseases and conditions capable of arresting development or delaying puberty, as well as providing clues to some of the recognizable syndromes affecting the reproductive system. Since bone maturation is a good indicator of overall physical maturation, the physical examination should begin with measurements of height, weight, arm span, and evaluation of Tanner staging of breast and pubic hair development. Height should be compared to norms for age and for bone age,and then carefully monitored for at least 6 months. A eunochoid body habitus (arm span exceeds height by>5cm) suggests delayed epithyseal closure due to hypogonadism.In the presence of breast budding (Tanner stage II),a normal spontaneous puberty generally can be expected and the patient may be reassured. Congenital malformations such as midline defects and skeletal abnormalities (cleft lip/palate,scoliosis)suggest congenital GnRH deficiency resulting from genetic mutations. A fundoscopic examination should be performed to detect papilledema and visual fields. Laboratory Evaluation and Imaging The most valuable blood tests are the gonadotropins, because elevation confirms immediately a defect of the gonads or deficiency of the sex steroids. Screening tests such as a complete blood count, thyroid tests, and urinalysis may be worthwhile. An X-ray of bones of extremities is invaluable. A measurement of bone age should be obtained for comparison with chronological age and for assessment of the potential for future growth. Patients with constitutional delay of puberty typically exhibit a bone age between 12 and 13.5 years, which generally does not progress further without the exposure to gonadal steroids that is needed for epiphyseal closure. More expensive and complicated tests, such as a karyotype or magnetic resonance imaging of the CNS, are usually obtained only when specific evidence suggests their applicability. Use of gonadotropin releasing hormone (FSH, LH) & estradiol can be of value in differenting primary (hypergonadotropic) from secondary (hypogonadotropic) hypogonadisam. By mid adolescence, gonadotropin levels, particularly FSH, are grossly elevated in girls with primary gonadal failure. In patient with hypogonadism, low basal gonadotropin levels are consistent with the diagnosis of constitutional delay of puberty, but also with congenital GnRH deficiency or pituitary gonadotropin deficiency. Ultra-sensitive immunofluorometric assays for FSH and LH may help to distinguish the low but detectable concentrations typically observed in those with constitutional delay from the undetectable levels in patients with congenital GnRH deficiency. When the estradiol level is definitely low,a serum FSH level in the low normal range has the same interpretation. If the hypothalamic-pituitary-ovarian axis were intact and functioning normally, the FSH level should be high when estrogen levels are grossly low; therefore, a “normal” value is abnormally low in that clinical context and indicates hypothalamic-pituitary dysfunction or suppression. Moreover, although the level of immunoreactive FSH may be normal, the level of biologically active FSH may not be, because patient with hypogonadotropic hypogonadism may secrete gonadotropins having altered patterns of glycosylation and reduced biological activity. Further laboratory evaluation is directed toward determining the cause of hypogonadotropic or hypergonadotropic hypogonadism, once that is established. 9 Hypogonadotropic Hypogonadism In girl with hypogonadotropic hypogonadism, measurement of the serum prolactin concentration is indicated to identify those with hyperprolactinemia due to a pituitary lactotrope adenoma, from any other hypothalamic or pituitary tumor or disorder that interrupts the normal delivery of hypothalamic dopamine via the tuberoinfundibular tract,or from medications that interfere with the actions of dopamine. Therefore, hyperprolactinemia, if not due to medications is an indication for imaging by MRI. If growth velocity has slowed and the bone age grossly delayed measurement of the serum TSH and free thyroxine (T4) concentration also is indicated to identify those who may have primary or secondary hypothyroidism, The serum DHEA-S concentration may be helpful for distinguishing constituitional delay of puberty from congenital GnRH deficiency. Although pelvic Ultrasonography can be used to determine the presence or absence of a uterus in virginal girls,it must be interpreted cautiously because results can be misleading when the reproductive organs are immature or infantile. Whereas mullerian anomalies are a common cause of primary amenorrhea, they are not associated specifically with delayed puberty. Hypergonadotropic Hypogonadism A karyotype should be obtained in all girls with hypergonadotropic hypogonadism to detect chromosomal abnormalities, except when a history of previous chemotherapy or gonadal radiation provides an obvious explanation. The most common disorder of this type is gonadal dysgenesis, with Turner syndrome (45,X) being the prototype. In addition to other structural X chromosome abnormalities, Karyotype will identify those harbouring a Y chromosome(e.g., 46XY, & Swyer syndrome),in whom gonadectomy will be indicated due to the significant risk for malignant transformation in occult testicular elements (20-30%). In patient with hypergonadotrpic hypogonadism and a normal (46, XX) karyotype, the diagnostic possibilities include 17 α-hydroxylase deficiency,a rare steroidogenic enzyme defect associated with sexual infantilism and hypertension [e,g, CAH],and other uncommon causes of primary ovarian failure. Treatment of Delayed Puberty Patients with constitutional delay of puberty can be managed expectantly, providing reassurance and psychological support and education. If a girl is healthy but simply late, reassurance and prediction based on the bone age can be provided. No other intervention is usually necessary except in more extreme cases of delay. When it is extremely distressing to the adolescent, a low dose of testosterone or estrogen for a few months may bring the first reassuring changes of normal puberty. The next priority in the treatment of delayed puberty is to correct the specific cause, when that is possible, such as thyroid hormone therapy for hypothyroidism, dopamine agonist therapy for hyperprolactinemia, and excision of a craniopharyngioma or other operable central lesion. If the delay is due to systemic disease or undernutrition, the therapeutic intervention is likely to focus mainly on those conditions. Oral or transdermal estrogen therapy can be used, beginning at low doses & increasing gradually at intervals of 3-6 month according to response with the goal of completing sexual maturation over a period of 2-3 years. Estrogen therapy will begin with low, continuous and progressively increasing doses, without progesterone during the first year of treatment. Ethinyl estradiol has been widely used (2µg/day in the beginning to 20µg at the final adult sequential treatment). Natural estrogens (17β-estradiol) with fewer metabolic side effects are now frequently used (0.2mg to 2mg/day) either orally (micronized estradiol) or by transdermic administration. Estrogens are first given alone for 1 year with progressive doses up to 0.5 mg estradiol daily and then associated with progesterone. Natural progesterone, 17hydroxyprogesterone or pregnanes is given in a sequential mode from day 15 to day 24 of the cycle. After 2 or 3 years, adult doses will be adapted. A progestin should not be added to the treatment regimen until there is substantial breast development with full contour is achieved. Once breast development has been accomplished and menses are established, hormone therapy can be discontinued at intervals for 1-3 months, to observe whether spontaneous menses will begin, as can be expected in girls with constitutional delay of puberty. Persistent hypogonadism beyond 18 years of age clearly suggests congenital GnRH deficiency. In general, GH therapy is best limited to those with documented GH deficiency. Serum GH and IGF-I levels typically are low in patient with constitutional delay of puberty but increase after treatment with estrogen, and usually are normal in those with congenital GnRH deficiency. • Treatment of delayed puberty and/or primary amenorrhea requires precise etiological diagnosis, and evaluation of the psychological consequences to the patient and her family. • Specific treatment must be undertaken when possible to improve pubertal development. For example, Correction of associated hypothyroidism or inhibition of the corticotrophic axis by dexamethasone in case of adrenal hyperplasia may also be needed. • Constitutional delay of growth and puberty is classically a situation of waiting and observing until pubertal development occurs spontaneously; meanwhile, parents and patients must be reassured. • If GH therapy is started early (between 2 and 10 years), estrogen treatment can be initiated at an age-appropriate time (12/13 years) without compromising adult height. If GH is started later, estrogen therapy will be delayed with a view to achieve stature. • Definitive lack of pubertal development due to an organic congenital or acquired disease requires a protocol of estrogenization with several goals: Points to Ponder: • Delayed puberty is defined as the absence of onset of puberty by more than 2 SD later than the average age. i) to allow the development and maintenance of secondary sex characteristics; ii) to induce the maturation of internal genital organs for future menstruation and adequate uterine development to allow successful nidation; iii) to induce a correct peripubertal growth spurt without reducing the final height; iv) to improve the constitution of bone mass and prevent accelerated loss. “Challenges for Youth Today & Tomorrow” Chennai, Tamil Nadu Surat, Gujarat Report by: Dr. S. Sampathkumari, Executive Committee Member Adolescent Health Committee FOGSI Report By : Dr. Usha Valadra, Executive Committee Member Adolescent Health Committee FOGSI Adolescent Health Education Camp at Government Panchayat School, Kandigai Counseling on Adolescent Problems followed by awareness talks on Menstrual Hygiene, Diet, Anaemia, Vaccines and Sexual abuse were handled by Dr. S. Sampathkumari & Dr. Premalatha. On International Youth Day conducted a seminar with young women’s club members which was a grand success. In those with no such identifiable cause, congenital GnRH deficiency must be distinguished from constitutional delay of puberty, but in most a final diagnosis can be established only after serial observations & evaluation. If it becomes clear that there is a permanent defect of the reproductive system, treatment usually involves replacement of the appropriate hormones. The goals of short-term hormone therapy are to foster age appropriate secondary sexual development and to induce a growth spurt and a normal adolescent increase in bone density without causing premature epiphyseal closure. Bone age need to be monitored at 6monthly intervals during treatment. Patients with an isolated GnRH deficiency, the longer-term therapy is required to maintain sex hormone levels in the normal physiologic range and to induce ovulation with exogenous gonadotropin therapy when fertility becomes a priority. 10 Adolescent Health Committee FOGSI Preconception Care in India Present and Future ADOLESCENCE These interventions could be delivered using health education, vaccination, nutritional supplementation and food fortification, provision of contraceptive information and services, screening, counselling and management (medical and social). Dr. Prachi Renjhen Consultant Alchemist Hospital, Gurgaon Special attention could be given to those individuals, couples, families and communities who are socially and economically marginalized and vulnerable to health and social problems especially the adolescent females. Preconception care is any intervention provided to women and couples of childbearing age, regardless of pregnancy status or desire, before pregnancy, to improve health outcomes for women, newborns and children. The awareness that this is true growing steadily .The National Family Health Surveys (NFHS)-3 conducted 2005-2006 was designed to provide estimates of important indicators on family welfare, maternal and child health, and nutrition and on several new and emerging issues, including family life education, safe injections, perinatal mortality, adolescent reproductive health, high-risk sexual behaviour. Benefits of preconception care would be, reduction in too-early pregnancies, too-close subsequent pregnancies and unplanned pregnancies .This would reduce maternal and childhood mortality and morbidity and improve maternal and child health outcomes. It could also contribute to reducing the risk of genetic disorders and environmental exposure, improving the health and well-being of women in other areas of public health such as nutrition, infertility/sub fertility, mental health, intimate partner violence, substance use. In this way, it could make useful contributions to Millennium Development Goals 1, 3, 4 and 5. According to NFHS-3, more than half of women are married before the legal minimum age of 18. Unplanned pregnancies and teenage pregnancies are relatively common. Overall, one in six women age 1519 has begun childbearing: 12 percent have become mothers and 4 percent were pregnant with their first child at the time of the survey. Fifty percent had given a birth before they were 20 years old and more than 25% before they were 18 years old. Early childbearing is most common in rural areas and among women with no education. In the long term, preconception care could contribute to Seventy Six percent of women who had a live birth in the five years preceding the survey (NFHS-3) received antenatal care. Just over half of mothers (52 percent) had three or more antenatal care visits. Onefourth of all pregnancies in the five years preceding the survey underwent an ultrasound test. About 1/5 th of India's population is in adolescent age group – 200 million. It's estimated that by 2020, 23.6 million pregnancies will result in 17.6 million births to adolescent. Informed choice of family planning methods is not common. The infant mortality rate in India is steadily declining. Still, more than one in 18 children die within the first year of life, and more than one in 13 die before reaching age five. The above statistics indicates the need for incorporation of intervention –preconception care-in already existing programs that ensure that a woman enters pregnancy in good health. Preconception care is the provision of biomedical, behavioural and social health interventions to women and couples before conception occurs. It's aimed at improving health status, and reducing behaviours, individual and environmental factors that could contribute to poor maternal and child health outcomes, resulting in improved maternal and child health outcomes .The term proximal preconception care has been used to delineate a limited period (of up to 2 years) before conception occurs, and to distinguish it from distal preconception care, to which no limit has been ascribed. • Help women to make well-informed and well-considered decisions about their fertility and their health. • Contribute to the social and economic development of families and communities. • Promoting male involvement and creating awareness of the importance of men's health and men's behaviours on maternal and child health outcomes. Adolescent health committee of FOGSI has launched programs like “Challenges for Youth Today & Tomorrow”2011, “Protecting young girls”Project -Rubella Project, Young Women's Club. In our country which is struggling to provide prenatal care, delivery care, post natal care and child care, it is important to consider that should it take up the additional challenge of providing preconception care. • Congenital disorders including genetic disorders Conclusion • Early, unwanted pregnancies, and pregnancies in rapid succession Global recognition of the potential benefits associated with preconception health promotion is not new. Effective preconception care involves a broad variety of partners, including men, health care providers, youth leaders and community volunteers; and delivery sites such as schools, primary health care facilities and community centers. Outreach and awareness must begin in adolescence if it is to truly improve the health of women and newborns. Preconception care offers the earliest opportunity to reduce risk, allowing women to enter pregnancy in the best possible health and to have the greatest chance of giving birth to a healthy baby. • Vaccine preventable infections • Tobacco use • Preterm birth and low birth weight • Sexually Transmitted Infections, including HIV • Infertility and sub-fertility • Female Genital Mutilation • Mental health problems • Substance use • Violence - intimate partner violence and sexual violence 2. Meeting report : To Develop a global consensus on preconception care to reduce maternal and childhood mortality and morbidity WHO HQ, Geneva 6-7 February 2012 3. Adolescent reproductive health in India. Status ,policies ,Programs and issues. Jan 2003 1. Sohni Dean, Zulfiqar Bhutta, Elizabeth Mary Mason, Christopher Howson, Venkatraman Chandra-Mouli, Zohra Lassi, Ayesha Imam Comprehensive Adolescent Health Care Workshop In 2012 under Dr. P.K .Shah President FOGSI's theme “ Let the life of every mother & neonate count” the Adolescent Health Committee FOGS had been given 24 Workshops on Comprehensive Adolescent Health Care to cover up issues related to ARSH. A whole day workshop on topics related to ARSH (PCOS, Thyroid disorders, Unsafe Abortion, Teenage pregnancy, Puberty Menorrhagia, Sexually transmitted diseases, HIV-AIDS, Anaemia, Obesity & eating disorders in Adolescents, Contraception etc.) was followed by a Public forum & inauguration of Young Women's club which is a subsidiary club of the Adolescent friendly health centers in each society. A CD tool kit was also provided to the respective societies which contains ready made powerpoints on ARSH topics & details of the Young Women's Club. We are very grateful to Dr. Alka Kuthe Executive Committee member of the Adolescent Health Committee from Amrawati who coordinated the workshop at the National level so well. Our special thanks to Dr. Anupama Dave from Indore & her team for helping in preparing the powerpoint material. We are also thankful to Emcure Pharma for their support of this activity. In India there are no specific programs for pre conception care however, Governmental and nongovernmental organizations (NGOs) have initiated various programs such as the National Health Programs, National Rural Health Mission And Reproductive Child Health Program, Integrated Child Development Services (ICDS) Scheme, Adolescent Girl, Scheme ,State Plans Of Action For The Girl Child which directly or indirectly contribute to preconception care .These program initiatives have also received support from regional and international organizations and agencies. • Environmental risks • Nutritional deficiencies and problems Référence .Care before and between pregnancy.http://www.who.int/pmnch/ media/news/2012/borntoosoon_chapter3.pdf Preconception care initiatives in INDIA The health, economic and social benefits of preconception care need to be communicated effectively to decision makers at the international level whose support is crucial for global and regional level action and research, and to decision makers at the country level whose support is crucial to incorporating preconception care into existing programmes. Beyond that, lay people must be informed about preconception care, and ways of making them care about it must be found. Key stakeholders must be reached to, and preconception care must be promoted actively using a variety of ways including the mass media and social media. It provides for including interventions that have not traditionally been included in maternal, newborn and child health programmes such as 11 • Improving the health of babies and children as they grow into adolescence and adulthood. The success of preconception care programs is directly related to the availability and accessibility of health care for women. Accordingly, WHO's World Health Report 2005: Make Every Mother and Child Count, indicates that reproductive health comprises an essential element of the continuum of maternal and child health, and calls for a reformulation of interventions from vertical programs to those offering a wider range of services. MOGS Conference on Changing Trends in OBGY Report by Dr. Reena Wani Pre-Congress workshop : on Adolescent & Youth Friendly Health Services- The Need of the Hour! The conference & the workshop was well attended. 12 Adolescent Health Committee FOGSI ADOLESCENCE Obesity in Adolescents Dr. S. Sampathkumari Executive member Adolescent Health Committee FOGSI Hon. Secretary - OGSSI Registrar (OG), Inst. of Social Obstetrics KGH, Madras Medical College, Chennai- Tamil Nadu The term adolescence is derived from Latin 'Adolescere' meaning to grow, to mature and considered as transition stage from childhood to adulthood. They are no longer children, yet not adults, characterized by rapid physical growth, significant physical, emotional, psychological and spiritual changes. The progression from appearance of secondary sexual characteristics to sexual and reproductive maturity is the marked feature. Development of adult mental process and identity & Transit from total social economic dependence to relative independence Global demographic & socio economic information on adolescents Among population 1.10 billion are adolescents. 1 in every 5 human is an adolescent & 85% live in developing countries. According to WHO: Adolescence: 10 to 19 yrs - Early: 10 – 13 yrs, Middle: 14 – 16 yrs, Late: 17 – 19 yrs. Youth:15 – 24 yrs, Young people: 10 – 24 yrs Obesity: Defined as excessive accumulation of body fat which results in individuals being 20% or heavier than the ideal body weight. Any weight in excess of normal range is overweight. Obesity is increase in size of adipose tissue. Adiposites are special cells containing fat. Adipose tissues are sensitive to nutritional change and need to be balanced since they are used as storage bins for fat, size is reduced by limiting calories. Increase in body weight from an excessive increase in body fat, Obesity is not weight or mass but excess adipose tissue Joseph et al, 1996. Adipose tissue is a major energy store in the body and its size can increase if food intake is greater than the body's energy demands - Caterson et al, 1997 Genetic influence, mutations in genes – Generally when both parents are obese the child is 70 – 80 % prone to obesity and when one parent obese it is 40 – 50 %. Factors that cause obesity are: Race (Black & Hispanic), Parental obesity, High birth weight, Low birth weight. Other environmental factors are sedentary life, food availability, portion size, television viewing time. Impact of obesity on psychological, social & health factors is enormous. Special dinner out, fast food, captivating ads and snacking greatly affect the metabolic and endocrine functions of the body thus weaken physical health, state of well being and shorten life expectancy. The social factors cause disability & unhappiness that cause stress & mental illness. The BMI (Body Mass Index) is taken as the parameter to decide obesity. According to WHO, the BMI should be below 20 for adolescents below 14 years and 25 for 15 year olds. BMI above 28 for 16yaer olds is considered obese. But, 'Tienboon and others' contend that BMI is inappropriate to decide obesity. The incidence of obesity among American teenagers is 12 - 15%. The 'Ten state nutrition study' conducted in US concluded that females are fatter than males at all ages. This fact is confirmed by a study which found that 32.4% girls among 14 yr olds are fatter when compared to 3.6% of fat boys. Perhaps the higher level of physical activity among boys could be the reason for lesser obese boys. The situation in Australia is quite contrasting, where 50% men 9of this 16% are adolescents) are obese to 33% women. About 80% of obese adolescents turn out to be obese adults. The Indian scenario is equally disturbing as 22.8% of population is adolescents. A study among affluent adolescents found out that 31% in Delhi, 24% in Pune and 22% in Chennai are overweight, about 7.5% in Delhi are obese. (Indian Pediatrics 2002; 39: 449-452, Indian Pediatrics 2004; 41: 559-575, Diabetes Res Clinical Practice 2002; 57: 185-190 City-Breds 3 Times More Likely To Be Obese Than Rural Folk: Survey • According to the National Family Health Survey (NFHS), 13 overweight and obesity are more than three times higher in urban centres as compared to rural areas • “Obesity in adults is still understandable. But we are seeing 8-yearolds who are obese. Even 12-year olds are suffering from diabetes and hypertension today,'' according to Ms. Naini Setalvad, a nutritionist. • “On an average, 16% of city children are overweight while 6% are morbidly obese. Even by Indian standards, these percentages are high'' - Dr Mufazzal Lakdawala, bariatric surgeon BIG PROBLEM About 30 million Indians are obese. Around 20% of school going children are overweight. Number of women in the 15-49 age group who are overweight or obese increased from 11% in NFHS-2 to 15% in NFHS-3 (1998 -99 / 2005 – 06). Source: Times of India, 25th October 2009, Sunday. Effects of obesity The problems faced by obese persons are inability to qualify for many types of employment & discrimination in employment opportunities, higher rates of unemployment & a lower socioeconomic status, ignorant persons often make rude and disparaging comments, experience discrimination at work, cannot enjoy theatre seats or a ride in a bus or airliner, a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. Further many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassments and the negative effect on daily activities confines them to indoors, ultimately to low self esteem. Obese adolescents suffer advanced bone age, puberty earlier than non obese and are prone to PCOS (in girls). Disturbed pattern of eating: Following are the causative factors of unrestrained eating behavior. • Consumption of an imbalance of high-energy and low nutrient foods over low-energy and high nutrient foods, i.e., eating a donut rather than a piece of fruit • interpretation of diverse feelings of situations as reasons to eat • susceptibility to eating cues unrelated to physiological needs • guilt related to eating under any circumstances • lack of understanding of bodily needs for nourishment • Unwillingness to eat with others, including family members • Lack of structure in eating patterns – unbalanced • Night eating • Binge eating • Eating only in the latter part of the day after starvation in the early part • Nausea described as connected with eating in the early part of the day • Lack of any feeling of control over food intake • Eating rapidly and indiscriminately Let us now look at the nutritional needs of adolescents. Age and physical activity determine the bodily needs of nutrition. About 2700 2800 calories are required by males of 11-18 yrs, 2100-2200 cals for females of 11-18 yrs. The intake must be a proper mix of Protein 12%, Carbohydrates 58%, and Fat 30%. The calorie requirement for obese people is limited to 1500-1800 cals. Calorie needs are related to growth rate, basal metabolic rate & physical activity. Medical Complications often associated with obesity are: • CVS Diseases – Hyper Tension, Left Ventricular Hypertrophy • Stroke • Diabetes Mellitus • Kidney Disease • Gall Bladder disease • Respiratory Disease (Asthma, Snoring) • Orthopedic Problems (Arthritis) • Menstrual problems (PCOD) • Fat Accumulates in thigh - difficulty in walking • Sore & rashes Heart and Stroke foundation research shows that the number of deaths attributable directly to overweight and obesity has almost doubled over the last 15 yrs. US-based studies indicate that obese individuals can lose more than 10 years of life compared to their normal weight peers. Obesity is considered as 2nd leading cause of preventable death Treatment 1. Calorie restriction - 3 meals a day, smaller proportion • Fresh fruits, sprouts and nuts are healthy & nutritious • Avoid dense snacks – Burgers, Pizzas • Avoid zero calorie / high sugar drinks • Aerated drinks affect bone density and cause teeth damages • No fast food? High in calorie, fat, sodium and low in fibre, contain preservatives • No Cheese – Have paneer • No maida – Have whole grain wheat • No fried food – Have grilled or baked foods • No soft drinks – Have low fat milk drinks • Don't skip breakfast – cause for diabetes • High sugar breakfast spikes the sugar level but dips fast, feeling hungry soon – increased consumption of food 2. Physical activity • Daily chores – walking, climbing stairs, cycling, swimming, household activities • Exercises – planned & structured leisure time physical activity – to improve & maintain fitness. 30 – 60 mint./day • Exercise increases absorption of calories, Improves physical & mental health • Sports – Involves competition, Good for heart, lung and muscle strength, Greater endurance & flexibility • Excessive tv viewing is associated with weight gain – sedentary life, especially when snacking junk food & drinking aerated waters • Combine tv watching with activities like stationery cycling , spot jogging • Walk up stairs – Avoid elevator • Walk – Avoid Bus, Car • Swimming – ideal exercise • Playing ball – soft ball / Kick ball 3. Behavior modification 4. Hormonal treatment Health is wealth. This old adage will never go out of fashion. For it is a healthy body that causes healthy mind. To remain active for a long, for a productive life it is essential that obesity is at check at all times and at all costs. Early detection and intervention for appropriate weight gain, proper food habits, and physical activity can enhance the longevity of life. Let us educate parents, teachers & other who interact with adolescents about medical and psychosocial consequences of adolescent obesity. “Challenges for Youth Today & Tomorrow” Shimla, Himachal Pradesh Cuttack, Orissa Dr. Alok Sharma, Executive Committee member Adolescent Health Committee FOGSI Report By: Dr. Durga Shankar Dash, Executive Committee Member Adolescent Health Committee FOGSI Trichy, Tamil Nadu Report By: Dr. Ramani Devi, Executive Committee Member Adolescent Health Committee FOGSI Jalandhar, Punjab Report By: Dr. Nidhi Garg, North Zone Coordinator Adolescent Health Committee FOGSI 14 Adolescent Health Committee FOGSI ADOLESCENCE "Challenges for Youth Today & Tomorrow" National Project of the Adolescent Health Committee FOGSI Establishing Adolescent Friendly Health Centers - FOGSI In 2012 we continued with the Challenges for Youth Today & Tomorrow project with five Zonal TOTs inviting many FOGSI societies. All together we had 20 society representatives as city coordinators from each zone. The Zonal TOTs were well coordinated by Dr. Anu Vij from Navi Mumbai who did an excellent job. Hyderabad, Andhra Pradesh Our heartfelt thanks to Emcure Pharma specially Mr. Arun Khanna COO Emcure Pharma for his constant encouragement & support, Mr. Atul Kichlu for his excellent coordination, Mr. Harshal, Mr. Kedar & their team for their wonderful execution of this project since 2009 till date enabling both the doctors & the Adolescents to get maximum benefit from the various CME & health projects which were taken up under the “Challenges for youth today & tomorrow” project. Dr. Shanthakumari Vice President FOGSI was the chief guest. Young Women's club was inaugurated in the same event in presence of Dr. Roza Olyai Chairperson Adolescent Health Committee. West Zone TOT Navi Mumbai, Maharashtra West Zone TOT was held in Navi Mumbai, invited Chief Guest was Dr. Ashwini BhaleraoGandhi Vice President FOGSI, Dr. Anu Vij who coordinated the TOT was the faculty speaker along with Dr. Roza Olyai Chairperson Adolescent Health Committee FOGSI. Mumbai, Maharashtra Dr. Ashwini Bhalerao-Gandhi, Vice President FOGSI was the Chief Guest & Dr. Reena Wani was the invited guest speaker. Young Women's Club was inaugurated in the same event in presence of Dr. Roza Olyai Chairperson Adolescent Health Committee. Central Zone TOT Lucknow, Uttar Pradesh Central TOT was held in Lucknow & well coordinated by Central Zone coordinator Prof. Dr. Kiran Pandey from Kanpur. Invited guest speaker was Dr. Uma Singh who coordinated the local activity with inauguration of the Young Women's club in Lucknow. Congratulations... India shines during the XX FIGO World Congress of Gynecology and Obstetrics – Rome 2012 Gwalior, Madhya Pradesh Prof.Dr. C.N.Purandare has been Elected as the President Elect FIGO Beside regular School & College health visits on ARSH, Gwalior Obstetric & Gynecological Society is vibrant with various CMEs on SRH - Report By Dr. Jyoti Bindal, President GOGS Dr. Duru Shah has been the awarded the prestigious FIGO "Distinguished Merit Award" 15 Research work done by Dr. Krishna Kavita & Dr. Roza Olyai which was presented during the FIGO Congress in Rome, is now published in the International Journal of Obstetric and Gynecology. This was the study done by the Adolescent Health committee FOGSI in 2009 which is about attitude and knowledge of adolescent girls towards Sexual Health, Cervical cancer and HPV Vaccine in India. Interest levels towards vaccination in five different metro states of India. 16 Adolescent Health Committee FOGSI ADOLESCENCE "Challenges for Youth Today & Tomorrow" National Project of the Adolescent Health Committee FOGSI Young women's club has been inaugurated & established in more FOGSI societies this year & is spreading fast across India ! Hyderabad Mumbai Jamnagar, Gujarat Young Women's Club has been inaugurated & established in more FOGSI societies this year & is spreading fast across India! Young Women's Club is a subsidiary club of the Adolescent Health Center, National Project of the Adolescent Health Committee FOGSI under coordination of Dr. Roza Olyai as its founder. Till date we have had various clubs established in many cities like Delhi, Gurgoan, Hyderabad, Mumbai, Amrawati, Raipur, Bhopal, Gwalior, Pune, Nagpur, Trivandrum, Navi Mumbai, Lucknow, Chennai, Amritsar, Jalandar, Trichy, Bellary, Ghaziabad, Jhansi, Kolkata & have planned in many more cities this year. For details kindly contact Dr. Roza Olyai Vice President Elect FOGSI (2014) Report by: Dr. Kalpana Khandheria, Executive Committee Member Adolescent Health Committee FOGSI After covering colleges & some schools of Jamnagar City,we are now covering the districts. Dr. Kalpana & her team addressed 200 students of Vehvaria Madressa School of Bohra Community & 900 students of resident school at taluka place Dhrol. GM Patel Dhrol 14-10-2012 Madresa School 07-10-2012 Navi Mumbai 24 Workshops on Comprehensive Adolescent Health Care Bellary, Karnataka Navi Mumbai Lucknow Report by:Dr Suman Gaddi, President Bellary Obstetric & Gynecological Society It was a wonderful experience during the workshop as Dr. Gangadhar Gouda Director VIMS Bellary inaugurated the workshop. In short, Dr. Chandrakala M from Coimbatore and Dr. Ramaraju HE from Bellary were the National faculties and co-ordinators. Dr. Shankar J.Prof. in OBG VIMS Bellary, Dr. Asha Rani Asst. Prof. VIMS Bellary and Dr.Jyoti Patil, Dr.Anupama Sundar, Dr.Praneetha Ajay were the local faculties and deliberated on other issues pertaining to Adolescent health. Ghaziabad, Uttar Pradesh Report By: Dr.Vinita Mittal & Dr Smita Agarwal (president & Secretary Ghaziabad Obstetric & Gynecological Society) Ghaziabad, Uttar Pradesh A comprehensive full day workshop on adolescent health was held under the guidance of the National trainers & representatives of the Adolescent Health Committee FOGSI: Dr Tarini Taneja( Muzafarnagar) and Dr Prachi Renjhen( Gurgoan), consisting of interactive panel discussion and colourful presentations. Young Women's club was inaugurated at the workshop with senior representatives of various schools.The club will be monitored by Dr.Vinita Mittal & Dr. Smita Agarwal (President & Secretary of Ghaziabad Obst. & Gyn. Society) along with their team members. Bellary, Karnataka The 'Young Womenâ€™s Club' in Bellary Obstetric & Gynecological Society was successfully inaugurated by the president of BOGS Dr. Suman Gaddi and the co-ordinator Dr Ramaraju. Dr. Chandana a postgraduate student is the secretary of young women's club. Jalandhar, Punjab Surat, Gujarat Report by : Dr. Sushma Chawla Wokshop Report by: Dr. Rajesh Tuli, Secretary Surat Obstetric & Gynecological Society Dr. Alka Kuthe (Amravati) along with Dr. Shilpa Thakkar (Rajkot) & Dr. Usha Valadra ( Surat) represented the Adolescent Health Committee. 17 18