Turkiye Klinikleri Journal of Health Sciences

.: REVIEW
Çocuklarda Nonalkolik Yağlı Karaciğer Hastalığı: Beslenme Tedavisine Güncel Bakış
Nonalcoholic Fatty Liver Disease in Children: A Current Overview of Nutrition Therapy
Gamze YURTDAŞa, Gamze AKBULUTb
aİzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi, Beslenme ve Diyetetik Bölümü, İzmir, TÜRKİYE
bGazi Üniversitesi Sağlık Bilimleri Fakültesi, Beslenme ve Diyetetik Bölümü, Ankara, TÜRKİYE
Turkiye Klinikleri J Health Sci. 2021;6(2):329-39
doi: 10.5336/healthsci.2020-76200
Article Language: TR
Full Text
ÖZET
 Nonalkolik yağlı karaciğer hastalığı (NAYKH) çocuklarda en sık görülen karaciğer hastalığı olup basit yağ infiltrasyonundan alkolik olmayan 'steatohepatite' kadar uzanan karaciğer hastalıkları spektrumu olarak tanımlanmaktadır. NAYKH, çocuklarda insülin direnci, obezite ve dislipidemi yüksek trigliserid ve düşük yüksek yoğunluklu lipoprotein kolesterol düzeyleri ile ilişkilidir. NAYKH'nin patogenezi henüz tam olarak bilinmemesine rağmen genetik ve çevresel birçok faktörün etkili olduğu gösterilmiştir. Pediatrik NAYKH'de prenatal (maternal obezite, gestasyonel diyabet, düşük doğum ağırlığı vb.) ve postnatal (obezite, hiperinsülinemi, insülin direnci vb.) birçok faktörün hastalığın patogenezinde rol oynadığı öne sürülmüştür. NAYKH, tedavi edilmediği durumlarda, siroz, hepatosellüler karsinom ve son dönem karaciğer hastalığına kadar ilerleyebilmektedir. Pediatrik NAYKH'de primer tedavi olarak yaşam tarzı değişikliği önerilmektedir. Yaşam tarzı değişikliği tedavisinde tıbbi beslenme tedavisi ve egzersiz kombinasyonu yoluyla vücut ağırlık kaybı hedeflenmektedir. Ancak NAYKH olan çocuklarda hangi tip diyetin uygulanacağına yönelik kanıta dayalı bilgi mevcut değildir. Ayrıca yapılacak fiziksel aktivitenin türü ve süresi ile ilgili net bir öneri bulunmamaktadır. Son yıllarda, çocuklarda yapılan ve planlanan çalışmalarda NAYKH üzerine etkili olabilecek diyet bileşimi, diyet modelleri, probiyotik, antioksidanlar üzerinde odaklanılmıştır. Tıbbi beslenme tedavisi açısından antiinflamatuar özellikte olan Akdeniz diyeti veya Hipertansiyonu Durdurmak İçin Beslenme Yaklaşımı (DASH) diyet modellerinin NAYKH'nin önlenmesi ve tedavisinde etkili olabileceği bildirilmiştir. Bu derlemede, NAYKH olan çocuklarda tıbbi beslenme tedavisine yönelik olarak güncel yaklaşımları değerlendirmek amaçlanmıştır.

Anahtar Kelimeler: Nonalkolik yağlı karaciğer hastalığı; beslenme tedavisi; diyet
ABSTRACT
 Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in children and is defined as a spectrum of liver diseases ranging from simple fat infiltration to non-alcoholic steatohepatitis. NAFLD is associated with insulin resistance, obesity and dyslipidemia high triglyceride and low high density lipoprotein cholesterol levels in children. Although the pathogenesis of NAYKH is not yet fully known, many genetic and environmental factors have been shown to be effective. It has been suggested that prenatal (maternal obesity, gestational diabetes, low birth weight, etc.) and postnatal (obesity, hyperinsulinemia, insulin resistance, etc.) factors play a role in the pathogenesis of pediatric NAFLD. NAFLD can progress to cirrhosis, hepatocellular carcinoma, and end-stage liver disease when untreated. Lifestyle change is recommended as the primary treatment in pediatric NAFLD. In the treatment of lifestyle change, body weight loss is targeted through a combination of medical nutrition therapy and exercise. However, there is no evidence-based information on what type of diet to use in children with NAFLD. In addition, there is no clear recommendation regarding the type and duration of the physical activity. In studies conducted and planned in children in recent years, it has been focused on diet composition, diet models, probiotics, antioxidants that may be effective on NAFLD. It has been reported that Mediterranean or Dietary Approach to Stop Hypertension (DASH) diet models, which are antiinflammatory, can be effective in the prevention and treatment of NAFLD. In this review, it is aimed to evaluate current approaches to medical nutrition therapy in children with NAFLD.

Keywords: Nonalcoholic fatty liver disease; nutrition therapy; diet
REFERENCES:
  1. European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO Clinical Practice Guidelines for the Management of Non-Alcoholic Fatty Liver Disease. Obes Facts. 2016;9(2):65-90. [Crossref] [PubMed] [PMC] 
  2. Rinella ME. Nonalcoholic fatty liver disease: a systematic review. JAMA. 2015;313(22):2263-73. Erratum in: JAMA. 2015;314(14):1521. [Crossref] [PubMed] 
  3. Anderson EL, Howe LD, Jones HE, Higgins JP, Lawlor DA, Fraser A, et al. The Prevalence of Non-Alcoholic Fatty Liver Disease in Children and Adolescents: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(10):e0140908. [Crossref] [PubMed] [PMC] 
  4. Gibson GR, Beatty ER, Wang X, Cummings JH. Selective stimulation of bifidobacteria in the human colon by oligofructose and inulin. Gastroenterology. 1995;108(4):975-82. [Crossref] [PubMed] 
  5. Vos MB, Abrams SH, Barlow SE, Caprio S, Daniels SR, Kohli R, et al. NASPGHAN clinical practice guideline for the diagnosis and treatment of nonalcoholic fatty liver disease in children: recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr. 2017;64(2):319. [Crossref] [PubMed] [PMC] 
  6. Draijer L, Benninga M, Koot B. Pediatric NAFLD: an overview and recent developments in diagnostics and treatment. Expert Rev Gastroenterol Hepatol. 2019;13(5):447-61. [Crossref] [PubMed] 
  7. Yu EL, Golshan S, Harlow KE, Angeles JE, Durelle J, Goyal NP, et al. Prevalence of Nonalcoholic Fatty Liver Disease in Children with Obesity. J Pediatr. 2019;207:64-70. [Crossref] [PubMed] [PMC] 
  8. Rehm JL, Connor EL, Wolfgram PM, Eickhoff JC, Reeder SB, Allen DB, et al. Predicting hepatic steatosis in a racially and ethnically diverse cohort of adolescent girls. J Pediatr. 2014;165(2):319-25.e1. [Crossref] [PubMed] [PMC] 
  9. Mann JP, Valenti L, Scorletti E, Byrne CD, Nobili V. Nonalcoholic Fatty Liver Disease in Children. Semin Liver Dis. 2018;38(1):1-13. [Crossref] [PubMed] 
  10. Friedman SL, Neuschwander-Tetri BA, Rinella M, Sanyal AJ. Mechanisms of NAFLD development and therapeutic strategies. Nat Med. 2018;24(7):908-22. [Crossref] [PubMed] [PMC] 
  11. Day CP, James OF. Steatohepatitis: a tale of two "hits"? Gastroenterology. 1998;114(4):842-5. [Crossref] [PubMed] 
  12. Buzzetti E, Pinzani M, Tsochatzis EA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism. 2016;65(8):1038-48. [Crossref] [PubMed] 
  13. Di Sessa A, Cirillo G, Guarino S, Marzuillo P, Miraglia Del Giudice E. Pediatric non-alcoholic fatty liver disease: current perspectives on diagnosis and management. Pediatric Health Med Ther. 2019;10:89-97. [Crossref] [PubMed] [PMC] 
  14. Shakir AK, Suneja U, Short KR, Palle S. Overview of Pediatric Nonalcoholic Fatty Liver Disease: A Guide for General Practitioners. J Okla State Med Assoc. 2018;111(8):806-11. [PubMed] [PMC] 
  15. Shah J, Okubote T, Alkhouri N. Overview of Updated Practice Guidelines for Pediatric Nonalcoholic Fatty Liver Disease. Gastroenterol Hepatol (N Y). 2018;14(7):407-14. [PubMed] [PMC] 
  16. Nobili V, Marcellini M, Devito R, Ciampalini P, Piemonte F, Comparcola D, et al. NAFLD in children: a prospective clinical-pathological study and effect of lifestyle advice. Hepatology. 2006;44(2):458-65. [Crossref] [PubMed] 
  17. DeVore S, Kohli R, Lake K, Nicholas L, Dietrich K, Balistreri WF, et al. A multidisciplinary clinical program is effective in stabilizing BMI and reducing transaminase levels in pediatric patients with NAFLD. J Pediatr Gastroenterol Nutr. 2013;57(1):119-23. [Crossref] [PubMed] [PMC] 
  18. Panera N, Barbaro B, Della Corte C, Mosca A, Nobili V, Alisi A, et al. A review of the pathogenic and therapeutic role of nutrition in pediatric nonalcoholic fatty liver disease. Nutr Res. 2018;58:1-16. [Crossref] [PubMed] 
  19. Van Der Heijden GJ, Wang ZJ, Chu Z, Toffolo G, Manesso E, Sauer PJ, et al. Strength exercise improves muscle mass and hepatic insulin sensitivity in obese youth. Med Sci Sports Exerc. 2010;42(11):1973-80. [Crossref] [PubMed] [PMC] 
  20. González-Ruiz K, Ramírez-Vélez R, Correa-Bautista JE, Peterson MD, García-Hermoso A. The Effects of Exercise on Abdominal Fat and Liver Enzymes in Pediatric Obesity: A Systematic Review and Meta-Analysis. Child Obes. 2017;13(4):272-82. [Crossref] [PubMed] 
  21. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH, et al; American Heart Association; American Academy of Pediatrics. Dietary recommendations for children and adolescents: a guide for practitioners: consensus statement from the American Heart Association. Circulation. 2005;112(13):2061-75. Erratum in: Circulation. 2005;112(15):2375. Erratum in: Circulation. 2006;113(23):e857. Gilman, Matthew W [corrected to Gillman, Matthew W]. [Crossref] [PubMed] 
  22. Sekkarie A, Welsh JA, Vos MB. Carbohydrates and diet patterns in nonalcoholic fatty liver disease in children and adolescents. Curr Opin Clin Nutr Metab Care. 2018;21(4):283-8. [Crossref] [PubMed] 
  23. Gibson PS, Lang S, Dhawan A, Fitzpatrick E, Blumfield ML, Truby H, et al. Systematic Review: Nutrition and Physical Activity in the Management of Paediatric Nonalcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr. 2017;65(2):141-9. [Crossref] [PubMed] 
  24. Mager DR, I-iguez IR, Gilmour S, Yap J. The effect of a low fructose and low glycemic index/load (FRAGILE) dietary intervention on indices of liver function, cardiometabolic risk factors, and body composition in children and adolescents with nonalcoholic fatty liver disease (NAFLD). JPEN J Parenter Enteral Nutr. 2015;39(1):73-84. [Crossref] [PubMed] 
  25. Dowla S, Pendergrass M, Bolding M, Gower B, Fontaine K, Ashraf A, et al. Effectiveness of a carbohydrate restricted diet to treat non-alcoholic fatty liver disease in adolescents with obesity: Trial design and methodology. Contemp Clin Trials. 2018;68:95-101. [Crossref] [PubMed] [PMC] 
  26. Jin R, Welsh JA, Le NA, Holzberg J, Sharma P, Martin DR, et al. Dietary fructose reduction improves markers of cardiovascular disease risk in Hispanic-American adolescents with NAFLD. Nutrients. 2014;6(8):3187-201. [Crossref] [PubMed] [PMC] 
  27. Schwimmer JB, Ugalde-Nicalo P, Welsh JA, Angeles JE, Cordero M, Harlow KE, et al. Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys: A Randomized Clinical Trial. JAMA. 2019;321(3):256-65. Erratum in: JAMA. 2019;322(5):469. [Crossref] [PubMed] [PMC] 
  28. Jeznach-Steinhagen A, Ostrowska J, Czerwonogrodzka-Senczyna A, Boniecka I, Shahnazaryan U, Kuryłowicz A, et al. Dietary and Pharmacological Treatment of Nonalcoholic Fatty Liver Disease. Medicina (Kaunas). 2019;55(5):166. [Crossref] [PubMed] [PMC] 
  29. Mann JP, Valenti L, Scorletti E, Byrne CD, Nobili V. Nonalcoholic Fatty Liver Disease in Children. Semin Liver Dis. 2018;38(1):1-13. [Crossref] [PubMed] 
  30. Mann JP, Tang GY, Nobili V, Armstrong MJ. Evaluations of Lifestyle, Dietary, and Pharmacologic Treatments for Pediatric Nonalcoholic Fatty Liver Disease: A Systematic Review. Clin Gastroenterol Hepatol. 2019;17(8):1457-76.e7. [Crossref] [PubMed] 
  31. Ramon-Krauel M, Salsberg SL, Ebbeling CB, Voss SD, Mulkern RV, Apura MM, et al. A low-glycemic-load versus low-fat diet in the treatment of fatty liver in obese children. Child Obes. 2013;9(3):252-60. [Crossref] [PubMed] [PMC] 
  32. Vos MB, Weber MB, Welsh J, Khatoon F, Jones DP, Whitington PF, et al. Fructose and oxidized low-density lipoprotein in pediatric nonalcoholic fatty liver disease: a pilot study. Arch Pediatr Adolesc Med. 2009;163(7):674-5. [Crossref] [PubMed] [PMC] 
  33. Browning JD, Baker JA, Rogers T, Davis J, Satapati S, Burgess SC, et al. Short-term weight loss and hepatic triglyceride reduction: evidence of a metabolic advantage with dietary carbohydrate restriction. Am J Clin Nutr. 2011;93(5):1048-52. [Crossref] [PubMed] [PMC] 
  34. Oliveira CP, de Lima Sanches P, de Abreu-Silva EO, Marcadenti A. Nutrition and Physical Activity in Nonalcoholic Fatty Liver Disease. J Diabetes Res. 2016;2016:4597246. [Crossref] [PubMed] [PMC] 
  35. Arciero PJ, Gentile CL, Pressman R, Everett M, Ormsbee MJ, Martin J, et al. Moderate protein intake improves total and regional body composition and insulin sensitivity in overweight adults. Metabolism. 2008;57(6):757-65. [Crossref] [PubMed] 
  36. Markova M, Pivovarova O, Hornemann S, Sucher S, Frahnow T, Wegner K, et al. Isocaloric Diets High in Animal or Plant Protein Reduce Liver Fat and Inflammation in Individuals With Type 2 Diabetes. Gastroenterology. 2017;152(3):571-85.e8. [Crossref] [PubMed] 
  37. Suárez M, Boqué N, Del Bas JM, Mayneris-Perxachs J, Arola L, Caimari A, et al. Mediterranean Diet and Multi-Ingredient-Based Interventions for the Management of Non-Alcoholic Fatty Liver Disease. Nutrients. 2017;9(10):1052. [Crossref] [PubMed] [PMC] 
  38. Dernini S, Berry EM. Mediterranean Diet: From a Healthy Diet to a Sustainable Dietary Pattern. Front Nutr. 2015;2:15. [Crossref] [PubMed] [PMC] 
  39. Ryan MC, Itsiopoulos C, Thodis T, Ward G, Trost N, Hofferberth S, et al. The Mediterranean diet improves hepatic steatosis and insulin sensitivity in individuals with non-alcoholic fatty liver disease. J Hepatol. 2013;59(1):138-43. [Crossref] [PubMed] 
  40. Properzi C, O'Sullivan TA, Sherriff JL, Ching HL, Jeffrey GP, Buckley RF, et al. Ad Libitum Mediterranean and Low-Fat Diets Both Significantly Reduce Hepatic Steatosis: A Randomized Controlled Trial. Hepatology. 2018;68(5):1741-54. [Crossref] [PubMed] 
  41. Della Corte C, Mosca A, Vania A, Alterio A, Iasevoli S, Nobili V, et al. Good adherence to the Mediterranean diet reduces the risk for NASH and diabetes in pediatric patients with obesity: The results of an Italian Study. Nutrition. 2017;39-40:8-14. [Crossref] [PubMed] 
  42. Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al; DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001;344(1):3-10. [PubMed] 
  43. Xiao ML, Lin JS, Li YH, Liu M, Deng YY, Wang CY, et al. Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet is associated with lower presence of non-alcoholic fatty liver disease in middle-aged and elderly adults. Public Health Nutr. 2020;23(4):674-82. [Crossref] [PubMed] 
  44. Razavi Zade M, Telkabadi MH, Bahmani F, Salehi B, Farshbaf S, Asemi Z, et al. The effects of DASH diet on weight loss and metabolic status in adults with non-alcoholic fatty liver disease: a randomized clinical trial. Liver Int. 2016;36(4):563-71. [Crossref] [PubMed] 
  45. Shapiro WL, Yu EL, Arin JC, Murray KF, Ali S, Desai NK, et al. Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States. J Pediatr Gastroenterol Nutr. 2019;68(2):182-9. [Crossref] [PubMed] [PMC] 
  46. Bower G, Toma T, Harling L, Jiao LR, Efthimiou E, Darzi A, et al. Bariatric Surgery and Non-Alcoholic Fatty Liver Disease: a Systematic Review of Liver Biochemistry and Histology. Obes Surg. 2015;25(12):2280-9. [Crossref] [PubMed] 
  47. Manco M, Mosca A, De Peppo F, Caccamo R, Cutrera R, Giordano U, et al. The Benefit of Sleeve Gastrectomy in Obese Adolescents on Nonalcoholic Steatohepatitis and Hepatic Fibrosis. J Pediatr. 2017;180:31-7.e2. [Crossref] [PubMed] 
  48. Nobili V, Manco M, Devito R, Di Ciommo V, Comparcola D, Sartorelli MR, et al. Lifestyle intervention and antioxidant therapy in children with nonalcoholic fatty liver disease: a randomized, controlled trial. Hepatology. 2008;48(1):119-28. [Crossref] [PubMed] 
  49. Lavine JE, Schwimmer JB, Van Natta ML, Molleston JP, Murray KF, Rosenthal P, et al; Nonalcoholic Steatohepatitis Clinical Research Network. Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. JAMA. 2011;305(16):1659-68. [Crossref] [PubMed] [PMC] 
  50. Chalasani N, Younossi Z, Lavine JE, Charlton M, Cusi K, Rinella M, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2018;67(1):328-57. [Crossref] [PubMed] 
  51. Nobili V, Bedogni G, Alisi A, Pietrobattista A, Risé P, Galli C, et al. Docosahexaenoic acid supplementation decreases liver fat content in children with non-alcoholic fatty liver disease: double-blind randomised controlled clinical trial. Arch Dis Child. 2011;96(4):350-3. [Crossref] [PubMed] 
  52. Janczyk W, Lebensztejn D, Wierzbicka-Rucińska A, Mazur A, Neuhoff-Murawska J, Matusik P, et al. Omega-3 Fatty acids therapy in children with nonalcoholic Fatty liver disease: a randomized controlled trial. J Pediatr. 2015;166(6):1358-63.e1-3. [Crossref] [PubMed] 
  53. Della Corte C, Carpino G, De Vito R, De Stefanis C, Alisi A, Cianfarani S, et al. Docosahexanoic Acid Plus Vitamin D Treatment Improves Features of NAFLD in Children with Serum Vitamin D Deficiency: Results from a Single Centre Trial. PLoS One. 2016;11(12):e0168216. [Crossref] [PubMed] [PMC] 
  54. Vajro P, Mandato C, Licenziati MR, Franzese A, Vitale DF, Lenta S, et al. Effects of Lactobacillus rhamnosus strain GG in pediatric obesity-related liver disease. J Pediatr Gastroenterol Nutr. 2011;52(6):740-3. [Crossref] [PubMed] 
  55. Famouri F, Shariat Z, Hashemipour M, Keikha M, Kelishadi R. Effects of Probiotics on Nonalcoholic Fatty Liver Disease in Obese Children and Adolescents. J Pediatr Gastroenterol Nutr. 2017;64(3):413-7. [Crossref] [PubMed] 
  56. Alisi A, Bedogni G, Baviera G, Giorgio V, Porro E, Paris C, et al. Randomised clinical trial: The beneficial effects of VSL#3 in obese children with non-alcoholic steatohepatitis. Aliment Pharmacol Ther. 2014;39(11):1276-85. [Crossref] [PubMed] [PMC] 

.: Up To Date

.: Process List

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com