Obesity and overweight. Recommendations for obese people from Russian nutritionists Recommendations for the diagnosis and treatment of obesity
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2017
Other forms of overnutrition (E67), Other forms of obesity (E66.8), Extreme obesity accompanied by alveolar hypoventilation (E66.2), Obesity, unspecified (E66.9), Ingestion-induced obesity medicines(E66.1)
Endocrinology
general information
Short description
Approved
Joint Commission on the quality of medical services
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26
Obesity- a chronic, relapsing disease characterized by excessive deposition of adipose tissue in the body. This is a complex multifactorial disease that develops as a result of the action of genetic and environmental factors.
In clinical practice, obesity is assessed using body mass index (BMI). BMI is calculated by dividing body weight in kilograms by height in square meters. In accordance with WHO recommendations, the following interpretation of BMI indicators for the adult population has been developed:
. up to 19 kg / m 2 - weight deficit;
. 19-24.9 kg / m 2 - normal weight;
. 25-29.9 kg / m 2 - overweight;
. 30 kg / m 2 and above - obesity.
The risk of mortality increases significantly with BMI>30. At BMI>40, there is a pronounced negative effect obesity on health status and mortality risk. (A) The World Health Organization (WHO) uses the term "morbid obesity" to refer to patients with a BMI >40. According to the definition of the US National Institutes of Health (NIH), obesity is considered to be morbid if BMI ≥35 and the presence of serious complications associated with obesity, and obesity if BMI> 40, regardless of the presence of complications.
INTRODUCTION
Code(s) according to ICD-10:
| ICD-10 | |
| The code | Name |
| E66 | Obesity |
| E66.1 |
Obesity due to medication If necessary, identify medicinal product use additional code external causes(class XX). |
| E66.2 |
Extreme obesity accompanied by alveolar hypoventilation Obesity hypoventilation syndrome Pickwickian syndrome |
| E66.8 | Other forms of obesity. Morbid obesity |
| E66.9 | Obesity, unspecified. Simple obesity NOS |
| E67 | Other types of power redundancy |
Date of development/revision of the protocol: 2013 (revised 2017).
Abbreviations used in the protocol:
| AG | - | arterial hypertension |
| HELL | - | blood pressure |
| SHNG | - | sex hormone-binding globulin |
| BMI | - | body mass index |
| CWR | - | cardiovascular risks |
| CT | - | CT scan |
| HDL | - | high density lipoproteins |
| LG | - | luteinizing hormone |
| LNP | - | low density lipoproteins |
| MRI | - | Magnetic resonance imaging |
| MT | - | body mass |
| FROM | - | Waist |
| PZhK | - | subcutaneous fat |
| SD | - | diabetes |
| CVD | - | cardiovascular diseases |
| ultrasound | - | ultrasound procedure |
| FR | - | risk factors |
| FSH | - | follicle-stimulating hormone |
| thyroid | - | thyroid |
| EGDS | - | esophagogastroduodenoscopy |
Protocol Users: doctors general practice, internists, endocrinologists, cardiologists, gastroenterologists, hepatologists, gynecologists, rheumatologists, surgeons, neuropathologists.
Evidence level scale:
| BUT | High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias whose results can be generalized to an appropriate population. |
| AT | High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to the appropriate population . |
| With |
Cohort or case-control or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the appropriate population. |
| D | Description of a case series or uncontrolled study or expert opinion. |
| GPP | Best Clinical Practice. |
Classification
1. By etiology and pathogenesis:
primary obesity (alimentary-constitutional or exogenous-constitutional) (in 95% of cases):
gynoid (lower type, gluteal-femoral);
android (upper type, abdominal, visceral);
with individual components of the metabolic syndrome;
with advanced symptoms of metabolic syndrome;
with severe eating disorders;
with night eating syndrome;
with seasonal affective fluctuations;
with a hyperphagic reaction to stress;
with Pickwick's syndrome;
with secondary polycystic ovaries;
with sleep apnea syndrome;
· with puberty-youthful dispituitarism.
2.
Symptomatic (secondary) obesity (in 5% of cases):
With an established genetic defect:
As part of known genetic syndromes with multiple organ damage;
genetic defects involved in the regulation fat metabolism structures.
Cerebral:
(adiposogenital dystrophy, Babinski-Pehkranz-Froelich syndrome);
Tumors of the brain, other cerebral structures;
dissemination of systemic lesions, infectious diseases;
Hormonally inactive pituitary tumors, syndrome of "empty" Turkish saddle, "pseudotumor" syndrome;
against the background of mental illness.
Endocrine:
The hypothyroid
Hypoovarian
in diseases of the hypothalamic-pituitary system;
in diseases of the adrenal glands.
3. Classification of obesity according to the course of the disease:
· stable;
Progressive
residual ( residual effects after persistent weight loss).
4.
Classification of obesity by body mass index.
Degrees of obesity by BMI:
Europeans:
Obesity I degree: BMI from 30 to 34.9;
Obesity II degree: BMI from 35 to 39.9;
obesity III degree: BMI of 40 and above.
Asians:
Obesity I degree: BMI from 25 to 28.94;
Obesity II degree: BMI from 29 to 32.9;
III degree obesity: BMI of 33 and above.
Obesity III degree is also called pathological or extreme obesity. This name is clinically confirmed, because in patients suffering from morbid obesity, the risk of early death is increased by 2 times compared to those whose BMI is equal to those corresponding to the I degree of obesity (according to European studies).
Classification with an assessment of the degree of risk of concomitant diseases
| Risk of comorbidities | ||||
| Degree of obesity | BMI kg/m2 |
OT (women) 80-88 cm OT (male) 94-102 cm |
OT (Women) ³88 cm OT (male) ³102 cm |
|
| Overweight | 25,0-29,9 | elevated | tall | |
| The average | 30,0-34,9 | Obesity I degree | Tall | Very tall |
| Moderate | 35,0-39,9 | Obesity II degree | Very tall | Very tall |
| Extreme (morbid) | ³ 40 | Obesity III degree | Extremely high | Extremely high |
Diagnostics
METHODS, APPROACHES AND DIAGNOSIS PROCEDURES
Diagnostic criteria:
BMI is a simple, reliable screening criterion for assessing normal, overweight body and obesity.
An algorithm for diagnosing obesity, which includes two components:
1) assessment of BMI with correction for ethnic features to identify individuals with an increased amount of adipose tissue;
2) the presence and severity of complications associated with obesity.
Complaints:
overweight;
increase in blood pressure;
shortness of breath during physical exertion;
snoring in sleep
Increased sweating
· Menstrual disorders - in women, reduced potency in men - due to obesity-associated diseases.
Anamnesis:
changes in body weight over the past 2 years;
eating habits, physical activity
taking medicines ( this information necessary for early diagnosis overweight, selection of adequate treatment tactics): corticosteroids, antipsychotics, antidepressants, oral contraceptives, sugar-lowering drugs);
· early diseases cardiovascular system (myocardial infarction or sudden death father or other first-line male relatives ≤ 55 years old, or mother or other female first-line relatives ≤ 65 years old);
identify and assess the impact of diseases associated with obesity (diabetes, hypertension, dyslipidemia, cardiovascular, respiratory and articular pathology, non-alcoholic fatty disease liver, sleep disorders, etc.).
Physical examination:
At the stage of the initial treatment of the patient, the following measures should be taken:
calculate BMI (body mass index);
measure FROM (waist circumference);
Examine for the presence of papillary-pigmentary degeneration of the skin (acanthosis nigricans) as a sign of insulin resistance;
assess the severity of comorbidities and the risk of developing CVD and type 2 diabetes:
a) assessment of BMI;
b) OT assessment;
c) calculation of cardiovascular risk:
− smoking;
- AH (degree, duration, etiology);
- LDL;
− HDL;
− blood glucose (venous plasma);
− uric acid, creatinine;
− family history of CVD;
- an additional risk factor is the age of a man 45 years or more, women 55 years and more (menopause).
OT score: ³80-88 cm for women, ³94-102 cm for men (relative to national standards). Measurement of OT must also be carried out with a BMI of 18.5-25 kg / m², because. excessive deposition of fat in the abdomen increases cardiovascular risk (CVR) and at normal body weight. With BMI³35 kg / m² - measurement of FROM is impractical.
BMI³30 kg/m² or BMI³25 kg/m², but OT³80 cm in women, OT³94 cm in men and having ³2 RF. For this category of patients, weight loss is the key to maintaining health. On the this stage it is necessary to identify priorities for this patient - what is the first priority in treatment, for example, smoking cessation for certain patients is more important than immediate weight loss. Grade psychological state patient, his motivation and desire to reduce weight.
Laboratory research:
· biochemical research blood: total cholesterol, HDL, LDL, triglycerides, glucose, ALT, AST, uric acid.
Glucose tolerance test: with an increase in fasting glucose of more than 5.6 mmol / l, aggravated family history of diabetes, indirect signs insulin resistance.
Instrumental research:
· ECG(exclude ischemic changes, rhythm disturbances, ECG signs previous myocardial infarction);
· Doppler - echocardiography with a study of the characteristics of the transmitral blood flow and an assessment of the local kinetics of the myocardium;
· Holter ECG monitoring(detection of clinically significant arrhythmias and conduction disorders, including diagnostically significant pauses);
If IHD is suspected - stress test, in case of physical impossibility of execution;
The patient of the stress test showed pharmacological stress echocardiography;
· MRI of the brain (Turkish saddle) - if you suspect a pathology of the hypothalamic-pituitary system;
· EGDS: according to indications;
· Ultrasound of organs abdominal cavity:
according to indications;
· Ultrasound of the thyroid gland: according to indications.
Indications for specialist consultations:
| specialist | goal |
| therapist/cardiologist | clarification of the general somatic condition, the presence of cardiovascular events |
| endocrinologist | exclusion of obesity associated with endocrine diseases; |
| neurologist/neurosurgeon | for patients with a history of traumatic brain injury, neuroendocrine diseases |
| ophthalmologist | patients with arterial hypertension, the presence of brain tumors, the consequences of traumatic brain injury |
| surgeon | to resolve the issue of surgical treatment of obesity (in republican healthcare organizations with a morbid form) |
| gynecologist | in violation of fertility, the presence of signs of polycystic ovary syndrome |
| psychotherapist | patients with eating disorders (attacks of compulsive eating at certain intervals of time, lack of a feeling of satiety, taking large amounts of food without feeling hungry, in a state of emotional discomfort, sleep disturbance with night meals in combination with morning anorexia); |
| geneticist | in the presence of signs of genetic syndromes |
| rheumatologist | In the presence of concomitant pathology of the joints, in particular osteoarthritis |
Diagnostic algorithm:(scheme)
Differential Diagnosis
Differential Diagnosis and rationale for additional research:
For differential diagnosis of primary and secondary obesity, hormonal studies are carried out in the presence of complaints and clinical manifestations of various endocrinopathies.
| Complaints | Inspection | Endocrinopathy | Diagnostic methods |
| General weakness, lethargy, drowsiness, chilliness, edema, loss of appetite, constipation, sexual dysfunction, bradycardia | Hypersthenic physique, puffiness of the face, edematous tongue with imprints of teeth, muffled heart sounds | Primary hypothyroidism | TSH, svT4, thyroid ultrasound |
| Redistribution of the pancreas (large belly, thin arms, legs), reddening of the face, purple striae, increased blood pressure, headaches, depressed mood | Android fat distribution, matronism, hyperpigmentation of natural skin folds, burgundy striae, pustular skin lesions, persistent increase in blood pressure, carbohydrate metabolism disorders | Syndrome of hypercortisolism | ACTH, cortisol in the blood, excretion of cortisol in daily urine, small / big sample with dexamethasone, ultrasound (CT/MRI) of the adrenal glands, MRI or CT of the pituitary gland |
| Menstrual disorders, amenorrhea, discharge from the nipples in women, decreased potency, libido, infertility, gynecomastia | Galactorrhea | Syndrome of hyperprolactinemia | Prolactin, CT/MRI with contrast of the pituitary gland, ultrasound of the ovaries of the uterus in women, prostate in men |
| Decrease in potency, libido, infertility, increase mammary glands, decreased muscle mass in men | Eunuchoid body type, decreased skin turgor, muscle laxity, gynecomastia, underdevelopment of the external genital organs | Hypogonadism syndrome (primary/secondary) | Testosterone, LH, FSH, estradiol, GSPP, breast ultrasound, skull x-ray (lateral view), andrologist consultation |
| Menstrual irregularities, amenorrhea, excessive body hair growth in women | Android body type, hirsutism, virilization | Syndrome of hyperandrogenism | LH, FSH, SHBG, testosterone, 17-OP, ultrasound of the small pelvis, adrenal glands, gynecologist's consultation |
Complications/diseases associated with obesity, and its negative consequences are:
DM type 2;
IHD;
insufficiency of blood circulation;
· arterial hypertension;
obstructive sleep apnea syndrome;
osteoarthritis;
· malignant tumors individual localizations;
Some reproductive disorders
· cholelithiasis;
non-alcoholic steatohepatitis;
psychological maladjustment;
social maladjustment.
Treatment abroad
Get treatment in Korea, Israel, Germany, USA
Get advice on medical tourism
WGO Global Guideline Obesity
Advisor:
- Elisabeth Mathus-Vliegen (Netherlands)
Experts:
- Pedro Kaufmann (Uruguay)
- Eve Roberts (Canada)
- Gabriele Riccardi (Italy)
- Obesity: concept
- Painting around the world
- Obesity and disease risk
- Evaluation of Obese Patients
- Treatment: a lifestyle approach
- Pharmacotherapy
- Other treatment options
- Treatment: surgery
- Treatment: schemes and summary conclusion
- Cascades
1. Obesity: concept
Introduction and summary
- Obesity is increasingly spreading around the world in all age groups.
- Obesity is a cause (and often a precursor) of various chronic diseases.
- Not being obese can help a person avoid developing various chronic diseases; obesity prevention is a better method than trying to control it. As a society, we must try to address the issue of preventing obesity in children and adults.
- Obesity must be treated to prevent the development of comorbid conditions, and if present, develop best practices patient management.
- The social and psychological aspects of obesity cannot be ignored, especially in relation to the prevention of childhood obesity. This is also very important for adult obese patients (together with the need to prevent discrimination, stigmatization, ridicule and lack of willpower).
- It is necessary to carry out research in the field of epidemiology, physiological mechanisms controlling body weight, pathophysiology of obesity. Treatment tactics may also lead to progress in the management of obese patients worldwide.
Some questions and key points in patient management
Some questions
Obesity is one of the most important health problems in both developed and developing countries. It is often associated with serious comorbidities. Obesity has a significant impact on a country's health care budget and has side effects on life expectancy.
While weight loss (i.e., resolution of obesity) is an important treatment endpoint, intermediate goals are more important for the individual patient, e.g., treatment of comorbidities such as insulin resistance, reduction in sleep apnea, reduction in diastolic blood pressure or increased joint mobility. In most cases, significant weight loss is combined with relief or better control of comorbidities.
What is the result of lifestyle changes, diet, surgery, or a combination of these on a long period? How to deal with cultural factors?
When can treatment be considered ineffective and when (at what body mass index) should other therapies be used? Should surgery be considered in patients with a body mass index (BMI) between 30 and 35? Most practice guidelines indicate that there is no need for surgical treatment if BMI<35.
- Obstructive sleep apnea: nocturnal pulse oximetry or standard sleep study
- cardiac functions
Chest x-ray
Electrocardiography
Additional diagnostic studies
- Assessment of the cardiovascular system
- Screening test for cancer
- Screening for secondary causes:
Cushing's syndrome
Hypothyroidism
Hypothalamus disease
5. Treatment: a lifestyle approach
diets
A recent meta-analysis summarized current trends (Table 7).
Table 7. Meta-analysis of diets to support weight loss: 29 studies with a follow-up period of at least 2 years
|
|
Dynamic observation (years) |
Research (count) |
Weight reduction (kg) |
PSV (kg) |
PSV (%) |
Weight reduction (%) |
GDM = hypoenergy balanced diet, VED = very low calorie diet, PSV = maintenance of weight loss
Source: Anderson et al., American Journal of Clinical Nutrition 2001;73:579–83.
Long-term use of diets requires further study; currently available data are shown in Table 8.
Table 8. Long-term efficacy of diets in 17 studies including 3030 patients with a follow-up period of at least 3 years and less than 50% of patients withdrew from the study. The mean duration of follow-up was 5 years (range 3–14 years) in 2131 patients (70%) with retention of all weight loss or a maximum reduction of 9–11 kg from initial weight loss.
|
|
|
Borders |
|
Primary Weight Loss (Mean) | ||
|
Successful weight maintenance | ||
|
Impact of Primary Treatment Diet + Group Therapy | ||
|
Diet only | ||
|
Diet + behavioral therapy | ||
|
Effect of Energy Level of the Primary Diet ONKD (300-600 kcal) | ||
|
Standard diet (800-1800 kcal) | ||
|
Influence of intensity of dynamic observation Active approach | ||
|
Passive Approach | ||
|
ONCD + behavioral therapy + active follow-up |
ONCD - very low calorie diet
Source: Ayyard and Anderson, Obesity Review 2000;1:113–9.
The minimum energy requirement for a normal weight patient on bed rest is approximately 0.8 kcal/min (1150 kcal/day).
- This maintains body temperature, heart and other organ function, and tissue repair.
- A high level of physical activity can increase the need for energy expenditure by 4 to 8 times
- In general, a normal adult requires an intake of approximately 22-25 kcal/kg of nutrients to maintain 1 kg of body weight.
To lose weight, energy intake must be less than its expenditure.
- Projected weight loss: 0.5 - 1.0 kg per week, based on a calorie deficit of 500 - 1000 kcal/day without change physical activity
- In general, diets containing less than 800 kcal/day are not recommended.
Low calorie diets include:
- Very low (less than 800 kcal/day)
Used only when drastic weight loss is needed
Medical supervision required
- Low (800 - 1500 kcal / day)
- Moderate (about 500 kcal less than in the usual daily diet)
- The reduction in energy intake can be achieved either by reducing appetite or by lowering the energy density of food, which also leads to weight loss. However, more controlled intervention studies are needed to determine the long-term effects on body weight of this technique.
Diet low in fat
The use of such a diet is still controversial, although epidemiological and environmental data indicate an association between reduced fat intake and stabilization or reduction in body weight.
- Low Fat Diet:<30% общей калорийности исходит от жиров
- Very Low Fat Diet: Reducing Fat<15% от общей калорийности, 15% калорий от белков и 70% - от углеводов. Данной диеты трудно придерживаться в течение длительного времени.
Diet low in carbohydrates
This diet shows better results at 6 months than the low fat diet, but by 12 months the difference is no longer noticeable.
- <60 г углеводов в сутки.
- Many diets (such as the Atkins and South Beach) start with<20 г углеводов в сутки и постепенно увеличивают их количество.
High fiber diet (legumes, vegetables, white bread)
Low glycemic index (LGI) or low glycemic load diet
Reducing the glycemic load of the diet can be an effective method of weight loss.
- The NHI diet improves the lipid profile and can be easily incorporated into the patient's lifestyle.
- Studies have shown that body weight, total body fat mass, BMI, total cholesterol, and LDL can be significantly reduced with an NGI diet.
- A recent systematic review by Cochrane concluded that overweight and obese people reduce it more effectively with an GI diet than with a high glycemic index or other diets. It also improves the risk profile for cardiovascular disease.
- Further studies are needed to determine the long-term effects and improve the quality of life of patients.
High fat diet
In randomized trials, replacing carbohydrates with protein in a reduced calorie diet has been shown to reduce body weight.
- High protein diets are usually high in fat
- The point of the diet is that protein can increase satiety, increase food-related thermogenesis, maintain body weight, and decrease energy efficiency.
Specific commercial diets
In randomized trials, these diets showed the same loss of adipose tissue and weight, a similar reduction blood pressure and little difference in terms of effect on total cholesterol and fasting glucose.
- Mediterranean diet (fruits and vegetables, olive oil, nuts, red wine, very a large number of raw meat, fish)
- Atkins diet (carbohydrate restriction)
- Zone (40% carbs, 30% fat, 30% protein)
- Weight monitoring or other similar programs (calorie restriction)
- The Ornish diet (10% fat restriction)
- Diet Rosemary Conley
Potential Adjuncts to Effective Diet Therapy
- Use of Meal Replacements - Increased Weight Loss in Randomized Trials
- Involvement of nutritionists - helps to reduce body weight in an outpatient setting
- Breakfast
- Extra fiber
- Physical activity is recommended as a means of weight loss, particularly in combination with dietary changes.
- The combination of increased physical activity with calorie restriction results in greater weight loss and changes in body configuration (fat versus muscle) than diet alone or physical activity alone.
- Physical activity is associated with a reduced risk of cardiovascular disease, even if there is no weight loss.
It reduces the amount of abdominal fat and affects insulin resistance.
It increases plasma HDL levels, lowers triglycerides and blood pressure.
Physical exercise for resistance can change the shape of the figure
Adults should set a long-term goal of at least 30 minutes of moderate physical activity per day
Physical activity is a predictor of body weight maintenance.
Behavioral changes and expert advice
Behavioral therapy (table 9) can lead to 8-10% weight loss in 6 months.
Table 9. Behavioral Therapy: Research Results Published 1990-2000
RCT - Randomized Controlled Trials, USPSTF - United States Preventive Services Task Force
Sources: Wing RR, “Behavioral approaches to the treatment of obesity,” in: Bray GA, Bouchard C, James WPT, editors, Handbook of obesity, 2nd ed. (New York: Dekker, 1998), pp. 855–74; McTigue et al., Annals of Internal Medicine 2003;139:933–49; Kushner, Surgery for Obesity and Related Diseases 2005;1:120–2.
- Psychological support, especially behavioral and behavioral-cognitive strategies, enhances weight loss
- Mostly beneficial when combined with diet and exercise
- Long-term maintenance programs can provide sustainable behavioral changes to help with weight gain
- Psychotherapeutic approaches, such as relaxation therapy or hypnotherapy, have not shown a positive effect
Behavioral therapy is mostly done on an individual basis or in small groups for 6 months on a weekly basis. Her key features:
- Goal setting and diet advice
- Self-monitoring – with patient-filled food diary
- Incentive Control
- Cognitive restructuring - conscious behavior in eating and dietary habits
- Prevention of relapses
6. Pharmacotherapy
Introduction
Medications, in general, play only a limited role in the treatment of obesity. Drugs designed for this purpose are limited in quantity and effectiveness (Table 10). However, weight loss medications can help patients agree to lifestyle changes, and can lead to clinically significant and effective reductions in symptoms, risk factors, and improved quality of life. The physician needs an understanding of the benefits and risks associated with the use of these drugs in order to choose the right remedy.
Studies of the action of drugs mainly cover a short period of time. Data on long-term effectiveness has not been published. Most of the research covers a period of 1-2 years. All medications were stopped after this time, and since obesity is an incurable disease, it comes back just like diabetes after stopping insulin therapy.
In randomized trials of drugs approved by the US Food and Drug Administration (FDA), in combination with lifestyle changes, compared with placebo and lifestyle changes alone, it was shown that weight loss from baseline with drugs was increased by 3 - 5%.
- Reducing risk factors for development cardiovascular disease mainly associated with the amount of weight loss
- Criteria for pharmacological therapy in combination with lifestyle changes to reduce weight and prevent weight gain:
BMI > 30
BMI > 27 with comorbidities
Table 10. Drugs prescribed for weight loss
FDA - US Food and Drug Administration, RCT - randomized controlled trial, LDL - low density lipoproteins, Substances controlled under scheme IV - in accordance with the Controlled Substances Act (1970) USA
- Randomized trials have shown a 3-4% increase in weight loss compared to placebo (drugs no longer available in Europe).
- Adrenergic stimulants increase the release of norepinephrine in certain areas of the brain, resulting in a decrease in food intake. However, there are only limited data on the efficacy and safety of drugs.
- It is necessary to carefully monitor blood pressure in patients with a tendency to increase it or receiving antihypertensive therapy.
- There is a potential (albeit low) risk of dependence on the drug (drugs are classified by the Drug Enforcement Agency in the US as Schedule IV controlled substances).
- Approved for short term use only; limited evidence suggests that stimulants may be effective for > 10 years.
Vitamin B12
Fat-soluble vitamins A, , E and K
Psychological factors affecting the outcome of surgery
- Disturbances in eating habits (such as eating at night)
- Abuse of certain foods
- Low socioeconomic status
- Limited social support
- Unrealistic expectations of surgical treatment
- Psychiatric problems: Most patients undergoing bariatric procedures have one or more psychiatric disorders.
Patients often require readmission or surgery due to complications or to treat underlying conditions. This risk requires a multidisciplinary assessment that includes the following:
- Therapeutic evaluation
- Surgical evaluation
- Nutritional Assessment
- Psychological assessment
results
Result for the patient:
- The potential benefit of bariatric surgery for moderately obese patients (BMI 30–35) remains unclear. One randomized trial showed a significant effect of surgical treatment with gastric banding compared with medical therapy and behavioral modification.
- The safety and efficacy of laparoscopic gastric banding (LGB) has been demonstrated in the surgical treatment of malignant obesity in the short term. Recent LBJ studies in Sweden have shown that the method is effective for a mean sustained weight loss of >50% at 8 years postoperatively with acceptably low morbidity.
- It is not known for sure whether patients with extremely severe obesity are suitable candidates for bariatric surgery.
- For these patients, the operative risk may be higher and surgical access may be difficult or even impossible. Patients with a BMI ≥ 70 may also have an increased risk of mortality
- For obese patients, a bariatric procedure may be risky, but the risk of remaining overweight is likely higher than the risk of surgery. This question remains unclear until the results of further studies become available.
- The effectiveness of bariatric procedures varies, and there are only limited long-term data:
There have been no large randomized trials comparing currently available bariatric procedures with medical treatment of severe obesity.
The Swedish Obese Patients (SOS) study showed that changes in body weight were significantly higher in the group of patients who underwent surgical treatment than in the control group. However, the increase in life expectancy of patients in the SOS study was modest.
Overall, weight loss with malabsorptive procedures appears to be greater than with restrictive procedures alone.
Improvement in obesity-related conditions, including diabetes, hyperlipidemia, hypertension, and sleep apnea, has been noted following bariatric surgical procedures.
The SOS data suggest that some of these effects, while significant, are less pronounced at 10 years compared to 2 years.
9. Treatment: schemes and summary conclusion
Management of the obese patient
- Ensure optimal medical care for patients with obesity:
Ensure respect from medical staff for the patient
To provide the patient with the same level of care as any other patient, to provide general preventive measures, observation and treatment of current diseases
- Maintain healthy behavior and sense of self, even in the absence of weight loss:
Record weighing readings without comment
Ask patients if they would like to discuss their weight or health status
Consider the existence of barriers between healthcare professionals – for example, the belief that obesity is mainly the result of the patient’s weak willpower
- Determine the class of obesity - the level of excess weight:
Assess overall body weight gain and central obesity - calculate BMI and measure waist circumference
- Estimate accompanying illnesses and risk status
- Is weight loss indicated?
Prevent further weight gain
Prevent the complications of obesity
The goal is to effectively influence the development of complications associated with obesity by reducing excess weight, maintaining a minimum weight and controlling associated risk factors.
Assessing the patient's expectations from the treatment
- Assessing the patient's readiness to understand:
Reasons and motivations for weight loss
Previous attempts to lose weight
Support expected from family and friends
Understanding the risks and benefits
Relationships to physical activity
Time of treatment
Potential barriers to patient adaptation to change
Discussing with the patient his preferences regarding diet and physical activity
- Choosing the best treatment method:
Discussing the goal of physical activity with the patient
- Is the patient a candidate for surgical treatment?
BMI 40 or higher
BMI of 35 or higher in combination with comorbidities
Severe sleep apnea
Obesity related cardiomyopathy
Severe diabetes mellitus
Severe joint damage
Failure of medical weight control. Patient must have attempted weight loss in the past
No medical or psychological contraindications
No risk, or acceptable risk for surgical treatment
The patient must be fully informed about the possible risks and results of the operation, understand the essence of the procedure and the risks associated with it, and be strongly motivated to accept the postoperative regimen.
Medical and surgical treatment should be carried out by a multidisciplinary team of physicians with experience in bariatric surgery, postoperative and dynamic monitoring of the patient
- Decide on medical weight loss
Orlistat: in combination with daily multivitamin therapy (may cause malabsorption of fat-soluble vitamins). Inform the patient about possible side effects.
With good blood pressure control
- Rimonabant (when approved by the national health authorities)
If you have metabolic syndrome
Drug therapy can only serve as an adjunct to a program that includes diet, physical activity, and behavioral therapy.
- Management of comorbidities:
Hypertension: lowering high blood pressure
Type 2 Diabetes: Reducing Elevated Blood Sugar
- Dyslipidemia:
Lowering total cholesterol, LDL and triglycerides
Increasing HDL levels through increased physical activity
- Discuss with the patient a strategy for maintaining body weight
- Encourage the patient to stick to realistic goals
- Patient documentation of their condition has proven to be one of the most successful behavioral techniques for weight loss and maintenance:
Record of food intake and energy expenditure
Body weight control (at least once a week)
- Diet low in fat and high in fiber
- Physical activity in accordance with the present state and comorbidities associated with obesity:
Classes in the gym
Developing home aerobics and strengthening endurance
Treatment result
General:
- 5-10% weight loss can have a significant impact on beneficial changes in waist circumference, blood pressure, circulating cytokines, and (variably) fasting glucose, triglyceride, and HDL levels
- A change in therapy should be considered if weight loss is less than 5% during the first 6 months of treatment.
- For the predicted success of treatment, the desire of the patient to lose weight is necessary.
Life style changes. Studies have shown that compared to standard treatment, lifestyle changes:
- Significantly reduce body weight and reduce the risk of cardiovascular complications
- Have a positive effect that is maintained for 3 years
Physical activity without reducing the calorie content of the diet leads to limited weight loss results.
Combined treatment. Changes in dietary habits and lifestyle, together with drug therapy, result in modest weight loss and may improve markers of cardiovascular complications, although these measures are effective mainly in pre-existing cardiovascular complications.
Maintain weight loss
There are many mechanisms in the body to modify the energy balance and restore the original body weight. Weight loss causes a decrease in the energy expenditure of the body, preventing the maintenance of weight. Unfortunately, the inability to maintain a reduced body weight is a common problem.
While short-term weight loss depends on reducing the calorie content of food, maintaining the achieved results depends on the level of physical activity. For most people, the long-term effect is still difficult to assess, and currently available treatments for obesity do not provide enough support for patients to make the required lifestyle changes.
Predictive factors for weight loss maintenance include:
- Eating low-fat foods rich in fiber and protein
- Frequent monitoring of body weight and food intake
- High level of physical activity
- Prolonged contact between patient and doctor
- Weight loss more than 2 kg in 4 weeks
- Frequent/Regular Attendance at a Weight Loss Program
- Patient confidence that body weight can be controlled
- Behavioral changes (may help)
Protective factors against re-weight gain: expenditure of approximately 2500 kcal/week, either by:
- Moderately active for approximately 80 minutes a day (brisk walking)
- Vigorous physical activity 35 minutes a day (jogging) Treatment and support methods:
- Polyclinic conditions
- Commercial programs
- Online Weight Loss Programs
Risk of weight loss
Some studies have shown that intentional weight loss reduces mortality, while unintentional weight loss is associated with an increased risk.
Due to the increased influx of cholesterol through the biliary system, weight loss may increase the risk of developing cholelithiasis. Low-fat diets that promote gallbladder shrinkage may reduce this risk.
Slow weight loss - for example, 0.5 - 1.0 kg per week - has been shown to be a prophylactic against the formation of gallbladder stones compared with patients with a higher rate of weight loss. Weight loss with additional gastric banding causes the same incidence of gallstones as in the general population.
10. Cascades
Action levels and management options for obese patients
What approaches to the treatment of obesity or its prevention (Table 11) are resource-dependent? Everyone involved in the management of obesity needs to act globally, regionally or locally. Overweight and obesity, as well as associated comorbidities, are generally amenable to preventive measures.
Individual level. The patient should avoid energy-dense foods, limit alcohol intake, be aware of the non-satiating effects of calorie-rich foods such as fats and alcohol (alcohol has additional appetite-suppressing effects), and be aware of the ability to induce satiety and the safety of proteins, followed by complex carbohydrates. .
- Maintain energy balance and maintain normal body weight
- Limit intake of energy-dense fat-containing foods and switch to unsaturated fats instead of saturated fats
- Increase consumption of fruits and vegetables, as well as legumes and grains
- Limit your intake of sugars (especially in drinks)
- Increase physical activity
Governments, international partners, civil society and non-governmental organizations, and the private sector should:
- Maintain a healthy environment
- Make healthier diet options more accessible and cheaper
- Encourage and promote physical activity The food industry should:
- Reduce the fat and sugar content of foods, as well as reduce the size of portioned meals
- Consistently introduce innovative, healthy and nutritious foods (low energy, high fiber, functional foods)
- Revisit current market strategies to improve health around the world
Table 11. Decision tree in the treatment of overweight and obesity
| obesity rate | |||||
| Degree 1 | Degree 2 | Grade 3 | |||
| Western countries | |||||
| BMI | 25,0-26,9 | 27,0-29,9 | 30,0-34,9 | 35,0-39,9 | > 40 |
| Waist (cm) | |||||
| Men Women | 94-102
80-88 | 94-102
80-88 | > 102
> 88 | > 102
> 88 | |
| Eastern/Asian countries* | |||||
| BMI | 23,0-24,9 | 25,0-29,9 | 30,0-34,9 | > 35 | > 35 |
| Waist (cm) | |||||
| Men Women | < 90
< 80 | < 90
< 80 | > 90
> 80 | > 90
>80 | |
| Treatment options | |||||
| No comorbidities | Diet Physical exercises | Diet Physical exercises | Diet Physical exercises Behavioral what therapy Pharmacotherapy 1.3 | Pharmaco- therapy 1 If not effective: surgery 2 | Surgery 2, doctor with or without pharmaco- therapy is ineffective |
| Have comorbidities | Diet Physical exercises Behavioral what therapy | Diet Physical exercises Behavioral what therapy Pharmacotherapy 1.4 | Diet Physical exercises Behavioral what therapy Pharmacotherapy 1.4 | Pharmacotherapy 1 Diet under the supervision of a doctor surgery 2.4 | Surgery 2, if the diet is under supervision doctor with or without pharmaco- therapy is ineffective 1 |
BMI - body mass index.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013
Obesity, unspecified (E66.9)
Endocrinology
general information
Short description
Approved
minutes of the meeting
Expert Commission
on health development
Ministry of Health of the Republic of Kazakhstan No. 23 dated December 12, 2013
Definition:
Obesity- a chronic, relapsing disease characterized by excessive deposition of adipose tissue in the body.
Obesity is a complex multifactorial disease that develops due to the action of genetic and environmental factors.
Protocol code:
Code(s) according to ICD-10:
E66.0 - Obesity due to excess intake of energy resources
E66.1 - Drug-induced obesity
E66.2 - Extreme obesity accompanied by alveolar hypoventilation (Pickwick's syndrome)
E66.8 - Other forms of obesity. Morbid obesity
E66.9 Obesity, unspecified
E67.0 - Other types of power redundancy
Protocol development date: April 2012.
Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
SHBG - sex hormone binding globulin
BMI - body mass index
CVR - cardiovascular risks
CT - computed tomography
HDL - high density lipoproteins
LH - luteinizing hormone
LDL - low density lipoproteins
MRI - magnetic resonance imaging
MT - body weight
OT - waist size
Subcutaneous fat - subcutaneous fat
DM - diabetes mellitus
CVD - cardiovascular diseases
Ultrasound - ultrasonography
RF - risk factors
FSH - follicle stimulating hormone
thyroid - thyroid gland
EGDS - esophagogastroduodenoscopy
Protocol Users: therapist, general practitioner, endocrinologist, gynecologist, cardiologist, rheumatologist, orthopedic traumatologist.
Classification
Clinical classification:
Etiopathogenetic:
1. Exogenous-constitutional obesity (primary, alimentary-constitutional):
- gynoid (gluteal-femoral, lower type)
- android (abdominal, visceral, upper type)
2. Symptomatic (secondary) obesity:
- with a known genetic defect
- cerebral (brain tumors, dissemination of systemic lesions, infectious diseases, against the background of mental illness)
- endocrine (hypothyroid, hypoovarian, diseases of the hypothalamic - pituitary system, diseases of the adrenal glands)
- iatrogenic (due to the intake of a number of drugs)
By the nature of the flow:
- stable
- progressive
- residual (residual effects after persistent weight loss)
Classification of obesity by BMI (WHO, 1997):
| Risk of comorbidities | ||||
| Degree of obesity | BMI kg/m2 |
OT (women) 80-88 cm OT (male) 94-102 cm |
OT (Women) ³88 cm OT (male) ³102 cm |
|
| Overweight | 25,0-29,9 | elevated | tall | |
| The average | 30,0-34,9 | Obesity I degree | Tall | Very tall |
| moderate | 35,0-39,9 | Obesity II degree | Very tall | Very tall |
| extreme | ³ 40 | Obesity III degree | Extremely high | Extremely high |
Diagnostics
The list of basic and additional diagnostic measures:
All patients undergo a biochemical blood test: total cholesterol, HDL, LDL, triglycerides, glucose, ALT, AST, uric acid. With an increase in fasting glucose of more than 5.6 mmol / l, a burdened family history of diabetes, indirect signs of insulin resistance (acantosis nigritans, hirsutism, abdominal type of obesity, etc.), a standard glucose tolerance test is indicated. Ultrasound of the abdominal organs is performed, according to indications - polysomnography, ultrasound of the thyroid gland, adrenal glands, MRI / CT of the adrenal glands, pituitary gland.
Diagnostic criteria:
Complaints and anamnesis:
Initial patient appointment. The main complaint is overweight. Other complaints: increased blood pressure, shortness of breath during physical exertion, snoring during sleep, increased sweating, menstrual irregularities - in women, decreased potency in men - are due to obesity-associated diseases. Assessment of body weight, referral to a specialist, decision on further management tactics.
Anamnesis: changes in body weight over the past 2 years, taking medications (this information is necessary for early diagnosis of overweight, selection of adequate treatment tactics). With a long-term excess of body weight, the ineffectiveness of dietary measures - the solution of the issue of medical and surgical care.
Physical examination:
Weight measurement, taking into account clothes and shoes, height measurement, BMI calculation, OT measurement. With BMI ³ 25 kg/m2, assessment of body weight dynamics: maximum/minimum body weight after 18 years. Eating habits, physical activity, medication (help in assessing the etiological factor).
OT score: ³80-88 cm for women, ³94-102 cm for men (relative to national standards). Measurement of OT must also be carried out with a BMI of 18.5-25 kg / m2, because. excessive deposition of fat in the abdomen increases CVR even with normal body weight. With a BMI³35 kg / m2 - measurement of FROM is impractical.
BMI³30 kg/m2 or BMI³25 kg/m2, but WC ³ 80 cm in women, WC ³ 94 cm in men and presence of ³ 2 RF. For this category of patients, weight loss is the key to maintaining health. At this stage, it is necessary to identify priorities for this patient - what is the first priority in treatment, for example, smoking cessation for certain patients is more important than immediate weight loss. Assessment of the patient's psychological state, his motivation and desire to lose weight.
Laboratory research:
Heredity, assessment of the risk of developing type 2 diabetes and CVD, which will be reflected in the medical history in the future. All patients undergo a biochemical blood test: total cholesterol, HDL, LDL, triglycerides, glucose, ALT, AST, uric acid. With an increase in fasting glucose of more than 5.6 mmol / l, a burdened family history of diabetes, indirect signs of insulin resistance (acantosis nigritans, hirsutism, abdominal type of obesity, etc.), a standard glucose tolerance test, a study of the level of insulin, C-peptide is indicated. Ultrasound of the abdominal organs is performed, according to indications - polysomnography, ultrasound of the thyroid gland, adrenal glands, MRI / CT of the adrenal glands, pituitary gland
Instrumental research:
1. MRI of the brain (Turkish saddle) with suspected pathology of the hypothalamic-pituitary system
2. Endoscopy in the presence of patient complaints
3. ECG and echocardiography
4. Ultrasound of the abdominal organs
Indications for expert advice:
1. Cardiologist
2. Gastroenterologist
3. Gynecologist according to indications
4. Andrologist according to indications
Differential Diagnosis
Differential Diagnosis:
For differential diagnosis of primary and secondary obesity, hormonal studies are carried out in the presence of complaints and clinical manifestations of various endocrinopathies.
| Complaints | Inspection | Endocrinopathy | Diagnostic methods |
| General weakness, lethargy, drowsiness, chilliness, edema, loss of appetite, constipation, sexual dysfunction, bradycardia | Hypersthenic physique, puffiness of the face, edematous tongue with imprints of teeth, muffled heart sounds | Primary hypothyroidism | TSH, svT4, thyroid ultrasound |
| Redistribution of the pancreas (large belly, thin arms, legs), reddening of the face, purple striae, increased blood pressure, headaches, depressed mood | Android fat distribution, matronism, hyperpigmentation of natural skin folds, burgundy striae, pustular skin lesions, persistent increase in blood pressure, carbohydrate metabolism disorders | Syndrome of hypercortisolism | ACTH, blood cortisol, 24-hour urinary cortisol excretion, small/large dexamethasone test, ultrasound (CT/MRI) of the adrenal glands, MRI or CT of the pituitary gland |
| Menstrual disorders, amenorrhea, discharge from the nipples in women, decreased potency, libido, infertility, gynecomastia | Galactorrhea | Syndrome of hyperprolactinemia | Prolactin, CT/MRI with contrast of the pituitary gland, ultrasound of the ovaries of the uterus in women, prostate in men |
| Decreased potency, libido, infertility, breast enlargement, decreased muscle mass in men | Eunuchoid body type, decreased skin turgor, muscle laxity, gynecomastia, underdevelopment of the external genital organs | Hypogonadism syndrome (primary/secondary) | Testosterone, LH, FSH, estradiol, GSPP, breast ultrasound, skull x-ray (lateral view), andrologist consultation |
| Menstrual irregularities, amenorrhea, excessive body hair growth in women | Android body type, hirsutism, virilization | Syndrome of hyperandrogenism | LH, FSH, SHBG, testosterone, 17-OP, ultrasound of the small pelvis, adrenal glands, gynecologist's consultation |
Treatment abroad
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Treatment
Treatment goals:
reduction and stabilization of body weight.
Treatment tactics:
Non-drug treatment:
The entire period of treatment is divided into 2 stages: reduction (3-6 months) and stabilization (6-12 months) of body weight. Joint work of the doctor and the patient is the key to success. At this stage, it is necessary to develop a treatment strategy: some patients refuse to reduce body weight, for them the method of choice is to prevent further weight gain. The main components of treatment are: diet, exercise and behavioral therapy.
1) Solution of the question: What kind of treatment does the patient need?
a) dietary advice, physical activity, behavioral therapy
b) diet + medication
c) diet + surgical treatment
2) Find out how motivated the patient is? What result does he want to get? What effort are you willing to put in?
3) Selection of the optimal diet. The WHO-recommended nutritional system involves reducing total calories and limiting fat to 25-30% of the total calorie intake. Changes in nutrition are introduced gradually, taking into account the patient's eating habits (national characteristics), the daily energy requirement is calculated (600 kcal deficit / day: 1000 - 1200 kcal for women, 1000-1500 kcal for men). With a feeling of hunger, + 100 kcal is possible.
4) Joint (doctor + patient) choice of the mode of aerobic physical activity (type, frequency, intensity - are selected individually. The recommended norm is 225-300 min / week, which corresponds to 45-60 min 5 r / week).
Medical treatment:
With a BMI ³ 30 kg / m2 and the absence of concomitant diseases, as well as with a BMI ³ 28 kg / m2 and the presence of diseases associated with obesity, if diet, exercise and behavioral therapy are ineffective, additional drug therapy is recommended.
1) Orlistat 120 mg, 1 ton for each main meal, no more than 3 times a day, the duration of the course is at least 3 months (with a decrease in body weight by 5% from the original). It has been proven safe to use for 4 years.
2) Metformin effectively reduces body fat in several ways: it prevents the absorption of simple saccharides from the intestines, reduces the level of "bad" cholesterol (LDL), inhibits glucogenesis in the liver and increases the utilization of glucose directly in tissues. Metformin (N,N-dimethylimide dicarboimide diamide) is not initially indicated for the treatment of obesity in healthy people, Metformin is effective for people with type 2 diabetes. When administered correctly, metformin causes little side effects(of which gastrointestinal disorders are more common) and is associated with a low risk of hypoglycemia. In patients with type 2 diabetes, the drug metformin (Glucophage) is able to reduce weight.
3) Analogues of glucagon-like peptide (GLP-1), which is synthesized by the intestine in response to the presence of food in it. Among other effects, glucagon-like peptide-1 delays gastric emptying and promotes satiety. A number of obese people have insufficient production of the hormone GLP-1, so dieting only increases its deficiency.
Application herbal preparations Not recommended.
Evaluation of the effectiveness of therapy for 6 months - 1 year. At this stage, it is necessary to control the food diary, correct and constantly monitor the psychological state of the patient. If during this period the target values of body weight (10% reduction from the initial BW) are not achieved, return to point 1, revise the treatment tactics, continue monitoring every 3-6 months. Using drug therapy- evaluation of effectiveness, the presence of side effects, as well as consideration for the abolition of therapy. Upon reaching the target level of body weight - re-evaluation of risk factors for the development of concomitant diseases. Monitoring patients for a long time.
Other types of treatment:
Surgical intervention:
With the ineffectiveness of drug therapy, the patient is shown surgical intervention:
- endoscopic installation of intragastric balloons
- shunt operations on small intestine(jejunoileoshunting)
- restrictive operations associated with a decrease in the volume of the gastric reservoir (vertical, horizontal gastroplasty, gastric banding)
- combined interventions (biliopancreatic and gastric bypass,)
After surgical treatment patients need replacement therapy preparations of iron, calcium, multivitamins are indicated. Corrective operations - abdominoplasty, liposuction - are possible only after stabilization of body weight.
Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
- reduction and stabilization of body weight
- control of total cholesterol, HDL, LDL, triglycerides, glucose, ALT, AST, uric acid 1 time in 6 months.
Hospitalization
Indications for hospitalization:
Hospitalization is planned.
To address the issue of management tactics for patients with overweight and obesity, a number of diagnostic measures are needed that can be carried out at the polyclinic level. At the stage of the initial treatment of the patient, the following measures should be taken:
1. Calculate BMI (body mass index)
2. Measure FROM (waist circumference)
3. Assess the severity of concomitant diseases and the risk of developing CVD and type 2 diabetes, BMI, WC.
4. Calculation of cardiovascular risk:
- smoking
- AH (degree, duration, etiology)
- LNP
- HDL
- Blood glucose (venous plasma)
- Family history of CVD
- Additional RF - age of a man 45 years and more, women 55 years and more (menopause)
5. Provide the patient with literature:
- how to choose the right products
- food calories
- preferred foods for breakfast, lunch, dinner
- physical activity
- lifestyle changes (eating behavior)
Prevention
Preventive actions:
At the stage of treatment - regular monitoring of the food diary, diary of physical activity. Interview with the patient - assessment of neuropsychiatric status.
Evaluation sheet, which presents data throughout the course of treatment: BMI dynamics, weight dynamics, nutrition and physical activity diaries, goals achieved (weight loss by 7% from baseline, reduction in waist circumference, reduction in blood pressure, improvement in lipid and carbohydrate metabolism etc.).
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
- List of used literature: 1. In the world of science, No. 12, 2007: - Moscow, In the world of science, 2007 - 96 p. 2. Diabetes. Dialogue with an endocrinologist: Tatyana Rumyantseva - St. Petersburg, Vector, 2009 - 256 p. 3. Evidence-based endocrinology: Edited by P. Camacho, H. Garib, G. Sizemore - St. Petersburg, GEOTAR-Media, 2009 - 640 p. 4. Selected lectures on endocrinology: A. S. Ametov - Moscow, Medical Information Agency, 2009 - 496 p. 5. Treatment of the heart and blood vessels in the elderly: D. P. Ilyin - St. Petersburg, Vector, 2009 - 160 p. 6. Obesity and lipid disorders: Henry M. Cronenberg, Shlomo Melmed, Kenneth S. Polonsky, P. Reid La - Moscow, Reed Elsiver, GEOTAR-Media, 2010 - 264 p. 7. Obesity and reproductive system women: - Moscow, N-L, 2010 - 68 p. 8. Obesity: Edited by A. Yu. Baranovsky, N. V. Vorokhobina - Moscow, Dialect, 2007 - 240 p. 9. Obesity: Edited by I. I. Dedov, G. A. Melnichenko - St. Petersburg, Medical Information Agency, 2006 - 456 p. ten. Diabetes and obesity. Prevention and treatment with plants: N. I. Maznev - Moscow, ACC-Center, 2005 - 160 p.
Information
List of protocol developers:
1. Danyarova L.B. - Head of the Endocrinology Department of the Research Institute of Cardiology and Internal Diseases, endocrinologist of the highest category, Ph.D.
2. Kuramysova A.S. - Junior Researcher of the Endocrinology Department of the Research Institute of Cardiology and Internal Diseases, endocrinologist.
Indication of no conflict of interest: is absent.
Reviewers:
Erdesova K.E. - Doctor of Medical Sciences, Professor of the Department of Internship of KazNMU.
Indication of the conditions for revising the protocol: The protocol is reviewed at least once every 5 years, or upon receipt of new data on the diagnosis and treatment of the relevant disease, condition or syndrome.
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Obesity is a problem for people all over the world. But the methods of combating obesity and recommendations for bringing weight to normal levels are different in different countries. Increasingly popular are ways to quickly eliminate excess fat. Is it efficient? And what do Russian doctors think about this?
At the next conference of endocrinologists, where one of the main topics was the problem of obesity, scientists compiled a list of recommendations for the elimination of morbid obesity.
Morbid obesity is a chronic disease in which a BMI is more than 40 units, with morbid obesity, excess weight threatens human health, so some scientists tend to reduce the body mass index to 35 units, especially if overweight is already accompanied by some health disorders.
Complications in health
- Type 2 diabetes;
- High blood pressure;
- The appearance of signs of stones in the kidneys and biliary tract;
- Hepatosis on the background of overweight;
- Varicose veins, thrombosis;
- Possible disorders in the reproductive organs;
- Mental disorders.
A group of Russian endocrinologists and nutritionists from different cities have made recommendations for the treatment of so-called "morbid" obesity in adults.
All doctors speak out unequivocally: morbid obesity can lead to early death, it is necessary to treat it. Any method of treatment should be aimed at reducing weight and eliminating signs of concomitant diseases.
Nutrition
With obesity, adjusting the diet is the most necessary thing. But, as a rule, diets at the first stage are out of the question. Patients not only cannot sustain a diet, but also cannot change their diet. Taste addictions are so strong that the refusal of one dish of the usual diet leads to headaches, sudden pressure surges, and heart attacks.
Therefore, the first stage is to reduce calories without changing the diet. Doctors recommend reducing the calorie content of food by 500 kcal. This regime should be followed for at least six months. Usually this is relatively easy to carry. Weight loss at the same time is about 700g per week. This is enough for a person to believe in himself. After about six months, the weight stops decreasing, it is necessary to move on to the next stage. But you can't force things.
Within six months, it is advisable to visit a psychologist or an experienced nutritionist. The doctor will lay the foundations of a healthy diet for the patient. A person must understand that some foods are very harmful to health, and giving them up is not such a big problem. If in half a year the concept proper nutrition is not formed, then further work with the patient is almost impossible.
Diet food
This is the second stage of treatment. Moreover, the patient must understand that such a diet is not for a day or a month - it is for life. The diet is selected strictly individually, there is only one thing in common - the diet should be low-fat. A huge incentive to perform dietary advice is persistent, albeit small, weight loss.
And yet there are times when therapeutic treatment and dietary food do not help. In such cases, doctors recommend surgical treatment.
Surgical treatment
Two types of surgery are possible
- bundling
- Shunting
When bandaging the stomach is divided into two parts with a soft balloon, the diameter of the intermediate hole can be changed. Both parts of the stomach are involved in digestion, but food mainly affects the receptors of the first section.
With shunting, the second site is completely excluded from digestion. There are several modifications of shunting.
Some patients insist on surgery, believing that this will help them get rid of excess weight without problems. But first, some people surgical intervention contraindicated. Secondly, the operation itself will not help. Be sure to follow the diet!
Because the diet is still necessary, many do not agree to the operation. That is, they prefer to ignore their illness.
Is there a way out?
As they say, there is always a way out of any even the most hopeless situation. And, as a rule, he is not alone. But with morbid obesity, too much depends on the patient. You need a great desire and even greater willpower. Of course, the support of loved ones is very important. And daily gymnastics!
TO HELP THE PRACTITIONER
UDC 616.43+616-008.9+616.39
CONCEPT AND OUTLOOK
S. V. Nedogoda, I. N. Barykina, A. S. Salasyuk
Volgograd State medical University, Department of Therapy and Endocrinology
In the article in question about a number of metabolic and hemodynamic disorders, as well as pathologies of organs and systems associated with obesity. The prerequisites for the creation of new national clinical guidelines "Diagnostics, treatment, prevention of obesity and associated diseases" are given.
Key words: obesity, metabolic syndrome, cardiometabolic risk.
NATIONAL CLINICAL RECOMMENDATIONS FOR OBESITY: CONCEPT AND PROSPECTS
S. V. Nedogoda, I. N. Barykina, A. S. Salasyuk
Volgograd State Medical University, Department of Therapy and Endocrinology
The article deals with metabolic and hemodynamic disorders, as well as the pathologies of organs and systems associated with obesity. The prerequisites for the creation of new national clinical guidelines "Diagnosis, treatment, prevention of obesity and related diseases" are given.
Key words: obesity, metabolic syndrome, cardiometabolic risk.
Obesity has become one of the most important medical and social problems in Russian Federation. So, according to the World Health Organization in 2013, 24.1% of the population of our country were obese, and according to this indicator, the Russian Federation was in 8th place in the world. With the world's obese population increasing at about 1% per year, the immediate outlook is not optimistic. In this regard, a national program to combat obesity is needed, and one of its important elements can be national clinical guidelines for the prevention, diagnosis and treatment of obesity.
The creation of modern clinical guidelines on obesity, of course, requires an interdisciplinary approach with the participation of therapists, cardiologists, endocrinologists, surgeons, rehabilitation specialists, nutritionists, preventive medicine specialists, etc. Therefore, in fact initial stage it is advisable to develop consensus on a number of key positions of the document being developed in order to avoid unnecessary controversy in the future.
Does the Russian Federation need new national clinical guidelines for the prevention, diagnosis and treatment of obesity?
In Europe, several important documents have been published in recent years: EASO guidelines (2008, 2014), NICE Guidelines (2012, 2014), and currently about 45 countries, including the Russian Federation (2011, 2014), have their own national recommendations on various aspects of obesity.
The development of recommendations on obesity is especially active in the United States, which is quite understandable by the fact that this country ranks second in the world in terms of the prevalence of obesity (31.8%). Over the past two years, AHA / ACC / TOS Guidelines (2013, ), AACE Advanced Framework (2014, ), ASBP Algorithm (2014, ), The Endocrine Society Guidelines Pharmacologic Management of Obesity (2015, ) have appeared that deal with the problem of obesity , but differ significantly from each other in terms of goals, objectives, methodology of creation and classification issues. To this list it is also necessary to add the Physical Activity Guidelines for Americans (2008, ),
ACC/AHA Lifestyle Guidelines (2013, ), Dietary Guidelines for Americans (2015, ). At the same time, all these documents, although there are undoubtedly differences, do not contradict, but rather complement each other.
Thus, a large number of different recommendations is a prerequisite for their harmonization and the formulation of a consolidated expert position on the Russian Federation within the framework of national Russian recommendations for the prevention, diagnosis and treatment of obesity, taking into account the characteristics of the national healthcare system that exists. legal framework and the need to address the problems of obesity, especially in primary care healthcare.
What should be the fundamental novelty of the proposed national clinical guidelines for the prevention, diagnosis and treatment of obesity?
The current 1997 WHO classification is based on the assessment of obesity by BMI only. At the same time, modern ideas about the heterogeneity of obesity, the role of visceral fat depots, and the metabolic phenotypes of obesity are ignored, and, most importantly, it does not fully allow assessing the individual cardiometabolic risk in a patient. In 2013, the American Association of Clinical Endocrinologists and the American College of Endocrinology proposed a new classification of obesity, the main feature of which was the recognition that obesity is a chronic disease with a specific set of complications and
recognition of the existence of "metabolically healthy" obesity. In addition, the list of complications of obesity according to the AACE & ACE criteria includes secondary types of obesity in genetic syndromes, hormonal diseases, and drug (iatrogenic) effects. Although it is clear that conditions where obesity itself is a complication of the underlying disease should not be in the list of complications of primary obesity.
In view of the foregoing, a clearer classification of obesity as a chronic disease is necessary, taking into account modern ideas about its heterogeneity and the degree of individual cardiometabolic risk.
First of all, it must be recognized that obesity is a chronic multifactorial heterogeneous disease, manifested by excessive formation of adipose tissue, progressing in a natural course, as a rule, having a high cardiometabolic risk, specific complications and associated comorbidities.
The proposed classification allows, using simple methods of anthropometric and clinical examination, to stratify patients according to cardio-metabolic risk, to assess the metabolic phenotype of obesity.
It seems appropriate, while retaining the WHO BMI estimate, to supplement it with an assessment of the obesity phenotype and cardiometabolic risk (Tables 1-4).
Table 1
Obesity degree BMI, kg/m2 WC, cm WC/OB Metabolic phenotype
normal weight <25 <102 (муж.) <88 (жен.) <0,9 (муж.) <0,85 (жен.) МЗФ*
>102 (male) >88 (female) >0.9 (male) >0.85 (female) MTF**
Overweight 25 29.9<102 (муж.) <88 (жен.) <0,9 (муж.) <0,85 (жен.) МЗФ
>102 (male) >88 (female) >0.9 (male) >0.85 (female) MTF
Obesity, grade 1 30 34.9<102 (муж.) <88 (жен.) <0,9 (муж.) <0,85 (жен.) МЗФ
>102 (male) >88 (female) >0.9 (male) >0.85 (female) MTF
Obesity, grade 2 35 39.9<102 (муж.) <88 (жен.) <0,9 (муж.) <0,85 (жен.) МЗФ
>102 (male) >88 (female) >0.9 (male) >0.85 (female) MTF
Obesity, grade 3 >40<102 (муж.) <88 (жен.) <0,9 (муж.) <0,85 (жен.) МЗФ
>102 (male) >88 (female) >0.9 (male) >0.85 (female) MTF
*MTF -**MZF ■
metabolically obese phenotype; - metabolically healthy phenotype.
obesity classification
table 2
Obesity phenotypes
BMI normal MTF BMI >25 kg/m2 MHF BMI normal MTF BMI >25 kg/m2 MTF
OT, cm<102 (муж.) <88 (жен.) <102 (муж.) <88 (жен.) >102 (male) >88 (female) >102 (male) >88 (female)
FROM/OB<0,9 (муж.) <0,85 (жен.) <0,9 (муж.) <0,85 (жен.) >0.9 (male) >0.85 (female) >0.9 (male) >0.85 (female)
Muscle mass Norm N ^ and
Fat mass** Norm T subcutaneous fat prevails over visceral ttt ttt Visceral fat prevails over subcutaneous
IVO index* 1 T p mm
NOMA-^<2,52 < 2,52 > 2,52 > 2,52
CRP, mg/l<3 <3 > 3 > 3
Fasting blood glucose, mmol/l<5,6 <5,6 >5,6 >5,6
Triglycerides, mmol/l<1,70 <1,70 > 1,70 > 1,70
HDL, mmol/l Men >1.04 Women >1.30 Men >1.04 Women >1.30 Men<1,04 Женщины <1,30 Мужчины <1,04 Женщины <1,30
Increased blood pressure, mm Hg. Art.<130/85 <130/85 >130/85 >130/85
* Visceral obesity index (VisceralAdiposityIndex, UA1). VVO (VA1) is an indicator of “visceral adipose tissue function” and insulin sensitivity, its increase is largely associated with an increase in cardiovascular risk. WVO calculation: Men: WVO (^A1) = (WC / 39.68 + (1.88 x BMI)) x (TG / 1.03) x (1.31 / HDL). Women: IVO (^A1) = (WC / 36.58 + (1.89 x BMI)) x (TG / 0.81) x (1.52 / HDL); **determined by imedansometry.
Table 3
Cardiometabolic risk in obesity*
Cardiometabolic risk Clinical picture Risk of developing CV events in the next 10 years, % 15-year risk of developing DM2, %
Low risk - BMI >25 kg/m2 - no obesity-associated diseases - SCORE<1 % - CMDS 0-1 <1, низкий <7
Average risk - BMI >25 kg/m2, - 1 or more obesity-associated diseases of the 1st degree of severity, - and/or SCORE >1<5 %, - и/или CMDS 2-3 >1 <5, средний или умеренно повышенный >7 <23
High risk - BMI >25 kg/m2 - Presence of 1 or more obesity-associated diseases of the 2nd degree of severity - and/or SCORE >5% - and/or CMDS 4 >5, high or very high >23 or T2DM
*A total CV risk on the SCORE scale of less than 1% is considered low. A cumulative CV risk in the range of >1% to 5% is considered moderate or moderately elevated. An overall CV risk in the range of >5% to 10% is considered high. The total cardiovascular risk on the SCORE scale >10% is considered very high. A certain group of individuals (patients with edema, elderly patients, athletes, patients with sarcopenic obesity) require an in-depth anthropometric examination and / or dual-energy x-ray absorptiometry with the determination of WC, VR and the VR / VR ratio, since their BMI does not always accurately reflect the real clinical picture and is not applicable to the diagnosis of obesity.
Sarcopenia is a condition in which muscle mass is significantly reduced (less than 2 standard deviations from the muscle mass of healthy adults).
Table 4
Assessment of cardio-metabolic risk according to the CMDS scale
Stage Description Criteria*
0 Metabolically No risk factors
1 healthy 1 or 2 risk factors One or 2 of the following: a) WC >112 cm in men and >88 cm in women; b) SBP >130 mmHg Art. or DBP >85 mm Hg. Art. or taking antihypertensive drugs; c) HDL<1,0 ммоль/л для мужчин, <1,3 ммоль/л для женщин или прием гиполипидемических препаратов; d) ТГ >
2 Prediabetes Presence of one of the following conditions:
or metabolic ^ Presence of 3 or more risk factors:
□ WC disorders >112 cm in men and >88 cm in women;
□ SBP >130 mmHg Art. or DBP >85 mm Hg. Art. or taking antihypertensives
drugs;
□ HDL<1,0 ммоль/л для мужчин, <1,3 ммоль/л для женщин или прием
lipid-lowering drugs;
□ TG >1.7 mmol/l or taking lipid-lowering drugs.
Metabolic disorders + prediabetes
DM2 and/or CVD
Presence of two or more of the following conditions: ^ Presence of 3 or more risk factors:
□ WC >112 cm in men and >88 cm in women;
□ SBP >130 mmHg or DBP >85 mm Hg. Art. or taking antihypertensive drugs;
□ HDL<1,0 ммоль/л для мужчин, <1,3 ммоль/л для женщин или прием гиполипидемических препаратов;
□ TG >1.7 mmol/l or taking lipid-lowering drugs. ^ NGN;
Presence of T2DM and/or CVD (angina pectoris, MI, history of stenting, PCI, stroke, amputation due to peripheral arterial disease)_
* WC values for this scale (WC >112 cm in men and >88 cm in women) correspond to the original validated CMDS scale (Guo F., Moellering D. R., Garvey W. T. The progression of cardiometabolic disease: validation of a new cardiometabolic disease staging system applicable to obesity // Obesity. - 2014. - T. 22. - No. 1. - P. 110-118).
A number of metabolic and hemodynamic disorders, as well as pathologies of many organs and systems, are often associated with obesity. Currently, there is no clear position whether these conditions are a complication of obesity, or whether they are concomitant diseases, the occurrence and progression of which is aggravated by the presence of obesity. In this document, it is intended to consider these conditions as associated (comorbid) diseases.
Obesity-associated diseases include:
Impaired glucose tolerance (IGT), impaired fasting glycemia (IGN);
Diabetes mellitus type 2;
Hypertriglyceridemia / dyslipidemia;
Obstructive sleep apnea syndrome (OSAS);
Non-alcoholic fatty liver disease (NAFLD);
Polycystic ovary syndrome (PCOS);
atrial fibrillation (AF);
Osteoarthritis;
stress urinary incontinence;
Gastroesophageal reflux disease (GERD);
Limitation of mobility and social adaptation;
Psycho-emotional disorders and/or stigmatization (Table 5).
Formulation of the diagnosis
When formulating the diagnosis of "Obesity", it is necessary to reflect all the components of the diagnosis presented in the classification.
In the diagnosis, it is necessary to indicate the presence and degree of obesity according to BMI, select the metabolic phenotype of obesity and indicate the degree of cardiometabolic risk.
Diagnosis example:
Obesity, grade 2, MTF, high risk of cardio-metabolic complications.
The diagnosis of all other diseases associated with obesity is formulated in accordance with the accepted ICD-X standards.
Metabolic syndrome and obesity
Initially, the concept of "metabolic syndrome" was proposed to identify a cluster of individuals with an increased risk of developing cardiovascular diseases and type 2 diabetes.
There are currently at least seven (WHO-World Health Organization; EGIR-European
I^FOpIÜ ©(W^TMSCH;
Table 5
Determining the severity of associated diseases associated with obesity*
Prediabetes and type 2 diabetes
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No risk factors associated with IR (OT, BP, HDL, TG, fasting glucose). Equivalent to cardiometabolic risk 0 1 or 2 risk factors (WT, BP, HDL, TG; cardiometabolic risk 1) Prediabetes or T2DM (cardiometabolic risk 2-4)
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) AD<130/85 мм рт. ст. АД >130/85 mmHg Art. in the absence of other risk factors Target BP not achieved on therapy antihypertensive drugs BP >130/85 mmHg Art. patients high risk: Cardiometabolic risk 2-4, smoking, CHF
Hypertriglyceridemia/dyslipidemia
Grade 0 (no) TG<1,7 ммоль/л и ЛПВП >1.0 mmol/l for men and >1.3 mmol/l for women TG 1.7-4.49 mmol/l and/or HDL<1,0 ммоль/л для мужчин и <1,3 ммоль/л для женщи
Grade 1 (moderate) Grade 2 (severe) in the absence of other risk factors TG >4.5 mmol/l in the absence of other risk factors TG >1.7 mmol/l and HDL<1,0 ммоль/л для мужчин и <1,3 ммоль/л для женщин у пациентов высокого риска: кардиометаболический риск 2-4
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No symptoms, apnea/hypopnea index (AH1)<5 АН1 5-29 при отсутствии или слабой выраженности симптомов АН! >thirty; AN! 5-29 with severe symptoms and/or clinical consequences
Grade 0 (none) No steatosis
Grade 1 (moderate) Grade 2 (severe) There is steatosis with no evidence of inflammation or fibrosis Non-alcoholic steatohepatitis (NASH)
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) Not meeting criteria for PCOS, no PCOS 1 or 2 risk factors (OT, BP, HDL, TG; cardiometabolic risk 1) and no infertility/anovulation Infertility/anovulation Oligomenorrhea; menorrhagia; Prediabetes / T2DM (cardiometabolic risk 2-4)
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No episodes of AF Newly diagnosed/paroxysmal AF Persistent/persistent AF
Osteoarthritis
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No symptoms or imaging changes Moderate symptoms and functional impairment (e.g. on validated questionnaires) and/or moderate anatomical changes Moderate-severe symptoms and functional impairment (eg, according to validated questionnaires) and / or pronounced anatomical changes in the joint; history of arthroplasty
Dysuric disorders
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No symptoms and/or normal urodynamics Moderate symptoms Severe symptoms
Grade 0 (none) Grade 1 (moderate) Grade 2 (severe) No symptoms or positive imaging findings Moderate symptomatic Severe symptomatic; erosive esophagitis, Barrett's esophagus (if there is no progressive weight loss)
Mobility disorders
Psychological disorders / Stigmatization
Grade 0 (none), Grade 1 (moderate), Grade 2 (severe)
Other complications*
"The severity of the diseases listed in the table may decrease with weight loss. In addition, weight loss can have a positive effect on: the severity of intracranial hypertension / pseudotumor conditions; primary cancer prevention in high-risk individuals; secondary prevention of breast cancer; chronic heart failure; infertility not associated with polycystic ovary syndrome; androgen deficiency / hypogonadism; sexual function associated with the mechanical aspect of sexual intercourse; erectile dysfunction; back pain; venous congestion and swelling of the lower extremities; thrombophlebitis; deep vein thrombosis; ulcerative gastric disease; maternal/fetal risk during pregnancy; improved risk of surgery and anesthesia; chronic lung disease, including asthma; gout; chronic kidney disease/nephroprotection; poor quality of life.
Group for the Study of Insulin Resistance; NCEP-ATPIII-National Cholesterol Education Program - Adult Treatment Panel III; AACE-American Association of Clinical Endocrinologists; IDF - International Diabetes Federation; International Metabolic Syndrome Institute, "Guidelines for the Diagnosis and Treatment of the Metabolic Syndrome of HFCF", the agreed definition of the IDF (International Diabetes Federation), NHLBI (National Heart, Lung and Blood Institute), WHO (World Health Organization), IAS (International Atherosclerosis Society) and IASO (International Association for the Study of Obesity) 2009) for alternative definitions and criteria for diagnosing metabolic syndrome. There are also no predictive data regarding the benefits of different criteria for diagnosing metabolic syndrome.
In this regard, it becomes obvious that in the medical community there are no uniform criteria for a cluster of symptoms associated with metabolic syndrome. At the same time, ethnic characteristics have a strong influence on the criteria for its diagnosis.
All criteria for the diagnosis of metabolic syndrome suggest the presence of three of its components. In fact, we are talking about various combinations of obesity, high blood pressure, increased levels of LDL, triglycerides, lower HDL, carbohydrate metabolism disorders.
The notion that the metabolic syndrome is a useful clinical concept is currently disputed, as it has not been conclusively proven that it adds anything to the predictive power of its individual factors. However, the presence of the metabolic syndrome in a number of recommendations is considered a factor that increases the total risk (AH), so it is advisable to define its criteria for RF. At present, there is no reason to recommend that "metabolic syndrome" be presented as an independent diagnosis. In the diagnosis, it is advisable to formulate the presence of those components that characterize a specific nosology - hypertension, dyslipidemia, abdominal obesity. At the same time, according to ICD X, obesity is a diagnosis of a chronic disease, in order to prevent the complications of which it is necessary to treat, first of all, obesity itself.
The development of new national clinical guidelines "Diagnostics, treatment, prevention of obesity and related diseases" involves the participation of a wide range of doctors and specialists in various specialties in this process, so the working group will be grateful for any constructive suggestions, comments and objections on the proposed concept, which may be sent to [email protected] and will be taken into account in future work.
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Contact Information
Nedogoda Sergey Vladimirovich - Doctor of Medical Sciences,
professor, head Department of Internal Medicine and Endocrinology, Volgograd State Medical University, e-mail: [email protected]