Hypothalamic obesity. Features of hypothalamic obesity, signs and treatment

The hypothalamus is the main center for regulating appetite and body weight. Damage to the ventromedial region of the hypothalamus, paraventricular and dorsomedial nuclei is manifested by hyperphagia and obesity. Damage to the lateral part of the hypothalamus, on the contrary, causes a decrease in appetite. Also, a key role in energy metabolism (including the regulation of appetite and body weight) belongs to the arcuate (arcuate) nucleus of the hypothalamus (the arcuate nucleus, which is in close contact with the capillaries at the base of the hypothalamus, is sensitive to the content of nutrients and hormones in the bloodstream, and thus receiving information about the energy reserves in peripheral tissues)

It is now considered proven that, regardless of the form of obesity (primary or secondary), the key link in the pathogenesis is a disruption of the hormonal connection between adipose tissue, which produces the hormone leptin, and the hypothalamus. The hypothalamus plays a major role in regulating the energy balance in the body. Damage to its ventromedial region or paraventricular nuclei is accompanied by: 1 - increased appetite, 2 - decreased energy expenditure and 3 - increased body weight (BW).

note! The diagnosis of “hypothalamic obesity” (HO) is established if there is a connection between the development of obesity and damage to the hypothalamus. Genetic defects of the melanocortin system and pharmacotherapy (antipsychotic drugs) can also lead to HO. According to modern concepts, mutations in melanocortin receptor type 4 (MC3/4-R) are the most common cause of monogenic obesity in humans. Only isolated cases of idiopathic hypothalamic dysfunction in children accompanied by obesity have been described.

A distinctive feature of HO is hyperphagia. However, obesity can develop without the presence of hyperphagia. The degree of weight gain during HO may vary. Typically, with HO, due to damage to the hypothalamus, body weight begins to suddenly, quickly and inevitably increase. G. Bray et al. (1984) suggested that it is the change in the rate of body weight gain after damage to the hypothalamus, and not its absolute value, that is the defining feature indicating the hypothalamic mechanism for the development of obesity.

The reasons leading to damage to the hypothalamus, and, accordingly, to the development of HO are:

[1 ] true tumors: ( ! the most common cause of the development of HO in children and adolescents), glioma, meningioma, germinoma, pituitary macroadenoma, teratoma, chordoma, metastases;

read also the article “Space formations of the hypothalamic region and disturbances of the central regulation of homeostasis” Dzeranova L.K., Pigarova E.A., Petrova D.V., Federal State Budgetary Institution “Endocrinological Research Center” of the Ministry of Health of Russia, Moscow; article published in the journal “Obesity and Metabolism” No. 3, 2014 [read]

[2 ] malformations and hamartomas: hypothalamic hamartoma;
[3 ] infectious lesions: tuberculosis, arachnoiditis, encephalitis;
[4 ] consequences of treatment: surgery, radiation therapy, and installation of subthalamic implants (for deep brain stimulation in Parkinson's disease);
[5 ] other anomalies: aneurysm, histiocytosis X, sarcoidosis.

The main clinical signs of HO are hyperphagia with pronounced eating disorders and hypothalamic dysfunction of various types: most often - hypogonadotropic hypogonadism, and with anatomical damage to the hypothalamus, in addition - drowsiness, growth hormone deficiency, secondary hypocortisolism, central hypothyroidism and diabetes insipidus. Fat deposition is observed mainly on the abdomen (in the form of an apron), buttocks, and thighs. Skin changes during HO are manifested by trophic disorders such as cyanotic or small pink striae (on the thighs, abdomen, shoulders, armpits), hyperpigmentation (neck, elbows, friction points). Various signs of autonomic dysfunction are observed: increased arterial and intracranial pressure, sweating disorders, autonomic, adrenergic (diencephalic) crises. Other symptoms associated with HO include headache, blurred vision, in women - various menstrual irregularities, infertility, hirsutism, and in men - decreased potency.

SISTERS WITH HYPOTHALAMIC TYPE OF OBESITY (after D.R. Klein, 1956)

Considering the complexity of HO syndrome, its treatment requires simultaneous impact on various parts of its pathogenesis. However, GO therapy is palliative; in addition, non-drug treatment (diet and exercise), although necessary, is ineffective. Studies on the use of various pharmacotherapy for HO are relatively few and include the use of sympathomimetics, somatostatin analogues (to suppress insulin secretion), and sibutramine. In addition, one study involving three patients with postoperative HO demonstrated the beneficial effect of supraphysiological doses of triiodothyronine, which resulted in weight loss in the absence of signs of thyrotoxicosis. In general, according to the studies conducted, pharmacotherapy for HO gives moderately positive results, however, longer and larger trials are needed to clarify the effectiveness of the use of various drugs for HO. An attractive treatment option for HO is bariatric surgery. A number of studies have shown that various types of bariatric interventions in patients with HO lead not only to a decrease or stabilization of body weight, but also, to one degree or another, contribute to the normalization of metabolic disorders that occur in this category of patients.

Hypothalamic obesity (hypothalamic-pituitary) is characterized by excessive accumulation of fat both in places of physiological deposits and by its dysplastic redistribution mainly in the area of ​​the mammary glands, thighs, and abdomen. Unlike nutritional or hereditary obesity, hypothalamic obesity is based on damage to the diencephalic region. If the frequency of all forms of obesity ranges from 30 to 50%, then one third of this number is due to hypothalamic obesity.

Among the causes of hypothalamic obesity, viral or chronic infection is indicated. The influence of focal infection in the form of recurrent tonsillitis, sinusitis (frontal sinusitis, sinusitis), odontogenic infection, as well as intoxication and skull trauma, brain tumors, and hemorrhage cannot be excluded. As with other forms of obesity, the nutritional factor is a mandatory component, because without excess nutrition there is no obesity. Genetic predisposition also occurs.

The development of hypothalamic obesity is associated with damage to the ventromedial and venrolateral nuclei of the posterior hypothalamus, which regulate appetite. It has been experimentally established that damage to the ventromedial nuclei leads to excitation of the ventrolateral ones - the “appetite center”. This is accompanied by a sharp increase in appetite and the development of obesity. The influence of impaired hypothalamic regulation occurs in two ways:

1. through the autonomic nervous system and
2. pituitary tropic hormones.

The first of them is realized by the predominance of the tone of the parasympathetic part of the autonomic nervous system, which leads to stimulation of the biosynthesis and release of insulin.

In the same direction, β-endorphin produced in the adenohypophysis acts on insulin secretion. In turn, hyperinsulinemia worsens obesity.

The effect on the pituitary gland is accompanied by inhibition of the production of fat-mobilizing tropic hormones: ACTH, STH, TSH and also by reducing the activity of thyroxine, adrenaline and glucagon. Violation of hypothalamic regulation and the listed hormonal changes cause a change in the balance between lipogenesis and lipolysis towards the predominance of lipogenesis processes. A consequence of inhibition of the gonadotropic function of the pituitary gland is hypofunction of the gonads. With the development of obesity during puberty, this can lead to hypogonadism.

Along with hormonal changes, obese patients are characterized by metabolic disorders: pathological tolerance to carbohydrates, persistent hyperlipidemia, changes in electrolyte metabolism. Apparently, changes in the ratio of potassium and sodium electrolytes underlie fluid retention due to an increase in extracellular fluid, which cannot but contribute to an increase in body weight.

A.Efimov, N.Skrobonskaya, A.Cheban

"What is hypothalamic obesity" - article from the section

Hypothalamic-pituitary obesity occurs when the hypothalamus is damaged and is accompanied by a violation of the hypothalamic and pituitary functions, which determine the clinical manifestations of the disease.

Etiology.

Damage to the hypothalamus, leading to hypothalamic-pituitary obesity, can cause

• - Infections;
• - Intoxication;
• - Metastases of malignant tumors;
• - Traumatic brain injuries;
• - Tumors.

Pathogenesis.

• - Lesions of the nuclei of the posterior part of the hypothalamus (ventromedial and ventrolateral), which regulate appetite;
• - Hyperinsulinemia and insulin resistance lead to increased appetite;
• - An increase in the level of opioid peptides leads to increased appetite;
• - Disruption of hypothalamic and pituitary functions, changes in the neurohumoral regulation of gastrointestinal hormones mobilize carbohydrates, promote glucose utilization, inhibit lipolysis, and activate lipogenesis.

Certain forms of hypothalamic obesity.

• - Adipose-genital dystrophy (Pechkrantz-Babinsky-Frölich disease). Fat deposition according to the “female type”, hypogenitalism; sometimes signs of diffuse or focal lesions of the central nervous system, flat feet, transient diabetes insipidus.
• - Progressive lipodystrophy (Barraquer-Symonds disease). Excessive or normal fat deposition in the lower body, atrophy of the upper body.
• - Lawrence-Moon-Bardet-Biedl syndrome. Obesity, hypogenitalism, growth retardation, polydactyly, retinitis pigmentosa.
• - Morgagni-Morel-Stewart syndrome. Obesity, hirsutism, hyperglycemia, arterial hypertension, thickening of the internal plate of the frontal bone.
• - Painful lipomatosis (Dercum's disease). The presence of painful fatty nodes against the background of generalized obesity, or against the background of normal weight.

Frequency of clinical signs in obese patients.

"We eat in order to live." Food is one of the sources of potential energy from the sun, which is converted inside the body into driving vital force. This is why eating behavior plays an important role in our lives. Two interconnected integrative systems—nervous and endocrine—are involved in its provision and regulation. They also “monitor” the further fate of the food we absorb - its correct transformation and timely delivery to its final destination - every cell of the body. “Excesses” are sent in reserve - to the fat depot, ready to be mobilized from there at the first request (lack of food and/or high energy expenditure). Excessively overloaded “reservoirs” indicate that there has been a failure in certain behavioral and/or metabolic mechanisms.

The nervous and endocrine systems “speak” different languages, but work together. There is a small organ in our body that perfectly “understands” both and serves as the main intermediary in their work. This is the hypothalamus. On the one hand, it is connected with key centers of nervous regulation - the cerebral cortex, amygdala, hippocampus, cerebellum, brainstem, and spinal cord. On the other hand, it regulates the functioning of the pituitary gland, the central “control panel” of the endocrine system. Control over the intake, processing and “targeted use” of food is also essential without the participation of the hypothalamus. Moreover, both from the “nervous” (feelings of hunger and satiety) and from the humoral (regulation of lipid, carbohydrate metabolism, etc.) mechanisms. It is not without reason that the hypothalamus is involved in disturbances of energy metabolism of any type.

Obesity is always a consequence of the dominance of energy “income” over “expense”. There are many reasons for this disharmony. But no matter which of them the disorders “start” with, over time a pathological cause-and-effect tangle is formed, covering a variety of regulatory mechanisms.

Hypothalamic obesity is a diagnosis when organic and/or functional lesions of the hypothalamus act as the primary trigger. As a result, there is an increase in the mechanisms of appetite stimulation (for example, an increase in the production of neuropeptide Y) and a suppression of the “feedback” system that inhibits it (for example, a decrease in the sensitivity of cells to the “controller” of energy metabolism - the hormone leptin). In addition, a shift in equilibrium also occurs due to a decrease in energy expenditure. Thus, the pathological basis for gaining excess weight is a simultaneous violation of both the flow of energy (food) into the body and its consumption.

The functioning of the hypothalamus can be disrupted by:

• congenital anomalies;
• tumors of the hypothalamus itself and organs associated with it anatomically and/or functionally (for example, hypothalamic hamartoma, craniopharyngioma, meningioma, etc.);
• head injuries and surgical interventions (including due to a persistent increase in intracranial pressure);
• infectious diseases of the central nervous system (for example, encephalitis, meningitis);
• systemic pathologies (for example, sarcoidosis, histiocytosis);
• congenital or acquired anatomical defects (for example, aneurysm).

Signs of hypothalamic obesity

A characteristic feature of this type of obesity is a very rapid rate of weight gain, usually accompanied by a pronounced increase in appetite.

Hypothalamic obesity (HO) is also manifested by multiple changes in most organs and systems. This is explained by the direct and/or indirect participation of the hypothalamus in their work.

GO is accompanied by:

• changes in eating behavior;
• lethargy, drowsiness;
• imbalance of hormones of the reproductive system and disorders of its functioning (infertility, menstrual disorders, decreased potency);
• symptoms of malfunctions of the autonomic nervous system (impaired sweating, increased blood pressure, headache, etc.)
• endocrine disorders (hypothyroidism, type 2 diabetes);
• changes on the skin;
• visual impairment, etc.

Endocrine obesity

Both the creation (lipogenesis) and consumption (lipolysis) of fat reserves are regulated by hormones - active executors of the “will” of the endocrine system. In addition, the secretions of the endocrine glands regulate the course of most energy-consuming processes in the body. Therefore, dysfunction of the endocrine glands (both hyper- and hypofunction) is one of the causes of excess fat accumulation. For example:

1. A lack of thyroid hormones leads to both a decrease in the intensity of metabolic processes and a slowdown in the breakdown of fats.
2. Excessive formation of secretions (glucocorticoids) of the adrenal cortex enhances the synthesis of fatty acids and their storage in fat depots in the form of triglycerides.
3. Excess insulin (due to pancreatic tumors; prolonged stress and malnutrition; pathologies of the pituitary gland, adrenal glands, reproductive system; liver diseases, etc.) also leads to increased formation and storage of fats. And... is a direct consequence of obesity.
4. Disturbance in the formation of the above-mentioned adipose tissue hormone, leptin, which not only regulates eating behavior through direct effects on the hypothalamus, but also increases the body’s energy costs through stimulation of the sympathetic nervous system. In addition, leptin reduces insulin production.
5. Diseases of the pituitary gland disrupt fat metabolism both directly and indirectly, changing the functioning of the subordinate endocrine glands (genital, thyroid, adrenal glands).

An imbalance in fat metabolism can also be a consequence of dysfunction of the gonads.

Signs of endocrine obesity

The main symptom is excess fat deposits. Their character is determined by the type of endocrine pathology. Other symptoms are:

• signs of pathologies that cause lipid metabolism disorders;
• a consequence of obesity itself.

• increased blood pressure and heart rhythm disturbances are consequences of increased stress on the cardiovascular system;
• difficulty breathing (shortness of breath);
• fluid retention;
• lethargy, decreased performance, sleep disturbance;
• increased sweating;
• consequences of physical inactivity and increased load on the musculoskeletal system (joint pain, spinal problems);
• disorders of the digestive system (constipation, heartburn), etc.

Treatment of hypothalamic obesity

Principles:

• decreased intake of energy sources into the body and increased energy expenditure (diet and physical activity);
• drug correction of metabolic disorders (for example, the use of substances that reduce the formation of insulin and/or increase the rate of metabolic processes);
• surgical interventions aimed at reducing food consumption and/or its absorption - the so-called. bariatric surgery.

Treatment of endocrine obesity

First of all, it is necessary to eliminate the root cause of obesity - specific hormonal dysfunction. For example, using hormone replacement therapy. Otherwise, the principles of treatment are similar to those given above.

A huge role is played by the patient’s motivation to get rid of the disease and awareness of its psychological causes. Therefore, psychotherapeutic assistance is not excluded.

Traditional medicine methods (instead of or together with classical ones) can also be used in the treatment of people suffering from obesity. Acupuncture, classical and resonant homeopathy, osteopathy, qigong therapy and herbal medicine have a holistic effect on a person, helping his body find and implement the optimal way to overcome the disease.

Several regulatory circuits controlled by the hypothalamus are considered responsible for the regulation of body weight, for example the ventromedial nucleus (satiety center) and the lateral nuclei (hunger center). The regulatory circuit thought to be responsible for long-term lipostatic effects involves body fat mass and is determined by a substance secreted by fat cells (leptin). According to the feedback principle, the amount of fat is maintained at a constant level by changing appetite and physical activity. Therefore, fat that is surgically removed is quickly restored.

Obesity (obesity) is considered a risk factor for hypertension, type 2 diabetes mellitus, hyperlipidemia, atherosclerosis, as well as urolithiasis and cholelithiasis. Excess body weight of more than 40% doubles the risk of premature death. Obesity is partly (poly)genetic (metabolic susceptibility) in origin, partly due to external factors. Two defective genes were found: one in two male mice with extreme obesity and one in type 2 diabetes. If the obesity gene is damaged, the 16 kDa leptin protein encoded by this gene is absent in the plasma. Injecting leptin into mice with a homozygous ob mutation prevents the manifestation of the gene defect. In normal mice, this manipulation causes a decrease in body weight. Mutation of the ob gene damages leptin receptors in the hypothalamus (including in the arcuate nucleus). The hypothalamus does not respond to high plasma leptin concentrations. Some obese people have a defective leptin gene, but many others have high plasma leptin concentrations. In the latter case, the chain of responses to leptin must be interrupted somewhere (red X). The following possible defects are suggested: leptin cannot cross the blood-brain barrier (impaired transport); the inhibitory effect of leptin on the secretion of neuropeptide Y (NPY) in the hypothalamus, which stimulates appetite and reduces energy consumption, is disrupted; leptin does not cause the release of α-melanocortin (α-MSH) in the hypothalamus, which acts through the MCR-4 receptors and causes the opposite effect of NPY.

Three very obese sisters were found to have a homozygous defective leptin receptor gene. Considering that these women did not experience puberty, and the secretion of GH and TSH was reduced, it is possible that leptin plays a role in other endocrine regulatory cycles.

In 90% of cases, eating disorders affect young women. Bulimia nervosa (binge eating followed by self-induced vomiting and/or laxative abuse) occurs more often than anorexia nervosa (weight loss through a very restrictive diet). These eating disorders are characterized by a distorted self-image of their body (patients feel “too fat” even if their body weight is normal or below normal) and an incorrect attitude towards food (the connection between self-esteem and body weight). There is a genetic predisposition (in identical twins there is a 50% coincidence) without established primary genetic defects. Probably, psychological factors are significant, such as disruption of relationships in the family (overprotection, avoidance of conflicts, cruelty), conflicts during adolescence, as well as sociocultural influences (beauty ideals, social expectations).

Eating disorders in anorexia nervosa range from a very strict diet to complete refusal of food; Often these people abuse laxatives. As a result, body weight decreases significantly, even to the point of exhaustion, which may require parenteral nutrition. This condition leads to severe vegetative hormonal disorders, for example, increased cortisone levels and decreased gonadotropin release (amenorrhea; decreased libido, impotence), hypothermia, bradycardia, hair loss, etc. If the condition takes a protracted course, the mortality rate reaches 20%.

Bulimia is characterized by binge eating followed by spontaneous induction of vomiting. Body weight may be normal.

Epidemiology of obesity

Over the past 35 years, the prevalence of obesity has more than doubled. It is especially common in women from many ethnic minorities (African-American, Mexican, Indian, Puerto Rican, Cuban, and Oceanian). Obesity is as harmful to health as smoking: it causes 500,000 premature deaths every year and doubles the mortality rate. Obesity is also widespread among young people and children. Among ethnic minorities, up to 30-40% of children and adolescents are overweight.

One risk factor is weight gain in adulthood. A weight gain of 75 kg or more compared to weight at the age of 12-20 years increases the relative risk of gallstone disease, diabetes mellitus, arterial hypertension and coronary artery disease.

Causes of obesity

Pathoanatomically, in addition to the indicated rare findings in the interstitial medulla or in the endocrine glands, accumulation of fat is found in the usual places of its deposition: in the subcutaneous tissue, omentum, perirenal, mediastinal tissue, in the epicardial region; They also find a high position of the diaphragm, fatty infiltration of the liver, layers of fat between the muscle fibers of the myocardium, and pronounced atherosclerosis.

Weight is influenced by both heredity and environmental factors. Heredity can explain up to 40% of differences in human weight. However, the marked increase in the prevalence of obesity over the past 20 years cannot be explained by genetic factors - rather, it is caused by changes in environmental factors, including lack of sleep, constant stress at work and at home, irregular meals and dietary patterns (fast food instead of diet, rich in vegetables, fruits and fish).

Excess calories taken in are stored as fat. Even a small but long-term difference between calorie intake and calorie expenditure can lead to significant fat deposition. So, taking in just 5% more calories than you burn can lead to the accumulation of about 5 kg of fatty tissue over a year. If you consume 7 kcal/day more than you burn over the course of 30 years, your body weight will increase by 10 kg. This is what Americans gain on average between 25 and 55 years of age. Technological progress is leading to lifestyle changes that promote a positive energy balance.

The foods and drinks favored by modern Americans are high in calories and fat, but low in many essential nutrients. According to various estimates, from 60 to 90% of Americans are malnourished in the sense that, despite excess calories, their diet does not meet the daily requirements for certain nutrients. In addition, only 9% of men and 3% of women regularly and vigorously move or play sports in their free time.

There is no doubt that the origin of persistent obesity is determined precisely by the cerebral cortex due to easily formed conditioned reflex connections, etc.

One cannot think that what is common to all forms of morbid obesity is a decreased need for calories and a decreased basal metabolic rate. On the contrary, the basal metabolism in states of extreme exhaustion, such as in severe enteritis, cancer cachexia, pituitary cachexia, often falls, but in obesity it remains normal (except for rare cases of hypothyroid obesity). All of the above confirms the complexity of the pathogenetic mechanisms of obesity.

Based on the participation of various parts of the regulatory system in the pathogenesis, the following forms of obesity are clinically distinguished:

1. Cerebral, or diencephalic (hypothalamic) obesity, which includes clinical cases of obesity after encephalitis of a wide variety of etiologies, for example, after epidemic encephalitis, encephalitis with typhus, scarlet fever, rheumatic chorea, etc. (as well as experiments with damage to the tuber cinereum and etc.).
2. Pituitary obesity, close to diencephalic and essentially representing a variant of the same diencephalic-pituitary form, and the pituitary gland is predominantly affected, and not the neuro-vegetative centers, as in the first variant. Fat is deposited on the chest, abdomen, pubis, thighs; characterized by a decrease in the specific dynamic effect of food. Dystrophia adiposo-genitalis is characterized by underdevelopment of the genital organs and general infantilism, along with signs of a tumor of the pituitary gland or interstitial brain. In Itsenko-Cushing's disease - basophilic adenoma of the pituitary gland, in addition to obesity with characteristic striae distensae on the abdomen, there are a number of symptoms common to hyperfunction of both the anterior lobe of the pituitary gland and the adrenal cortex and dysfunction of the gonads, such as: hirsutism (hair growth in women according to the male type), severe hypertension, apoplexy, as well as diabetes, osteoporosis and signs of a pituitary tumor. Close to this form is adrenal obesity with tumors of the adrenal cortex.
3. Hypogenital obesity, which develops in women during menopause, natural or artificial, as well as during lactation, in men with underdevelopment of the gonads (eunuchoid obesity). Prepubertal obesity in boys may also depend on a lack of sex hormones.
   Hypoovarian obesity is characterized by the location of fat in the form of leggings or the hanging of the abdomen in the form of an apron. However, the distribution of fat often occurs according to a general type, or fat is deposited mainly on the legs, etc.
4. Hypothyroid obesity, observed with insufficient thyroid function, sometimes without other symptoms of myxedema; characterized by a fat neck and moon-shaped face. A decrease in basal metabolic rate is pathognomonic.
   These and other special forms of obesity are observed very rarely; Thus, in one of the summary works on 275 obese patients, only 2 cases of cerebral and 5 cases of endocrine obesity were noted.

The largest number of cases is due to obesity of the usual form - a neurodystrophic process without sharp anatomical changes in the nervous and endocrine systems, often attributed to the exogenous type of obesity from overeating, but accompanied, however, by a violation of regulatory and metabolic processes, creating a vicious circle in the clinic of the disease and thus causing the persistent course of the disease. With a certain amount of persistence, this trend can be overcome by purposefully changing the influence of external factors.

Symptoms and signs of obesity

Patients do not tolerate heat well, especially on humid days. Massive fatty tissue represents a constant additional load, restricts the movements of the diaphragm, disrupts blood circulation and breathing. The heart is mechanically constrained, myocardial fibers atrophy from the pressure of fatty infiltration; At the same time, patients often develop coronary sclerosis and hypertension, which further disrupt the activity of the heart. Infectious and allergic bronchitis, atelectasis, hypostatic pneumonia, emphysema, often observed in obese patients, create further difficulties for the functioning of the heart. Therefore, it is clear that over time, cardiac complaints, along with impaired peripheral circulation (brain, kidneys, limbs), acquire leading importance in the clinical picture. Obese patients are predisposed to cholelithiasis and acute necrosis of the pancreas.

Diagnosis of obesity

• Waist circumference.
• In some cases, body composition analysis.

BMI is a crude screening tool and has limitations for many subgroups. BMI varies by age and race; its use is limited in relation to children and the elderly. In children and adolescents, overweight is defined as a BMI >95th percentile or based on age- and gender-specific growth charts.

Asians, Japanese and many Aboriginal populations have lower minimum levels for overweight. In addition, BMI may be high in muscular athletes who do not have excess body fat and may be normal or low in previously overweight people who have lost muscle mass.

The risk of metabolic or cardiovascular disease caused by obesity is more accurately determined by the following factors:

• other risk factors, in particular, having a family history of type 2 diabetes or early cardiovascular disease;
• waist circumference;
• serum triglyceride levels.

Waist circumference, which increases the risk of obesity-related complications, varies depending on:

• White men: > 93 cm > especially > 101 cm > 39.8.
• White women: > 79 cm > especially > 87 cm > 34.2.
• Indian men: >78 cm > especially > 90 cm > 35.4.
• Indian women:>72 cm>especially>80 cm>31.5.

Body Composition Analysis. Body composition - the percentage of fat and muscle - is also taken into account when diagnosing obesity. Although probably unnecessary in routine clinical practice, body composition analysis may be useful if clinicians are wondering whether an elevated body mass index is due to muscle or excess fat.

Body fat percentage can be calculated by measuring the thickness of the skin fold (usually over the triceps) or determining the circumference of the muscle at the mid-upper arm.

Bioimpedance body composition analysis (BIA) allows you to estimate your body fat percentage in a simple and non-invasive way. It directly determines the percentage of total fluid in the body; The percentage of body fat is determined indirectly. BIA is the most reliable method for healthy people and in people with only a few chronic diseases that do not change the percentage of total body fluid. It remains unclear whether BIA poses a risk in people with implanted defibrillators.

Underwater (hydrostatic) weighing is the most accurate method of measuring body fat percentage. Being expensive and labor intensive, it is used more often in research than in clinical work. In order to accurately weigh a person during a dive, he must exhale completely beforehand.

Diagnostic imaging, including CT, MRI, and dual-energy X-ray absorptiometry (DXA), can also assess fat percentage and distribution, but is generally used for research purposes only.

Other types of research. Obese patients should be screened for obstructive sleep apnea using a tool such as the Epworth Sleepiness Scale and often the Apnea-Hypopnea Index. This disorder is often underdiagnosed.

Blood glucose and lipid levels should be measured regularly in patients with a large waist circumference.

Ignoring the disease by doctors

This occurs especially often with excess body weight or stage I obesity. The reason for ignoring it is often that the patient visits the doctor in connection with other problems and does not want to receive recommendations for weight loss. However, the doctor and the patient must be aware that even such a relatively small excess body weight is a risk factor for many diseases (hyperlipidemia, arterial hypertension, diabetes mellitus, etc.).

Therefore, the doctor must draw the patient’s attention to the harm caused by excess body weight and the importance of reducing it. With a discussion of the question of whether there is excess body weight and whether it is harmless, the patient begins to move towards accepting recommendations on how to regulate body weight.

Overexamination of the patient

In more than 90% of cases, excess body weight is an independent (primary) problem, and not a consequence of another disease.

Secondary obesity can be a consequence of a number of endocrine diseases (hypothyroidism, Cushing's disease/syndrome). Less commonly, the cause of excess body weight is congenital genetic defects (Prader-Willi syndrome, etc. - relevant in children and young patients), the consequences of immobilization, head injuries, tumors of the hypothalamic zone, therapy with antipsychotics, etc.

Many of these causes of secondary obesity are easy to diagnose based on history and physical examination.

During a laboratory examination of an obese patient, it is necessary to determine the following indicators:

• TSH level;
• daily excretion of free cortisol in urine (with clinical suspicion of hypercortisolism - stretch marks, arterial hypertension, hyperglycemia, “Cushingoid” appearance, etc.);
• to assess the metabolic consequences of obesity: glucose levels, lipid profile, uric acid.

Often, redundant and expensive examinations are carried out to determine all known hormones or evaluate indicators that, although they play a role in the genesis of obesity, do not affect the choice of treatment methods (leptin levels).

On the other hand, without a thorough history and proper laboratory testing, you can miss an endocrine (or other) disease that led to the development of secondary obesity.

When evaluating an obese patient, it is possible to perform appropriate tests to exclude hypogonadism in men and hyperprolactinemia in men and women, although this is not part of the generally accepted examination plan.

A common, but not beneficial practice is to conduct an OGTT with measuring, in addition to glucose, also the level of insulin and/or C-peptide.

Based on the increased level of these indicators, the presence of insulin resistance can be stated (for the correct interpretation of increased insulin levels, see Chapter 10). In this case, medications that improve insulin sensitivity (usually metformin) are often prescribed. But the doctor and the patient must understand that:

• the use of metformin by itself does not cause weight loss;
• The effect of metformin on tissue sensitivity to insulin is reversible and disappears after discontinuation of the drug. In this regard, the drug should be taken for life,5 which can be justified only in rare cases, for example, with a high risk of type 2 diabetes in the near future.

Underestimation of eating disorders and depression

A significant proportion of obese patients have eating disorders (such as bulimia) and depressive disorders. Without eliminating these problems, standard recommendations for changing diet are ineffective, and therefore many patients need the help of a psychotherapist (psychiatrist).

In everyday practice, these problems often go undetected in obese patients.

Obesity forecast

Obese patients die at an earlier age than thin people. The immediate cause of death is most often heart failure, myocardial infarction, cerebral hemorrhage, lobar pneumonia and other infections, consequences of cholelithiasis, surgery, etc.

Without treatment, obesity tends to progress. The likelihood and severity of complications is proportional to the absolute amount of fat, fat distribution and absolute muscle mass. After weight loss, most people return to their pre-treatment weight within 5 years, and obesity therefore requires a lifelong management program similar to any other chronic disease.

Complications of obesity

Obesity worsens the quality of life and is a significant risk factor for a number of diseases and premature death.

Complications of obesity include:

• Metabolic syndrome.
• Diabetes mellitus type 2.
• Cardiovascular diseases.
• Non-alcoholic steatohepatitis (fatty infiltration of the liver).
• Gallstone disease.
• Gastroesophageal reflux.
• Obstructive sleep apnea syndrome (OSAS).
• Reproductive system disorders, incl. infertility.
• Many types of malignant neoplasms.
• Deforming osteoarthritis.
• Social and psychological problems.

Obesity is also a risk factor for non-alcoholic steatohepatitis (which can lead to cirrhosis of the liver) and reproductive disorders such as low serum testosterone in men.

Obstructive sleep apnea can occur when excess fat in the neck compresses the airway during sleep. Breathing stops momentarily hundreds of times a night. It is a disorder that often goes undiagnosed.

Obesity can lead to obesity-related hypoventilation syndrome (Pickwick syndrome). Impaired breathing leads to the development of hypercapnia, decreased sensitivity to carbon dioxide in stimulating respiration, and hypoxia.

Osteoarthritis and tendon and fascial diseases can occur as a result of obesity. Excess weight probably predisposes to the development of gallstones, gout, pulmonary embolism, and some types of malignancies.

Obesity treatment

General principles. Americans spend more than $70 billion annually on commercial “weight loss products.” In most cases, people manage to lose weight with their help, but, alas, after 1-5 years the lost kilograms come back in abundance. Obesity is a chronic disease, and long-term maintenance of normal weight requires equally long efforts. For a sustainable change in lifestyle, the patient needs to change his behavior. It is also very important to have an understanding of the basics of proper nutrition. Patients should be encouraged to systematically, gradually lose weight. At the same time, sensitivity to insulin increases, blood pressure and lipid levels in the blood decrease, and fatty infiltration of the liver decreases.

Reducing caloric intake should take into account the patient's age and associated risk factors. Below is a formula that, if followed, allows you to lose about 0.5 kg per week. Daily calorie intake = (Current weight in kg x 28.6 kcal) - 500 kcal.

Reducing the amount of fat in the diet- an important part of any weight loss program. Many patients are helped by reducing the amount of fat in the diet to 10-20% of its daily calorie content (about 20-30 g of fat per day). In most commercial weight loss programs, the daily calorie intake is 800-1200 kcal. If you follow it consistently, this program allows you to lose from 200 g to a kilogram per week for 30 weeks.

From amateur diets Most of them are of little use, and some of them are simply harmful. In addition, a decrease in calorie intake can lead to micronutrient deficiencies and disrupt metabolic processes.

That is why it is recommended to lose weight under the supervision of a nutritionist. The nutritionist should recommend that the patient eat three times a day, avoid snacking between meals, eliminate fatty and high-calorie foods from the diet, and eat more vegetables and fruits.

Physical activity important not only for long-term maintenance of normal weight, but also for general health. You need to increase the load gradually. According to research, once you reach a normal weight, 80 minutes of daily moderate physical activity, such as brisk walking, or 35 minutes of vigorous physical activity, such as brisk cycling or aerobic exercise, is enough to maintain it. However, you don't have to join an organized exercise program; a consistently active lifestyle can help you maintain your weight just as well as aerobic exercise. Recent research shows that weight training is best for weight loss and maintenance. By increasing muscle strength and muscle mass, this type of exercise thereby speeds up metabolism and enhances the oxidation of fats as a source of energy. This makes it much easier to maintain normal weight for a long time.

If a patient constantly hears from doctors words about the need to lose weight, but they are all limited to only general phrases (“you need to eat less and move more”), he develops a denial of these recommendations and a belief in the ineffectiveness of the diet in his case (“this is not me - I eat little”; “I tried it many times, but it doesn’t help me”). The reason may be the patient’s ignorance of many important aspects of weight loss (the need to limit vegetable fats, such as olive and sunflower oil, which have the highest calorie content among all products).

The same applies to physical activity: clear recommendations are needed on how often, for how long and with what intensity to exercise.

At the same time, providing such detailed recommendations to the patient only makes sense at the stage when he seriously wants to lose weight and is ready to change his diet and lifestyle (not always pleasant for him) to achieve this goal. Detailed recommendations at earlier stages (for example, “denying the problem”) are ineffective and only waste time for the doctor.

“The main sources of calories are flour and sweets”

When reducing body weight, limiting the consumption of these foods first is a common misconception among patients, and sometimes among doctors.

Often such a diet turns out to be ineffective, because the most high-calorie foods rich in fat are consumed in the same quantity. It is important to explain to the patient that the “champions” in terms of calorie content are fats and alcohol, and:

• when losing body weight, you have to limit your fat intake (sunflower and olive oil, including in salads, when cooking and heating food);
• A common “trap” for patients trying to lose weight is eating foods rich in “hidden” fats and temporarily prescribing diet therapy.

A common mistake is relatively short-term adherence to so-called unbalanced diets (for example, a carbohydrate-free diet such as the Atkins diet or a similar “Kremlin” diet). Due to severe caloric restriction and the ketogenic effect (which reduces appetite), these diets provide fairly rapid weight loss, but this diet does not last long. After returning to the previous diet, body weight is likely to return to its previous level or even higher (“yo-yo syndrome”).

The so-called very low calorie diet has very limited use in the treatment of obesity. Sometimes it is used at the initial stage of weight loss, followed by a transition to a low-calorie diet (1200-1800 kcal/day) on a permanent basis. This provides a greater overall result than using only a low-calorie diet, but this method is only useful in the hands of an experienced nutritionist. Otherwise, there is a risk of weight gain upon completion of a very low-calorie diet (the above-described “yo-yo syndrome”). Fasting treatment also has all the disadvantages described above, and it is also contraindicated in patients with diabetes.

Physical activity

Increasing physical activity is no less important a component of treatment than changing diet.

The effect of diet on the “weight” indicator itself may be more pronounced than that of physical exercise. At the same time, the latter provide favorable changes in body composition (for example, with a decrease in fat tissue by 1 kg and an increase in muscle tissue by 1 kg, body weight does not change, but the body becomes healthier).

Therefore, properly selected moderate-intensity physical exercises of at least 2-4 hours per week are considered an essential component of a weight loss program.

A sharp change in the usual diet and lifestyle, including the introduction of intense physical activity without a preparation stage

The recommendations that the patient receives must be realistic: if they are too aggressive and impossible to implement in his daily life, this will most likely lead to refusal of treatment and cause stress.

Targets set for weight loss should also be realistic. Even if body weight remains formally overweight, such a reduction significantly improves metabolic parameters, well-being, and the condition of the cardiovascular and musculoskeletal systems. At the same time, the achieved body weight is easier to maintain, and the risk of relapse is lower than with a more significant reduction in body weight. More impressive results, especially in the short term (for example, under the motto “lose weight by summer”), are usually achieved either by a diet with a very low calorie content (see its disadvantages above), or through drugs or diets with a diuretic effect. However, the latter, although they move the needle on the scale, do not reduce the amount of adipose tissue, and therefore do not bring benefit in the treatment of obesity (and can be harmful, in particular increasing the risk of cardiac arrhythmias when combined with CNS stimulants).

Intense physical activity in an inactive, detrained patient can also cause deterioration of the condition (especially in old age). Therefore, the intensity of physical activity must be increased gradually. Participation in the treatment of a doctor - a specialist in physical therapy is considered optimal.

Supplements

Dietary supplements, including “dietary supplements for weight loss,” are substances with an unproven clinical effect and little-studied safety (since they have not undergone high-quality clinical trials). Of course, there are no dietary supplements in domestic and international recommendations for the treatment of obesity and the doctor should not prescribe these drugs.

With all the variety of herbal products available on the market for weight loss, they can be divided into four main types:

1. drugs that reduce appetite due to psychostimulating effects;
2. means that provide a feeling of fullness by filling the stomach with indigestible cellulose derivatives;
3. drugs with a diuretic effect;
4. laxatives.

Often several substances with different mechanisms of action are combined in one drug.

These agents are not useful in treating obesity for two main reasons.

1. When using many of them, weight loss occurs due to the diuretic effect. In addition, the combination of diuretics with psychostimulants carries a serious risk of life-threatening arrhythmias.
2. Even when herbal preparations cause weight loss by reducing calorie intake, their effect is reversible. Therefore, their use would only make sense long-term, but the safety of such use has not been tested, is highly questionable and is not recommended by the manufacturers of these dietary supplements.

Prescribing drug therapy only to patients with morbid obesity or completely refusing it. Use of medications in short courses (1-3 months)

Today in Russia, drugs are available that block the absorption of fats in the intestines - orlistat (Xenical, Orsoten) and reduce appetite - sibutramine (Meridia, Lendaxa, Reduxin)6. However, the effect of these drugs is reversible, therefore, for a lasting effect, they should be used for several years (in the future, it is possible to consolidate the acquired eating patterns and maintain the effect after discontinuation of the drug). Using these drugs in short courses is a mistake.

These drugs are indispensable primarily for grade III obesity (morbid) due to the fact that in a number of such patients, after losing body weight using non-drug methods, significant excess body weight remains. Reducing body weight from 145 to 125 kg (-14%) is a good result, but a body weight of 125 kg can also cause big problems. In this situation, drug therapy can improve treatment results. But even with less severe obesity (for example, stage II), the use of these drugs is advisable if non-drug therapy has no effect.

The indication for drug therapy is currently considered to be a BMI > 30 kg/m2.

Surgeries on the gastrointestinal tract have their own area of ​​application in the treatment of morbid obesity.

Diets for obesity

Diets with severe calorie restriction or protein diets serve as a safe alternative to fasting as a way to achieve significant, sustainable and permanent weight loss. The daily calorie intake for such diets is 400-800 kcal. Effective and safe programs include 0.8-1 g of protein per kilogram of desired weight or 70-100 g of protein per day and at least 45-50 g of carbohydrates to minimize nitrogen losses and avoid ketoacidosis, respectively. In general, rapid and permanent weight loss occurs over a period of weeks or months. After about six months, this process slows down, then stops, and further weight loss is very difficult to achieve. Unfortunately, once a person gives up a low-calorie diet, maintaining the achieved weight is also very difficult. A more active lifestyle and regular exercise can help with this. Promising results are obtained by alternating the use of diets with severe calorie restriction and “meal replacements” (for example, special cocktails that replace part of meals) simultaneously with food restrictions.

Drug treatment of obesity

Without drug treatment or diets with a sharp restriction of caloric intake, it is extremely difficult to achieve weight loss and fat loss, and then maintain the result. Drug treatment can help some patients maintain a normal weight for a long time, but it cannot be used for rapid weight loss. Obesity is a chronic disease, and as soon as the patient stops taking medications, the excess weight usually returns. In addition, the effectiveness of drug treatment may decrease over time, so it is very important that it is combined with proper nutrition, lifestyle and behavior changes.

Sibutramine is a relatively new drug approved by the FDA for long-term use in 1997. It is a monoamine reuptake inhibitor (serotonin, dopamine, norepinephrine), originally developed as an antidepressant. In most cases, it leads to dose-dependent weight loss. Sibutramine is available in capsules for once daily use. In one study, 39% of patients receiving sibutramine for a year lost 10% of their baseline weight (only 9% of those receiving placebo). Based on clinical studies, sibutramine is safe.

Orlistat approved by the FDA for the treatment of obesity in 1999. It inhibits gastric and pancreatic lipase, preventing the formation of free fatty acids from dietary triglycerides. Orlistat causes weight loss and a decrease in the mass of fatty tissue in internal organs, regardless of diet. The drug does not reduce the feeling of hunger and does not cause a feeling of satiety. Side effects include cramping abdominal pain, loose stools, increased release of gases; however, reducing the amount of fat in the diet to 60 grams or less will relieve most of these side effects. There was also a slight decrease in serum levels of fat-soluble vitamins A, D and beta-carotene, but they remained within normal limits. The drug is contraindicated in chronic malabsorption and cholestasis. Orlistat is available in capsules of 60 mK for taking 2 capsules 3 times a day.

Olestra is a fat substitute, which is an ester of sucrose and 6-8 fatty acid residues. In appearance and taste, olestra resembles butter, but it is not hydrolyzed by gastrointestinal lipases and is excreted unchanged in the feces. Olestra is used in the production of potato chips and is produced as a butter substitute. The drug allows the patient to reduce the intake of fats from food without depriving himself of the taste of the oil.

Surgical treatment for obesity

Surgery. The condition of patients should allow them to undergo surgery and subsequent long-term treatment.

The purpose of surgical treatment of obesity- reduce the volume of the stomach or create a bypass for incoming food, bypassing the stomach and part of the small intestine. In the first case, the patient will be satisfied with a small amount of food, in the second, part of what is eaten will not be absorbed.

Operations. Surgical interventions used for obesity can be divided into three categories.

Surgeries that reduce the volume of the stomach. In this case, the anatomy of the stomach changes to limit the flow of food, but the absorption process is not affected. This includes operations such as vertical gastroplasty with strengthening of the outlet with a polypropylene mesh or silicone ring, horizontal gastroplasty, gastric banding, including adjustable ones.

Operations that interfere with absorption. At the same time, the anatomy of the gastrointestinal tract changes in such a way as to reduce the absorption of nutrients and the intake of calories.

Operation technique

Gastrobypass surgery. In the upper part of the stomach, staple sutures are placed horizontally or vertically, thereby separating a pocket with a volume of 15-25 ml with access to the small intestine. The operation is reversible and can be performed laparoscopically or through open access. A Roux-en-Y anastomosis is performed with the afferent portion of the small intestine (where bile and pancreatic juice enter). The small intestine is divided at a standard distance of 75 cm from its origin. The length of the section of the small intestine between the stomach and the anastomosis site is 150 cm, and with distal gastric bypass - more than 150 cm. Weight loss is achieved due to early satiety (since the gastric “pocket” is quickly filled with food) and slight malabsorption. If sufficient weight loss cannot be achieved, you can lengthen the section of the intestine that is excluded from digestion.

Laparoscopic mini-gastrobypass surgery- This is a variant of gastric bypass with a longer tube formed along the lesser curvature of the stomach.

Gastric banding, including adjustable (laparoscopic). Gastric banding is often performed laparoscopically. In this case, a ring is placed on the upper part of the stomach, limiting its size to 15 ml, without removing the rest. Repeated operations to reduce the volume of the stomach have to be performed up to 6 times a year.

With an adjustable gastric band, the ring can be removed; You can also perform additional intervention by performing one of the operations that impair absorption.

results

Complications. Early complications are the same as after any surgical intervention.

Late complications include "ulcer and stenosis of the anastomosis, bleeding, increased certain gastrointestinal symptoms, such as diarrhea. Deficiencies of certain vitamins and microelements, neurological and mental disorders are possible. Patients should be under medical supervision; in case of deficiency of vitamins and microelements, appropriate nutritional supplements are prescribed additives.

Treatment of persistent forms of obesity is a difficult task.

Weight loss can be achieved by reducing the caloric intake of food. However, patients, who often experience an increased feeling of hunger, do not tolerate a stricter regime well. It is also not easy to ensure increased combustion through physical exertion, which causes increased shortness of breath and various other complaints.

It is especially important to begin systematic treatment as soon as a tendency towards weight gain is detected.

In the treatment of obesity, it is now often considered advisable to sharply reduce calories (to 1,200-1,000 calories and below) with a normal amount of protein, but a sharp reduction in carbohydrates (up to 100 g) and fats (up to 30 g). Salt intake is limited to 2-3 g per day. A general massage is prescribed, and later, when the patient gets stronger, walks and light exercise. Thyroidin is prescribed at 0.05-0.1 per day for a long period or in large doses for 1-2 weeks. Rapid weight loss is achieved by prescribing regular doses of Mercusal. For hypoovarian obesity, folliculin and sinestrol are beneficial. In addition to treating obesity itself, it is necessary, depending on concomitant diseases or complications, to treat cardiosclerosis, cholelithiasis, diabetes, etc.

Good results for obesity are obtained from treatment in Essentuki, where patients, along with alkaline salt waters and baths, receive various types of mechanotherapy and use a general regimen, as well as in Kislovodsk, where they are prescribed dosed walks, carbon dioxide baths, etc.

Diet therapy for obesity

When compiling a diet, rely on the above-described method of compiling a physiological diet, determining the calorie content of selected food products for preparing various dishes, use tables of product interchangeability; Thus, you will be able to diversify your diet as much as possible, and your nutrition will be complete and reasonable. End each day with a glass of kefir, but no later than 2 hours before bedtime.

If it seems to you that you will eat too often, then do not forget that the portions should be small. Using small dishes can also help; For this purpose, you can even use plates for first and second courses intended for children. After all, as many people say, he himself is full, but his eyes are not. This is because the plate was half empty, but with a child’s plate it will be easier.

It must be said here that if you want to lose weight and follow the above tips, you should drink more water (up to 1.5-2 liters per day). It will be even better if you take a glass of water before meals: this will reduce your appetite.

When eating according to a prescribed diet, it is imperative to gradually reduce the consumption of simple or easily digestible carbohydrates in the diet; reduce the consumption of sausages, replacing them with game meat and skinless poultry. Soups should be prepared in vegetable or weak meat or fish broths; reduce the content of table salt in dishes: if you do this gradually, you can quickly get used to slightly under-salted food. You should cook using gentle methods of cooking food (without oil, you can use a double boiler or grill, bake or stew food).

Having quickly achieved results, you can just as quickly “relax” and forget about the diet, and as a result, gain more.

Physical therapy for obesity

Another factor contributing to weight loss is physical activity. You can start by developing the habit of doing morning exercises, which, even if they consist of simple exercises, will allow you to warm up and tone absolutely all the muscles of the body.

Before starting physical therapy exercises, you must consult a doctor of the appropriate specialty. Only he, taking into account the state of the cardiovascular system of a particular patient, will be able to select the optimal physical activity for him.

You should walk whenever possible. So, if work is located several stops from home, then you can leave earlier and walk to it. In winter it is useful to ski, in the cool season you should walk more, ride a bike, and in summer you should swim more, walk barefoot on the sand or on the grass. People suffering from obesity can be advised to play more outdoor games with their children or grandchildren: this will be good physical activity, and children will also be delighted to communicate with adults.

When choosing a sport, pay attention to swimming, which allows you to spend up to 12 kcal per minute.

In swimming pools, aqua training has now become very fashionable, i.e. doing exercises in water. Here are some sample exercises in water. Performing them to maintain general tone, good mood and as a suitable physical activity is enough 1-2 times a week.

Obesity prevention

Daily caloric intake is calculated in accordance with the normal weight of a person, determined by the above formula. Systematic weighing is necessary to take into account the effectiveness of preventive measures, and in case of weight gain, additional dietary restriction.

Preventive measures against obesity are especially necessary for people engaged in sedentary work, aged 40 years and older.