Hypotrophy code icd. Obesity - principles of treatment. E84 Cystic fibrosis

Tue, 02/06/2018 - 17:14 / komali

Urolithiasis with excess body weight

Urolithiasis in overweight individuals.

With age, ICD is less common. But there is a category of patients to which general attention is focused. These are overweight people. This category of people often exhibits such common diseases as hypertension, atherosclerosis and coronary artery disease, obesity and diabetes mellitus. The combination of these diseases with insulin resistance is called metabolic syndrome(MS). Currently, MS is defined by an abdominal circumference of >102 cm in men and >88 cm in women and two other possible signs: increased triglyceride levels (>169 mmol/l) or decreased lipoprotein levels high density (<1.03 ммоль/л) у мужчин и <1.29 ммоль/л) у женщин, гипертензии (систолическое arterial pressure>130 mmHg or diastolic pressure >85 mmHg) or fasting glucose >5.55 mmol/l. In the future, availability urolithiasis(ICD) may be another criterion for the syndrome. It was found that in MS there is a 30% increase in the risk of urolithiasis with an increase in the number of urate stones due to hyperuricemia, hyperurcosuria, low urine pH and low diuresis.

Back in the 70s of the last century, the main feature of these individuals was identified - reduced sensitivity to insulin, which is overcome by the body due to increased insulin production. Due to difficulties in the absorption of glucose by cells, fat metabolism is activated. The presence of changes similar to MS patients in the form of low urine pH, decreased excretion and increased excretion of uric acid and calcium in the urine was confirmed in the experiment. In persons with MS, changes were found in the composition of blood fats and, in particular, increased amount triglycerides and free fatty acids. Excess free fatty acids have a toxic effect on many cells, in particular the heart, muscles, liver, kidneys, and endocrine organs.

The reasons for the frequent cases of ICD in MS require clarification. It has been established that the more types of diseases a patient has, the higher the likelihood of stone formation. Each MS participant adds the likelihood of kidney stones. A feature of ICD in these individuals is an equal number of men and women, redistribution in the composition of stones, namely, an increase in stones from uric acid (urates) due to a decrease in the number of stones from calcium phosphates. Patients with MS typically have a low pH, while the formation of stones from calcium phosphate requires a high urine pH. It should be emphasized that the highest frequency of stones in MS continues to be calcium oxalate. The formation of oxalate crystals is promoted by regularly detected hypocitraturia. Citrate in the urine forms soluble salts with calcium, which normally prevents the growth of calcium oxalate crystals. The formation of oxalates, in addition, is facilitated by the biochemical conditions that arise during hypertension and diabetes mellitus. These diseases are characterized by increased levels of oxidative stress, which contributes to the formation of excess free radicals that can damage the epithelial cells (urothelium) of the tubules and collecting ducts. Cell damage and inflammation at the site of injury turns out to be the site of retention and attachment of the “nuclei” of future stones, which would otherwise be washed away by the stream of urine. The presence of inflammation can be confirmed by detecting elevated levels of CRP and IL-6 in the blood.

Why does the number of urates increase with MS? This is due to two circumstances: firstly, a decrease in the formation of the alkaline component of ammonium by the cells of the proximal tubules, and, secondly, an increase in the pool of acids in the urine, including uric acid. Decreased ammonia production is a result of low sensitivity to insulin, which normally stimulates the formation of ammonia from glutamine. The combination of ammonium deficiency and excess acids results in a decrease in urine pH below 5.5. When urine pH is low, the solubility of uric acid decreases, which leads to the appearance of its crystals. It should be noted that at low pH crystallization can begin even at normal quantities MK in blood and urine. When studying the composition of stones in MS, mixed stones consisting of calcium oxalate and uric acid were also discovered.

Metabolic disorders leading to stone formation in overweight individuals are primarily associated with the dietary habits of these individuals. Overweight individuals tend to consume more meat products and animal protein, consisting of amino acids. In addition to the increase in uric acid in the blood and the possibility of developing gout, this contributes to the formation of a large volume of organic acids and a decrease in urine pH to the acidic side. Next, excess consumption table salt and sodium causes both an increase in blood pressure in salt-sensitive individuals and supersaturation of urine with calcium. Therefore, in hypertension, the formation of calcium oxalate stones is especially common. Refusal of dairy products due to poor milk tolerance leads to insufficient calcium intake (less than 600 mg/day) and osteoporosis of the skeletal bones. As a result, calcium does not retain oxalate in the intestine and hyperoxaluria develops, which promotes stone formation. Fatty foods that contribute to excess weight, in conditions of age-related decreases in the level of sex hormones and growth hormone, lead to dyslipidemia and the threat of kidney stones. Dyslipidemia in the form of increased total cholesterol, hypertriglyceridemia and the level of low-density lipoproteins and reduced levels of high-density lipoproteins is the cause of atherosclerosis and its important manifestations: ischemic heart disease and cerebral and stenosis renal arteries, as well as stones in the urinary tract. It is no coincidence that cholesterol impurities can be found in stones. Proximal tubule cells are damaged due to filtered excess free fatty acids, leading to decreased kidney function. It has been found that the anti-cholesterol drugs statins may reduce the risk of stone formation in obesity through anti-inflammatory and antioxidant effects unrelated to cholesterol lowering. This became obvious after receiving the results of long-term observation of patients. About 2 thousand people with urolithiasis and hyperlipidemia received statins for a long time. Observation for 10 years made it possible to prove that the incidence of stone formation significantly decreased in those taking statins. Treatment of dyslipidemia not only reduces the risk of atherosclerosis and its complications, but also the incidence of stone formation.

The presence of urolithiasis, in turn, can complicate the course of MS. Thus, nephrolithiasis promotes hypertension, causes local urinary retention, contributing to infection and chronic kidney disease. However, uremia is a rare complication of urolithiasis in the elderly, but it must be taken into account that with some types of stones such as brushitis, cystine, struvite, a decrease in renal function is more often detected.

Program about research I am a person with ICD and overweight

Crystallographic analysis of the stone (if available)

If you know the composition of a spontaneously passed stone or a stone obtained during surgical treatment, the choice further treatment is greatly facilitated. Determination of the composition of stones is carried out in our laboratory using a modern and accurate method of infrared spectroscopy. After colic, a stone does not always pass right away and it takes up to 6 weeks to look at the urine in the morning in a transparent or white container. If the stone turns out to be composed of cystine or struvite, then crystallographic analysis makes it possible to make a final diagnosis. The composition of a stone from a single component is rare, most of them have complex structure. Urologists focus on the most voluminous component of the stone, amounting to more than 60%. But the meaning of others components is also important for choosing further tactics for patient management (9).

Interpretation of results.

If you are overweight and have an abdominal circumference of more than 102 cm in men and 88 cm in women, the likelihood of metabolic syndrome increases. The likelihood of detecting (especially in women) urate stones, consisting of uric acid, as well as calcium oxalates in the kidneys, also increases. Although uric acid stones are characterized by a high frequency of “pure” stones, mixed stones consisting of uric acid and oxalates are also found in MS. Among the oxalates, wevvelites predominate over veddelites. It is possible to detect cholesterol stones as the main component or as an admixture to other constituent crystals of the stone.

Biochemical blood test: calcium, creatinine, total cholesterol, uric acid, triglycerides, low-density lipoproteins, high-density lipoproteins, glucose,

Interpretation of results.

The degree of obesity, cholesterol and triglyceride levels are quite high in individuals with ICD. This relationship between obesity, total cholesterol, and low-density lipoprotein is particularly noticeable in urate stones and mixed calcium stones, but is not as noticeable in “pure” vevvelitis. Levels of low-density lipoprotein in mixed calcium stones are also higher compared to “pure” stones. The calcium value allows us to exclude individuals with hyperparathyroidism as a cause of KSD. Individuals with urate are more likely to have chronic kidney disease, so creatinine data was included in the study. Elevated levels of uric acid in the blood (hyperuricemia) are combined with the main manifestations of MS: atherosclerosis and type 2 diabetes mellitus. The study of triglycerides, cholesterol, and lipoproteins is important for selecting individuals who are indicated for statin therapy to prevent further stone formation in MS. Statin therapy is valuable in people with hyperlipidemia as the basis of atherosclerosis, especially in those patients who have signs of inflammation and in whom atherosclerosis is very widespread. The presence of elevated CRP makes it possible to identify individuals with inflammation. Glucose levels are not only included in the MS criteria. The tendency to form kidney stones is distinctive feature overweight individuals with high levels of glucose and triglycerides in the blood. Moreover, it is the elevated level of fasting blood sugar, and not impaired glucose tolerance, that determines the tendency to ICD. Therefore, the number of examinations includes determination of blood sugar.

General urine analysis with sediment microscopy: pH, specific weight, glucose, protein, sediment: cells, cylinders, crystals.

Interpretation of results.

A pH level of less than 6.0 determines the likelihood of stone formation from uric acid. The solubility of calcium oxalates depends less on pH, but more on the calcium and oxalate content. Specific gravity is a surrogate for the patient's hydration status. In persons with infection stones, the pH is usually alkaline and bacteriuria is detected. In the sediment, rhomboid-shaped crystals of uric acid can be detected, and oxalate crystals have the shape of “envelopes” with sharply defined edges.

Metabolic urine test (24 hours): urine volume, calcium, oxalates, uric acid, potassium, sodium, chlorine, citrate.

Interpretation of results.

The results of a metabolic study make it possible to choose a more specific diet and drug therapy, including prescribing statins, targeting stone composition and underlying causes. Because of the high risk of stone recurrence, 24-hour urine is analyzed to determine lithogenic (uric acid, calcium, oxalate, sodium) and litholytic (potassium, citrate) compounds. The metabolic profile of patients who form mixed uric acid and oxalate stones shows abnormalities typical of both urate and calcium oxalate stones. In patients with increased content oxalate in the urine is more likely to form vevvelitis stones. In persons with uric acid disease, especially those with “pure” uric acid stones, the daily excretion of uric acid and creatinine in urine is higher.

Hypotrophy — chronic disorder nutrition characterized varying degrees weight loss. As a rule, young children suffer from malnutrition.

Code by international classification diseases ICD-10:

Causes

Etiology, pathogenesis. The disease is polyetiological. There are congenital (prenatal) and acquired (postnatal) malnutrition. Congenital malnutrition is most often caused by maternal diseases or associated with intrauterine hypoxia, fetal infection, genomic and chromosomal mutations. Among the causes of acquired malnutrition, exogenous and endogenous are distinguished. The first include nutritional factors (hypogalactia in the mother, incorrectly calculated diet during artificial feeding, one-sided feeding, etc.), pyloric stenosis and pylorospasm, drug poisoning(hypervitaminosis D, etc.), gastrointestinal infections intestinal tract, deficiencies in care, regimen, education, etc. Endogenous causes of malnutrition can be malformations of the gastrointestinal tract and other organs, lesions of the central nervous system, hereditary metabolic abnormalities and immunodeficiency conditions, endocrine diseases, etc. The basis of the pathogenesis of malnutrition is reduction in recycling nutrients with disruption of the processes of digestion, absorption and assimilation under the influence of various factors. There are I, II and III degrees of severity of malnutrition.

Symptoms (signs)

Clinical picture. Hypotrophy of the first degree is characterized by a loss of body weight of no more than 20% of that required by age. The subcutaneous fat layer on the abdomen becomes thinner, and tissue turgor decreases. The curve of body weight gain is flattened. Other indicators are usually within normal limits or slightly reduced. With II degree malnutrition, the loss of body weight is 25 - 30% compared to age norm. The subcutaneous layer is preserved only on the face; it is especially thin on the stomach and limbs. The skin is dry, easily folded, and hangs down in some places. There is growth retardation, appetite decreases, the child becomes irritable, loses previously acquired skills, and thermoregulation is impaired. Unstable stool: “hungry” stool (scanty, dry, discolored, with sharp and unpleasant smell) is replaced by dyspeptic (green, undigested food particles, with mucus). With grade III malnutrition, the loss of body weight is more than 30% of what it should be before age. There is no increase in body weight, the child is significantly stunted in growth. Externally - an extreme degree of exhaustion, the skin is pale - gray, the subcutaneous fat layer is completely absent. The mucous membranes are pale, dry, in the mouth there are elements of candidal stomatitis (thrush). Breathing is shallow, heart sounds are muffled, blood pressure is reduced. Body temperature is low, there are periodic rises to low-grade levels, there is no difference between axillary and rectal temperatures. Infectious processes are asymptomatic. There are often signs of subacute current rickets.

Diagnostics

Diagnosis malnutrition usually does not present difficulties. It is much more difficult to find out the causes of malnutrition.

Treatment

Treatment patients should be comprehensive and include measures aimed at “eliminating or correcting the cause significant factors, diet therapy, prescription of restorative procedures, enzymes and symptomatic remedies, elimination of foci of infection, vitamin therapy. In all cases, when prescribing a diet, it is necessary to determine food tolerance. During periods of increased food load, scatological control is needed. In case of 1st degree malnutrition, the amount of proteins and carbohydrates is usually calculated per 1 kg of body weight due to age, and fats - per 1 kg of existing body weight. In case of II degree malnutrition, food tolerance is established within 3 to 5 days. As a rule, breast milk or sour mixtures are prescribed (kefir, acidophilus “Malyutka”, biolact, etc.). The calculation is first carried out on the child’s existing body weight, then on approximately the expected one (existing +20) and only then on the expected one. From the 3rd - 4th day, the protein load is gradually increased, then the carbohydrate load and, lastly, the fat load. For grade III malnutrition, it is preferable to begin diet therapy with the introduction breast milk every 2 hours 20 - 30 ml. Having brought the amount of food to 50 ml, reduce the number of feedings. The order of increasing the load of proteins, carbohydrates and fats is the same as with degree II malnutrition, but more gradual. Food tolerance is determined within 2 weeks. With malnutrition of the II and III degrees, the missing amount of fluid, nutrients and electrolytes are administered intravenously: 5 - 10% glucose solution, isotonic solution sodium chloride, Ringer's solution, protein hydrolysates, albumin, protein, etc. (albumin 3 - 5 ml/kg; hemodez up to 15 ml/kg, but not more than 200 ml; rheopolyglucin 3 - 8 ml/kg). Insulin glucose therapy is indicated (s.c. 1 unit of insulin per 5 g of administered glucose).

Treatment hypotrophy of II - III degree must be carried out in a hospital. If there are foci of infection, antibiotics are prescribed (nephro-, hepato- and ototoxic drugs should be avoided), and surgery is performed if necessary. Enzyme therapy and vitamin therapy are widely used. Among the stimulants prescribed are apilac, gamma globulin, albumin, plasma, and blood transfusions. In some cases, it is advisable to use anabolic hormones (retabolil 1 mg/kg once every 2 weeks, etc.). Massage and exercise therapy, spending time in the fresh air are recommended.

Forecast depends on the cause that led to malnutrition and the possibilities of eliminating it. With primary malnutrition of the third degree, the prognosis is always serious; mortality rate is up to 30%.

Prevention. If possible, ensuring natural feeding, treatment of hypogalactia, rational feeding, early diagnosis diseases of newborns and infants.

Diagnosis code according to ICD-10. E46

Chronic, lifelong, multifactorial, genetically determined, life-threatening disease caused by the accumulation of excess body fat, leading to serious medical, psychosocial, physical and economic consequences.

The role of obesity in the development of cancer of the mammary glands, uterus, prostate, and colon is known. Obesity is accompanied by a decrease in physical and mental performance up to complete disability, deprives patients of the opportunity to lead a normal lifestyle, leads to social disadaptation and the development of depressive states.

ICD-10 CODES

E66.0. Obesity caused by excess supply of energy resources.
E66.1. Drug-induced obesity.
E66.2. Extreme obesity, accompanied by alveolar hypoventilation.
E66.8. Other forms of obesity.
E66.9. Obesity, unspecified.

Obesity surgery, or bariatric surgery(from the Greek baros - heavy, fat, weighty) - a relatively young field of surgical gastroenterology, the subject of which is morbid(morbid) obesity, i.e. clinically expressed forms of the disease.

Obesity-related diseases

The development of metabolic syndrome, described in 1988 by G. Riven, is based on abdominal obesity and the state of insulin resistance developing against this background, which in turn determines the development of type 2 diabetes mellitus, arterial hypertension, atherogenic dyslipidemia, coagulopathies, uric acid metabolism disorders, etc. The inevitable consequence of this complex and interconnected set of disorders is the development of atherosclerosis and cardiovascular diseases(the main cause of mortality in the population).

Epidemiology

In industrialized countries, morbid obesity affects from 2 to 6% of the population, which is 1,700,000 people on the planet; Two-thirds of the US population is overweight, with every fifth adult and every seventh teenager morbidly obese. Obesity is the cause of death for more than 700,000 people in the US and 1,000,000 in Europe each year. In the structure of mortality in Europeans, 13% of cases are associated with obesity.

Over the past 20 years, the incidence of obesity in Europe has tripled, and currently approximately half of adults and one in five children are overweight. Compared to the situation in 1970, the incidence of obesity among children has increased 10 times.

Obesity classification

BMI = weight (kg)/height 2 (m2).

Principles of obesity treatment

On early stages the development of obesity (with a BMI up to 35 kg/m2) is used conservative methods treatment(diet therapy, psychotherapy, prescription physical exercise, drug treatment), but they do not always restrain the progression of the disease and provide a sustainable result.

The principles of rational nutrition and diet therapy for obesity are clearly defined, but most patients are unable to radical change lifestyle:

• lifelong introduction of strict self-restraint in food;
• systematic monitoring of the energy content of the diet;
• increasing physical activity.

Treatment of obesity as a lifelong disease involves solving a dual problem:effective and clinical significant reduction body weight at the first stage and maintaining the result throughout life, which is the most difficult. It was previously shown that for obesity with a BMI of more than 35-40 kg/m2, conservative treatment methods are ineffective in the long term: 90-95% of patients restore body weight to the previous level within the first year.

Surgery

In order to reduce body weight in 1953, V. Henriksson (Sweden) treated two patients resection of a large area small intestine .

Due to the irreversible nature of changes in the intestinal tract, this operation has not become widespread. In the 1960s-1970s it was common jejunoileobypass surgery. Due to a sharp decrease in the absorptive surface of the small intestine after surgery, significant sustained loss of body weight was observed, and effective correction hypercholesterolemia. At the same time, the study of long-term results showed that they were achieved at the cost of severe disturbances in water-electrolyte balance, hypoproteinemia, liver failure, nephrolithiasis and polyarthralgia due to anaerobic bypass enteritis in the small intestine excluded from passage. Currently, jejunoileal shunting is used extremely rarely.

Various modifications should be considered as a historically passed stage horizontal gastroplasty, which were popular in the 1980s. Their essence boiled down to transverse (horizontal) suturing of the stomach using a stapler, leaving a narrow exit from its small part to the larger one. Due to the insufficient and unstable effect, as well as due to the relatively high frequency late complications and reoperations over time, the number of supporters of vertical gastroplasty and unregulated gastric banding has significantly decreased.

BMI indicators for women

• less than 19- Underweight
• 19 - 24 - Normal body weight
• 24 - 30 - Excess body weight
• 30 - 40 - Obesity
• above 40- Severe obesity

BMI indicators for men

• less than 20- Underweight
• 20 - 25 - Normal body weight
• 25 - 30 - Excess body weight
• 30 - 40 - Obesity
• above 40- Severe obesity

Body mass index or, for short, BMI- this is an approximate value that allows you to indirectly judge whether a person is overweight or obese.

It is useful for every person to know whether he is overweight. Women who are “always losing weight” are especially susceptible to this issue. Often, even slender ladies dream of losing a few kilograms, but they focus only on fashion, and not on the advice of medical specialists.

Even coveted ideal figure may not be so ideal for a particular person. Because the concept of normal depends on height, age, physique (asthenic, hypersthenic or normosthenic), as well as on the speed of metabolic processes in the body.

To decide once and for all for yourself main question“Do I need to lose weight or can I wait a little longer?” We recommend knowing your personal indicator - body mass index.

The formula for determining BMI was proposed by mid-19th century sociologist and statistician Adolf Ketele, and the mathematical expression of body mass index is as follows: a person's body weight in kilograms divided by the square of height in meters.

Despite the fact that there are a large number of methods for assessing body weight and excess fat mass (including Broca’s formula, Lorenz’s formula, formulas for determining fat content, etc.), it is the BMI value that is by far the most indicative and reliable in medically. If you know your body mass index, you can clearly assess your own health risks and susceptibility to obesity-related diseases.

If the BMI value is in the range 16-18.49 , this means that there is a deficiency of body weight and dietary adjustments are necessary to gain weight.

Normal body mass indexes are 18.5-25 for women And 25-27 for men. People with such BMI values, according to statistics, have the longest life expectancy and a much lower risk of developing many serious diseases.

Slight excess normal values BMI with minimal risk for good health - from 25 to 30. If your values ​​are in this range, it is worth paying extra attention to physical activity and developing habits healthy nutrition. With age (after 30-40 years), weight invariably increases for all people, so try not to gain weight anymore or at least slow down the rate of weight gain.

If the body mass index is more than 30, this is classified as one of the stages. This condition requires immediate measures to reduce body weight under the supervision of a nutritionist or endocrinologist. To more accurately determine the degree of obesity, additional methods and tests for determining body fat content will be required.

It is worth keeping in mind that this formula for determining normal weight is not suitable for professional athletes with developed muscles. Calculation using this formula can show them one of the stages of obesity, since it does not take into account the actual fat content in the body.

Another reason why the body mass index may be unreasonably high is edema or concomitant diseases in which water accumulates in the body.

Obesity(lat. adipositas- literally: “obesity” and lat. obesitas- literally: fullness, obesity, fatness) - fat deposition, increase in body weight due to adipose tissue. Adipose tissue can be deposited both in places of physiological deposits and in the area of ​​the mammary glands, hips, and abdomen.

Obesity is divided into degrees (based on the amount of adipose tissue) and types (depending on the reasons that led to its development). Obesity leads to increased risk the occurrence of diabetes mellitus, hypertension and other diseases associated with the presence overweight. The causes of excess weight also affect the distribution of adipose tissue, the characteristics of adipose tissue (softness, elasticity, percentage of fluid content), as well as the presence or absence of skin changes (stretch marks, enlarged pores, so-called “cellulite”).

What Causes Obesity:

Obesity can develop as a result of:

• imbalance between food intake and energy expended, that is, increased food intake and decreased energy expenditure;
• obesity not an endocrine pathology appears due to disorders in the pancreas, liver, small and large intestines;
• genetic disorders.

Predisposing factors for obesity

• Sedentary lifestyle
• Genetic factors, in particular:
  • Increased activity lipogenesis enzymes
  • Decreased activity of lipolysis enzymes
• Increased consumption of easily digestible carbohydrates:
  • drinking sugary drinks
  • diet rich in sugars
• Certain diseases, in particular endocrine diseases (hypogonadism, hypothyroidism, insulinoma)
• Eating disorders (for example, binge eating disorder), in Russian literature called eating disorders psychological disorder leading to eating disorders
• Tendency to stress
• Lack of sleep
• Psychotropic drugs

In the process of evolution, the human body has adapted to accumulate a supply of nutrients in conditions of abundance of food in order to spend this supply in conditions of a forced absence or limitation of food - a kind of evolutionary advantage that allowed it to survive. In ancient times, being plump was considered a sign of well-being, prosperity, fertility and health. An example is the sculpture “Venus of Willendorf”, dated to the 22nd millennium BC. e. (possibly the earliest known illustration of obesity).

Viruses

Infection of humans with adenovirus-36 (Ad-36) (long thought to be the causative agent of respiratory and eye diseases) converts mature adipose tissue stem cells into fat cells; Moreover, those cells in which the virus was not detected remained unchanged.

Pathogenesis (what happens?) during Obesity:

Regulation of the deposition and mobilization of fat from fat depots is carried out by a complex neurohormonal mechanism (cerebral cortex, subcortical formations, sympathetic and parasympathetic nervous system, as well as endocrine glands). The main role in the pathogenesis of obesity is played by dysfunction of the central nervous mechanisms - cortex brain and hypothalamus (hypothalamus), where the centers that regulate appetite are located. Violation of coordination between energy expenditure and appetite, which determines the supply of energy material and the intensity of metabolic processes, causes the accumulation of fat. Apparently, the functional state of the centers that regulate eating behavior may have congenital characteristics or acquired (brought up) from childhood in connection with the family lifestyle, the nature of nutrition, etc. Disorders functional state hypothalamic centers that regulate appetite may also be a consequence inflammatory process or injuries accompanied by damage to the hypothalamus.

The pathogenesis of obesity cannot be ignored endocrine organs and above all the pituitary gland, adrenal glands, islet apparatus of the pancreas, thyroid and gonads.

An increase in the functional activity of the pituitary gland - adrenal cortex system and the pancreatic insular apparatus promotes the accumulation of fat in fat depots. A decrease in the somatotropic activity of the adenohypophysis, accompanied by a weakening of the processes of fat mobilization from the depot and its subsequent oxidation in the liver, also acts as a pathogenetic factor, especially in the nutritional-constitutional form of obesity. Plays a certain pathogenetic role in hypothalamic-pituitary obesity thyroid(due to a lack of thyroid hormones, the release of fat from fat depots and its oxidation in the liver is inhibited).

Reduced formation of adrenaline - an active lipolytic factor - has essential in reducing the mobilization of fat and is one of the pathogenetic factors of obesity. The role of the gonads in the pathogenesis of primary obesity has not been sufficiently studied.

Symptoms of Obesity:

Clinical manifestations different types obesity are basically similar. There are differences in the distribution of excess fat in the body and in the presence or absence of symptoms of nervous or endocrine system damage.

Most common nutritional obesity, usually in individuals with a hereditary predisposition to obesity. It develops in cases where the calorie content of food exceeds the body's energy expenditure, and is usually observed in several members of the same family. This type of obesity often affects middle-aged and elderly women who lead a sedentary lifestyle. When collecting anamnesis with detailed clarification daily ration It is usually established that patients systematically overeat. For nutritional obesity characterized by a gradual increase in body weight. Subcutaneous adipose tissue is distributed evenly, sometimes in to a greater extent accumulates in the abdomen and thighs. There are no signs of damage to the endocrine glands.

Hypothalamic obesity observed in diseases of the central nervous system with damage to the hypothalamus (tumors, as a result of injuries, infections). This type of obesity is characterized by the rapid development of obesity. Fat deposition is observed mainly on the abdomen (in the form of an apron), buttocks, and thighs. Trophic changes in the skin often occur: dryness, white or pink stretch marks (striae). By clinical symptoms(For example, headache, sleep disorders) and data neurological examination The patient can usually be diagnosed with brain pathology. As a manifestation of hypothalamic disorders, various signs are observed along with obesity autonomic dysfunction- increased blood pressure, sweating disorders, etc.

Endocrine obesity develops in patients with certain endocrine diseases(for example, hypothyroidism, Itsenko-Cushing's disease), the symptoms of which predominate in clinical picture. Upon examination, along with obesity, which is usually characterized by uneven deposition of fat on the body, other signs of hormonal disorders are revealed (for example, masculinization or feminization, gynecomastia, hirsutism), and stretch marks are found on the skin.

A peculiar type of obesity is the so-called painful lipomatosis(Dercum's disease), which is characterized by the presence of fatty nodes that are painful on palpation.

In patients obesity of II-IV degrees changes are noted from of cardio-vascular system, lungs, digestive organs. Tachycardia, muffled heart sounds, and increased blood pressure are often observed. Sometimes respiratory failure and chronic cor pulmonale develop due to the high position of the diaphragm. Most obese patients have a tendency to constipation, the liver is enlarged due to fatty infiltration of its parenchyma, symptoms are often detected chronic cholecystitis and pancreatitis. There is pain in the lower back, arthrosis of the knee and ankle joints. Obesity is also accompanied by menstrual irregularities, and amenorrhea is possible. Obesity is a risk factor for the development of diabetes mellitus, atherosclerosis, hypertension, and coronary heart disease, with which it is often combined.

Obesity in children, as in adults, develops against the background hereditary characteristics or due to acquired metabolic and energy disorders. Obesity is most often observed in the 1st year of life and at 10-15 years. As in adults, exogenous constitutional obesity is more common in children, which is based on a hereditary (constitutional) predisposition to excess fat deposition, often combined with family tendencies to overeat and overfeed children. Excessive fat deposition usually begins as early as the 1st year of life and is not equally common in boys and girls. Girls are born with more developed subcutaneous adipose tissue than boys; This difference increases with age, reaching a maximum in adults, and causes a higher incidence of obesity in girls and women.

Children 10-15 years old have the most common cause obesity is hypothalamic syndrome puberty, which is characterized by the appearance of thin stretch marks on the skin of the thighs, mammary glands, buttocks, inner surface shoulders There is, as a rule, a transient increase in blood pressure; in some cases there are signs of increased intracranial pressure. Less commonly, the cause of hypothalamic obesity in children is the consequences of traumatic brain injury or neuroinfection.

Diagnosis of Obesity:

Most commonly used diagnostic criterion obesity is the definition of excess total body weight in relation to the norm established statistically. However, to determine the severity of the disease, it is not so much the excess total body weight that is important, but the excess mass of adipose tissue, which can differ significantly even among individuals of the same age, height and body weight. In this regard, the development and introduction into the clinic of diagnostic techniques for determining body composition and specifically fat mass is quite relevant.

The starting point for determining the degree of obesity is the concept of normal body weight. Normal body weight is determined using special tables taking into account gender, height, body type and age and is average size corresponding to each group.

Along with the concept of normal body weight, the concept of ideal body weight is of significant importance in the clinic. This indicator was developed at the request of health insurance companies and was supposed to determine at what body weight insured events (illness or death) are least likely. It turned out that the body weight at which life expectancy is maximum is approximately 10% less than normal body weight. Ideal body weight is determined taking into account the human constitution (normosthenic, asthenic and hypersthenic). Exceeding this indicator is considered overweight. We speak of obesity in cases where excess body weight is more than 10%.

A number of methods have been proposed to calculate ideal body weight. The simplest formula was proposed by the anthropologist and surgeon Broca (1868):

Mi = P- 100 ,

Where Mi- ideal body weight, kg, R- height, cm

Depending on the value of this indicator, 4 degrees of obesity are distinguished: 1st degree of obesity corresponds to excess of ideal body weight by 15-29%, 2nd degree - by 30-49%, 3rd - by 50-99%, 4- I am more than 100%.

Currently, the most widely used indicator of obesity is the body mass index (BMI), or Quetelet index:

BMI = Body weight (kg) / height (m2).

It is believed that for people aged 20-55 years old with height close to average (men - 168-188 cm, women - 154-174 cm), BMI quite accurately reflects the situation. Most studies examining the relationship of body weight with morbidity and mortality confirm that the maximum acceptable body weight corresponds to a BMI of 25 kg/m2.

Classification of excess mbody assemblies in adults depending on BMI (WHO report, 1998)

Measurement of waist and hip circumference. Big clinical significance has not only the severity of obesity, but also the distribution of fat. It must be determined primarily in patients with average overweight, since it does not take into account BMI. It is believed that the risk of complications in obesity largely depends not on excess body weight, but on the localization of adipose tissue deposits. The amount of visceral fat can be measured using MRI. However, a simpler and fairly accurate criterion reflecting the distribution of fat is the ratio of the circumference of the waist and hips (WHR).

Measurement of WTB is important in determining body fat deposition, which is of particular importance in assessing disease risk. Depending on the distribution of fat, there are two types of obesity: android and ganoid. Android, or apple-shaped obesity, refers to the distribution of fat around the waist. The deposition of fat around the buttocks and thighs is known as hypoid, or pear-shaped obesity. In the case of android fat distribution, the likelihood of morbidity and mortality is higher than in the ganoid type. When the bulk of fat is deposited on the torso and abdominal cavity, the likelihood of complications associated with obesity (hypertension, ischemic disease heart, diabetes mellitus type 2). It is believed that normally in women the TTB does not exceed 0.8, and in men - 1; the excess of these parameters is associated with metabolic disorders. If the waist circumference in men reaches 102 cm, and in women - 88 cm, in this case there is a serious risk of increasing the risk of morbidity and weight loss should be recommended (Table 40.3).

Determination of overweight and obesity by waist circumference (cm)

Obesity Treatment:

The main methods of treatment for overweight and obesity

• These include following a diet high in fiber, vitamins and other biologically active ingredients(cereals and whole grain products, vegetables, fruits, nuts, herbs, etc.) and limiting the consumption of carbohydrates that are easily digestible by the body (sugar, sweets, baked goods, baked goods and pasta made from premium flour), as well as physical exercise.
• General approach for drug treatment Obesity consists of testing all known drugs for the treatment of obesity. For this purpose, drugs are used to treat obesity.
• If the result drug treatment turns out to be insignificant or absent, then it is necessary to stop such treatment.

Then the question of surgical treatment is considered. Liposuction, an operation during which fat cells are sucked out, is currently not used to combat obesity, but only for the cosmetic correction of local small fat deposits. Although the amount of fat and body weight may decrease after liposuction, according to a recent study by British doctors, such an operation is useless for health. Apparently, it is not the subcutaneous, but the visceral fat, located in the oil seal, as well as around internal organs located in the abdominal cavity. Previously, isolated attempts were made to perform liposuction for weight loss (the so-called megaliposuction with the removal of up to 10 kg of fat), but at present it is considered extremely harmful and dangerous procedure, which inevitably gives many serious complications and leads to serious cosmetic problems in the form of uneven surface of the body.

Diets often increase obesity. The reason is that a crash diet (a sharp reduction in calorie intake) can help you lose weight quickly, but after stopping the diet, your appetite increases, your food digestibility improves, and you gain weight beyond what you had before the diet. If an obese patient tries to lose weight again using a strict diet, each time losing weight becomes more and more difficult, and gaining weight becomes easier, and the weight gained increases each time. Therefore, diets focused on quick results (losing as much weight as possible in a short time) are a harmful and dangerous practice. In addition, many weight loss products contain diuretics and laxatives, which leads to water loss rather than fat loss. Losing water is useless for combating obesity, is harmful to health, and weight is restored after stopping the diet.

Moreover, according to a study by American psychologist Tracy Mann and her colleagues, diets are generally useless as a means of combating obesity.

However, it should be noted that without adequate control of the caloric content of food and taking into account the adequacy of the amount of incoming calories physical activity successful treatment obesity is impossible. For successful weight loss, WHO recommends calculating usual calorie content food, and then reduce calorie content by 500 kcal monthly until a figure is 300-500 kcal below adequate energy requirements. For persons not engaged in active physical labor, this value is 1500-2000 kcal.

Surgical treatment of morbid obesity

As it was found out based on long-term studies, the maximum effect in the treatment of obesity has surgery(bariatric surgery). Only surgical treatment makes it possible to solve this problem completely. Currently, there are mainly two types of surgery used in the world for obesity. In the USA and Canada, gastric bypass surgery is used in the form of Roux-en-Y gastric bypass (90% of all operations). It makes it possible to get rid of 70-80% of excess weight. In Europe and Australia, adjustable gastric banding dominates (90% of all operations), which makes it possible to get rid of 50-60% of excess weight.

Currently, all bariatric surgeries are performed laparoscopically (that is, without an incision, through punctures) under the control of a miniature optical system.

Surgical treatment of obesity has strict indications; it is not intended for those who believe that they are simply overweight. It is believed that indications for surgical treatment of obesity arise with a BMI above 40. However, if the patient has problems such as type 2 diabetes mellitus, hypertension, varicose veins and problems with leg joints, indications arise already at a BMI of 35. IN Lately In the international literature, studies appear that study the effectiveness of gastric banding in patients with a BMI of 30 and above.

Prevention of Obesity:

Obesity prevention consists in eliminating physical inactivity and rational nutrition. In children, compliance with feeding rules and regular monitoring is necessary. physical development child by systematically measuring height and body weight (especially with a constitutional predisposition to obesity). Important early detection and treatment of diseases accompanied by hypothalamic and endocrine obesity.