Obesity

Obesity is excess fat deposits in subcutaneous tissue, organs and tissues. It is manifested by an increase in body weight by 20 percent or more of the average values due to adipose tissue. It causes psycho-physical discomfort, causes sexual disorders, diseases of the spine and joints. Increases the risk of atherosclerosis, coronary heart disease, hypertension, myocardial infarction, stroke, diabetes mellitus, kidney and liver damage, as well as disability and mortality from these diseases. The most effective in the treatment of obesity is the combined use of 3 components: diet, physical activity and the corresponding psychological adjustment of the patient.

ICD 10

E66 Obesity

Meaning

According to WHO international experts, obesity is a global epidemic of our time, covering millions of inhabitants of the planet, regardless of professional, social, national, geographical, gender and age groups. In the United States, up to 30% of the working-age population are obese and another 25% are overweight. Women are subject to the development of obesity twice as often as men, the critical age for the appearance of excess weight is from 30 to 60 years.

Obese patients are 2-3 times more likely to suffer from hypertension, 3-4 times – angina pectoris and coronary heart disease than people with normal weight. Almost any diseases, even such as acute respiratory viral infections, influenza and pneumonia, in obese patients, are longer and more severe, have a higher percentage of complications.

Causes

The development of obesity is most often caused by a violation of the balance between the intake of energy from food and the energy costs of the body. Excess calories that have entered the body and are not consumed by it are converted into fat, which accumulates in the body’s fat depots (mainly in subcutaneous tissue, omentum, abdominal wall, internal organs, etc.). An increase in fat reserves leads to an increase in body weight and disruption of the functioning of many body systems. Overeating leads to obesity in more than 90%, and about 5% of cases of obesity are caused by a metabolic disorder.

A number of factors contribute to the development of obesity:

• a low-activity lifestyle;
• genetically determined disorders of enzymatic activity (increased activity of lipogenesis enzymes and decreased activity of cranial brain injuries of enzymes that break down fats (lipolysis);
• errors in the nature and diet (excessive consumption of carbohydrates, fats, salt, sweet and alcoholic beverages, eating at night, etc.);
• some endocrine pathologies (hypothyroidism, hypogonadism, insulinoma, Cushing’s disease);
• psychogenic overeating;
• physiological conditions (lactation, pregnancy, menopause);
• stress, lack of sleep, taking psychotropic and hormonal drugs (steroids, insulin, birth control pills), etc.

Pathogenesis

Changes in eating behavior occur as a result of a violation of the hypothalamic-pituitary regulation responsible for controlling behavioral reactions. An increase in the activity of the hypothalamic-pituitary-adrenal system leads to an increase in the production of ACTH, the rate of cortisol secretion and acceleration of its metabolism. There is a decrease in the secretion of somatotropic hormone, which has a lipolytic effect, hyperinsulinemia develops, a violation of thyroid hormone metabolism and tissue sensitivity to them.

Classification

In 1997 The World Health Organization has proposed a classification of degrees of obesity based on the definition of an indicator – body mass index (BMI) for people aged 18 to 65 years. BMI is calculated by the formula: weight in kg / height in meters squared. According to BMI, the following variants of body weight and the risk of developing concomitant complications are distinguished:

• BMI from 18.5 to 24.9 (normal) – corresponds to the normal body weight. With such a BMI, the lowest morbidity and mortality rates are noted;
• BMI from 25.0 to 29.9 (elevated) – indicates excess body weight or obesity.
• BMI from 30.0 to 34.9 (high) – corresponds to the I degree of obesity;
• BMI from 35.0 to 39.9 (very high) – corresponds to the II degree of obesity;
• BMI of 40 or more (excessively high) indicates obesity of the III and IV degrees.

A BMI of 30 or more indicates the presence of obesity and a direct threat to health, requires a medical examination and the development of an individual treatment regimen. By comparing the actual and ideal body weight, obesity is divided into 4 degrees:

1. I – excess weight is no more than 29%
2. II – characterized by an excess of weight by 30-40%
3. III – by 50-99%
4. IV – increase in the actual body weight compared to the ideal by 2 or more times. The calculation of the ideal body weight is carried out according to the formula: “height, cm – 100”.

According to the predominant localization of fat deposits on the body , the following types of obesity are distinguished:

1. Abdominal (upper or android) – excessive deposition of adipose tissue in the upper half of the trunk and abdomen (the figure resembles an apple in shape). It develops more often in men and is most dangerous to health, because it is associated with the risk of hypertension, diabetes mellitus, stroke and heart attack.
2. Femoral-gluteal (lower) – predominant deposition of adipose tissue in the hips and buttocks (the figure resembles a pear in shape). It is more common in women and is accompanied by impaired functions of the joints, spine, venous insufficiency.
3. Intermediate (mixed) – uniform distribution of body fat deposits.

Obesity can be progressive in nature with an increase in the volume of fat deposits and a gradual increase in body weight, be in stable or residual (residual after weight loss) stages. According to the mechanism and causes of development, obesity can be primary (alimentary-metabolic or exogenous-constitutional, or simple), secondary (hypothalamic or symptomatic) and endocrine.

1. The basis of the development of primary obesity is an exogenous, or alimentary factor associated with increased energy value of the diet at low energy consumption, which leads to the accumulation of fat deposits. This type of obesity develops as a result of the predominance of carbohydrates and animal fats in food or a violation of the regime and composition of nutrition (abundant and rare food, consumption of the main daily calorie content of food in the evening) and often has a family predisposition. Calories contained in fats contribute more to weight gain than those contained in proteins and carbohydrates. If the fats coming from food exceed the possibilities of their oxidation in the body, then excess fat accumulates in fat depots. Physical inactivity significantly reduces the ability of muscles to oxidize fats.
2. Secondary obesity accompanies such hereditary syndromes as Babinsky-Froelich disease, Gelino syndrome, Lawrence-Moon-Bardet-Bidl syndrome, etc. Also, symptomatic obesity can develop against the background of various cerebral lesions: brain tumors, dissemination of systemic lesions, infectious diseases, mental disorders, traumatic brain injuries.
3. The endocrine type of obesity develops in the pathology of the endocrine glands: hypothyroidism, hypercorticism, hyperinsulinism, hypogonadism. With all types of obesity, hypothalamic disorders are noted to one degree or another, which are either primary or arising in the course of the disease.

Symptoms

A specific symptom of obesity is overweight. Excess fat deposits are found on the shoulders, abdomen, back, sides of the trunk, back of the head, hips, in the pelvic region, while there is an underdevelopment of the muscular system. The appearance of the patient changes: a second chin appears, pseudogynecomastia develops, fat folds hang in the form of an apron on the abdomen, the hips take the form of breeches. Umbilical and inguinal hernias are typical.

Patients with grade I and II obesity may not make any special complaints, with more pronounced obesity, drowsiness, weakness, sweating, irritability, nervousness, shortness of breath, nausea, constipation, peripheral edema, pain in the spine and joints are noted.

Patients with obesity of the III—IV degree develop disorders of the cardiovascular, respiratory, and digestive systems. Hypertension, tachycardia, and deaf heart tones are objectively detected. The high standing of the diaphragm dome leads to the development of respiratory failure and chronic pulmonary heart. There is fatty infiltration of the liver parenchyma, chronic cholecystitis and pancreatitis. There are pains in the spine, symptoms of arthrosis of the ankle and knee joints.

Obesity is often accompanied by menstrual disorders, up to the development of amenorrhea. Increased sweating causes the development of skin diseases (eczema, pyoderma, furunculosis), the appearance of acne, striae on the abdomen, hips, shoulders, hyperpigmentation of the elbows, neck, places of increased friction.

Alimentary obesity

Obesity of various types has similar general symptoms, differences are observed in the nature of fat distribution and the presence or absence of signs of damage to the endocrine or nervous systems. With alimentary obesity, body weight increases gradually, fat deposits are uniform, sometimes predominate in the hips and abdomen. There are no symptoms of damage to the endocrine glands.

Hypothalamic obesity

With hypothalamic obesity, obesity develops rapidly, with predominant fat deposition on the abdomen, thighs, buttocks. There is an increase in appetite, especially in the evening, thirst, night hunger, dizziness, tremor. Trophic skin disorders are characteristic: pink or white striae (stretch marks), dry skin. Women may develop hirsutism, infertility, menstrual disorders, and men – deterioration of potency. Neurological dysfunction occurs: headaches, sleep disorders; vegetative disorders: sweating, arterial hypertension.

Endocrine obesity

The endocrine form of obesity is characterized by the predominance of symptoms of major diseases caused by hormonal disorders. The distribution of fat is usually uneven, there are signs of feminization or masculinization, hirsutism, gynecomastia, skin striae. A peculiar form of obesity is lipomatosis – benign hyperplasia of adipose tissue. It is manifested by numerous symmetrical painless lipomas, more often observed in men. There are also painful lipomas (Derkum lipomatosis), which are located on the limbs and trunk, painful on palpation and accompanied by general weakness and local itching.

Complications

In addition to psychological problems, almost all obese patients suffer from one or a number of syndromes or diseases caused by overweight, from the:

• cardiovascular system: coronary artery disease, arterial hypertension, angina pectoris, heart failure, stroke;
• metabolic processes: type 2 diabetes mellitus;
• digestive system: cholelithiasis, liver cirrhosis, chronic heartburn;
• sleep apnea syndrome;
• musculoskeletal system: arthritis, osteoarthritis, osteochondrosis;
• of reproductive organs: polycystic ovary syndrome, decreased fertility, libido, menstrual dysfunction, etc.

Obesity increases the likelihood of breast, ovarian and uterine cancer in women, prostate cancer in men, colon cancer. There is also an increased risk of sudden death against the background of existing complications. The mortality rate of men aged 15 to 69 years with an actual body weight exceeding the ideal by 20% is one third higher than that of men with normal weight.

Diagnostics

When examining patients with obesity, attention is paid to the anamnesis, family predisposition, find out the indicators of minimum and maximum weight after 20 years, the duration of obesity, the activities carried out, the patient’s eating habits and lifestyle, the existing diseases. To determine the presence and degree of obesity, the method of determining the body mass index (BMI), ideal body weight (Mi) is used.

The nature of the distribution of adipose tissue on the body is determined by calculating a coefficient equal to the ratio of the waist circumference (FROM) to the hip circumference (ABOUT). The presence of abdominal obesity is indicated by a coefficient exceeding 0.8 for women and 1 for men. It is believed that the risk of developing concomitant diseases is high in men with a height of > 102 cm and in women with a height of > 88 cm. To assess the degree of deposition of subcutaneous fat, the size of the skin fold is determined.

The most accurate results of determining the localization, volume and percentage of adipose tissue from the total body weight are obtained using auxiliary methods: ultrasound, nuclear magnetic resonance, computed tomography, X-ray densitometry, etc. In case of obesity, patients need consultations with a psychologist, a nutritionist and a physical therapy instructor.

To identify changes caused by obesity, determine:

• blood pressure indicators (to detect hypertension);
• hypoglycemic profile and glucose tolerance test (to detect type II diabetes mellitus);
• the level of triglycerides, cholesterol, low and high density lipoproteins (to assess lipid metabolism disorders);
• changes in ECG and EchoCG (to detect disorders of the circulatory system and heart);
• the level of uric acid in the biochemical blood test (to detect hyperuremia).

Treatment

Every obese person may have their own motivation for weight loss: cosmetic effect, reduction of health risks, improvement of performance, desire to wear smaller clothes, desire to look good. However, the goals regarding weight loss and its rate should be real and aimed primarily at reducing the risk of complications associated with obesity. The treatment of obesity begins with the appointment of a diet and exercise.

Diet therapy

If a hypocaloric diet is followed, there is a decrease in basal metabolism and energy conservation, which reduces the effectiveness of diet therapy. Therefore, a hypocaloric diet should be combined with physical exercises that increase the processes of basal metabolism and fat metabolism. The appointment of therapeutic fasting is indicated for patients who are on inpatient treatment, with a pronounced degree of obesity for a short period of time.

Drug therapy

Medical treatment of obesity is prescribed with a BMI > 30 or an ineffective diet for 12 or more weeks. The action of drugs of the amphetamine group (dexafenfluramine, amphepramone, phentermine) is based on the inhibition of hunger, acceleration of saturation, anorectic effect. However, side effects are possible: nausea, dry mouth, insomnia, irritability, allergic reactions, addiction.

In some cases, it is effective to prescribe the fat-immobilizing drug adiposine, as well as the antidepressant fluoxetine, which changes eating behavior. The drugs sibutramine and orlistat, which do not cause pronounced adverse reactions and addiction, are considered the most preferred today in the treatment of obesity. The effect of sibutramine is based on accelerating the onset of satiety and reducing the amount of food consumed. Orlistat reduces the absorption of fats in the intestine. In case of obesity, symptomatic therapy of the main and concomitant diseases is carried out. In the treatment of obesity, the role of psychotherapy (conversations, hypnosis) is high, changing the stereotypes of developed eating behavior and lifestyle.

Surgical treatment

Methods of bariatric surgery – surgical treatment of obesity are used in cases of persistent weight retention with a BMI > 40. In world practice, vertical gastroplasty, gastric banding and gastric bypass surgery are most often performed. An innovative minimally invasive method of treating morbid obesity is embolization of the left gastric artery. Six months after the operation, weight loss is achieved by an average of 20%. As a cosmetic measure, local removal of fat deposits is carried out – liposuction.

Prognosis and prevention

Timely systematic measures for the treatment of obesity are bringing good results. Even with a decrease in body weight by 10%, the total mortality rate decreases by > more than 20%; mortality caused by diabetes, > more than 30%; caused by concomitant obesity oncological diseases, > more than 40%. Patients with I and II degree of obesity remain able to work; with III degree – receive group III disability, and in the presence of cardiovascular complications – group II disability.

To prevent obesity, it is enough for a person with a normal weight to spend calories and energy as much as he receives them during the day. With a hereditary predisposition to obesity, after the age of 40, with physical inactivity, it is necessary to limit the consumption of carbohydrates, fats, an increase in the diet of protein and plant foods. Reasonable physical activity is necessary: walking, swimming, running, visiting gyms. If there is dissatisfaction with your own weight, in order to reduce it, you need to contact an endocrinologist and a nutritionist to assess the degree of violations and draw up an individual weight loss program.