Method of choosing delivery in pregnant women with large fetuses. What is nutritional obesity: possible causes of the disease and effective treatment methods Childbirth with obesity and prevention of the disease

Obesity is the increased deposition of fat in the body, leading to excess weight. Obesity is distinguished as an independent suffering (alimentary obesity) and as a symptom of other diseases (for example, damage to the central nervous system and endocrine glands). Sometimes obesity is accompanied by the development of painful nodular tumors () - the so-called Dercum's disease.

Obesity often occurs between the ages of 50 and 60 and is rare in younger people. More than half of all cases of obesity are attributed to nutritional obesity associated with poor nutrition. Excessive nutrition with predominant consumption of fats and fats, large meals before bed, abuse of high-calorie foods (chocolate, sweets, cakes) lead to increased formation and deposition of fat in the body. Lack of proper physical activity also contributes to the development of obesity. Hereditary and constitutional factors also play a certain role.

There are four degrees of obesity: 1 degree - (see) exceeds normal by no more than 29%; 2nd degree - from 30 to 49%; 3 - from 50 to 99%; 4 - 100% or more. In patients with grade 1 and 2 obesity, it is usually not limited.

Nutritional obesity 3rd degree.

The clinical picture depends mainly on the degree of obesity and the presence of concomitant diseases. The most common complaints: general weakness, fatigue, weakened memory, etc. An objective examination reveals white stripes similar to the “stretch marks” of pregnant women in the areas of greatest fat deposition. The skin tends to have high humidity. Sometimes the skin with subcutaneous fatty tissue on the abdomen hangs down in the form of an apron (Fig.). With high degrees of obesity due to impaired water-salt metabolism, moderate pain and limited joint mobility and changes in configuration may be observed. As a result of the high standing of the diaphragm, the vital capacity of the lungs decreases and the phenomena of respiratory failure develop. Obese patients are more susceptible to lung diseases. From the cardiovascular system, myocardial dystrophy and vascular atherosclerosis are the most common. An increase or decrease in gastric secretion, as well as a weakening of intestinal motor function, leading to constipation, are often observed.

A common complication of obesity are gallstones and kidney stones. Women often have.

The diagnosis of nutritional obesity is made on the basis of a statement of excess weight, characteristic complaints, taking into account family and hereditary factors, profession, lifestyle, nutrition, etc.

Differential diagnosis should be carried out with Itsenko-Cushing's disease (see) and hypothyroidism (see).

Drugs that reduce appetite (desopimon, Avicol, etc.) can only be prescribed with careful medical supervision.

In the absence of contraindications from the cardiovascular system, it is indicated. Therapeutic gymnastics is carried out for 20-60 minutes.

In classes, you should use exercises that have a maximum range of motion involving large muscle groups. It is recommended to perform the exercises in various positions (lying, sitting, etc.).

The daily routine is of great importance. In the morning you should do hygienic exercises (15-20 minutes) or take a walk (30-90 minutes) followed by water procedures (shower, wiping). It is useful to combine hygienic gymnastics with various sports (volleyball, badminton, etc.), as well as water treatments and massage.

Prevention - rational and sufficient physical activity (physical education, tourism, etc.).

Obesity (adipositas; synonymous with nutritional obesity) is the deposition of fat in the body in an amount exceeding its deposition in healthy individuals. Obesity as a separate nosological unit includes all cases in which excessive fat deposition is not a consequence of some other disease (for example, Itsenko-Cushing syndrome, hypothyroidism, etc.), but a major pathological disorder with an unidentified primary lesion of any organ or organ systems.

Obesity is relatively rare in young people, but there are indications of an increase in the incidence of obesity among young people. Obesity is most common between the ages of 50-59 years. At older ages, its frequency decreases. The maximum weight described in the literature reached 268 kg. The high prevalence of obesity and the reduction in life expectancy in overweight people compared to people of normal weight makes the problem of obesity one of the most important public health problems. Sometimes, against the background of existing obesity, painful diffuse formations or nodular tumors (lipomas) develop in the subcutaneous fat tissue, the so-called Dercum's disease, the etiology of which has not yet been established.

Etiology and pathogenesis. One of the essential components in the development of obesity is overeating. The etiological factors leading to overeating may be bad family habits (the habit of consuming excessive amounts of food since childhood). Obesity is often observed in people whose nature of work has changed (for example, when switching from physical work to administrative work) and, as a result, energy expenditure has decreased, but food consumption corresponding to the previous work has become firmly established in the stereotype and has been preserved, despite the decreased need for it. . Increased food consumption as one of the etiological factors is observed among food unit workers (cooks, etc.), who are faced with the need for frequent food samples. Increased food consumption also develops after mental trauma, after prolonged fasting. However, assigning these etiological factors an undoubted importance in the development of obesity in some people, it can be assumed that, along with this, they also had a violation of neurohormonal mechanisms that ensure, in a healthy person, a correspondence between calorie expenditure and intake and the retention of fat deposits and body weight within physiological limits .

Experimental data give grounds to assign significant importance to certain centers of the hypothalamus in the pathogenesis of obesity. It has been established that the destruction of the ventromedial nuclei of the hypothalamus causes gluttony and the development of severe obesity in animals. These nuclei of the hypothalamus are called “saturation centers.” The destruction of the lateral nuclei, located close to the ventromedial ones, causes, on the contrary, a decrease in the need for food and weight loss, which occurs even with the preliminary destruction of the ventromedial nuclei. Irritation of the lateral nuclei leads to an increased need for food. These lateral nuclei are called “appetite centers.” It is believed that the ventromedial and lateral nuclei are in a close functional relationship. Damage to the ventromedial nuclei in mice and the development of obesity can also be caused by the administration of aurothioglucose. There are indications of the influence of hypothalamic centers not only on the regulation of appetite, but also on changes in the production of growth hormone and on metabolic processes.

There are known cases of the development of obesity in people after encephalitis, brain tumors that occur with damage to the diencephalic region. It is possible that various etiological factors that lead to prolonged food intake in quantities that do not correspond to energy expenditure are associated with a violation of the functional state of the hypothalamic centers and the inability to regulate energy intake at the level of its consumption and maintain the normal chemical composition of various tissues and organs, including subcutaneous fat fiber. In a person with a well-functioning appetite regulation apparatus, reducing appetite would prevent overeating and help maintain weight within physiological limits.

Of undoubted importance in the genesis of obesity is a violation of the functional state of the cerebral cortex, which especially needs to be taken into account in the development of overeating and obesity as a result of the development and consolidation of bad habits and mental trauma. But the role of these cortical factors cannot be considered outside the close functional dependence of the cerebral cortex and the hypothalamus. Cortical influences in the genesis of overeating are likely to be largely realized through changes in the functional state of the centers of the hypothalamus. With the development of obesity as a result of mental factors, overeating in some patients is combined with a decrease in their physical activity.

There are indications that a change in the functional state of the centers that regulate appetite is due to the level of glucose utilization, which is indicated by a change in the arteriovenous difference in relation to glucose: an increase in this difference reduces appetite, and a decrease increases it. The utilization of other substances and their metabolites and changes in blood temperature are probably also important.

It is necessary to take into account the role of afferent nervous information from tissues about the state of metabolism and especially nerve receptors in them. Increased activity of the sympathoadrenal system enhances lipolysis processes. In changing the activity of this system, cortical influences and centers of the posterior hypothalamus may be important, the excitation of which increases the release of catecholamines. Changes in the state of the sympathetic ganglia must be taken into account in case of local disorders of fat deposition. The problem of the participation of pancreatic hormones and sex hormones in the development of obesity deserves further study.

Of the hormones, growth hormone and thyroid hormones have a lipolytic effect, which also enhances the lipolytic effect of catecholamines.

In the origin of obesity, the genetic factor is considered important, but its assessment is very difficult due to the presence in families where parents are overweight, incorrect dietary attitudes and overfeeding of children.

Pathological anatomy. In addition to excess fat deposits in places of its usual accumulation (subcutaneous fatty tissue, omentum, etc.), with more pronounced forms of obesity, growth of fatty tissue is observed in the epicardium, mesentery of the small intestines, retroperitoneal space, etc. In addition, fatty infiltration can be observed liver. A number of changes (atherosclerosis of various localizations, inflammatory processes of the biliary tract and the formation of stones in them, acute pancreatitis, etc.), often observed in obese people, are not specific to obesity, although they occur with it more often than usual.

Obesity levels according to M. N. Egorov (1965): 1st degree - excess weight up to 29% above normal; 11 - excess body weight from 30 to 49%; III - from 50 to 99% and IV degree - body weight is 100% or more above normal.

To determine normal weight, the main indicator is the ratio of height and body weight (see). To assess obesity, determination of the thickness of skin folds in several areas of the body (in the area of ​​the triceps brachii, subscapularis, thigh, abdomen, etc.) is also used.

Obesity is excess deposition of fat in the human body. Obesity as an endocrine syndrome occurs in the following diseases or conditions: with insulinoma, diffuse hyperplasia of the islets of Langerhans, in combination with diabetes mellitus, with chromophobe pituitary adenoma without damage to the hypothalamus, with Itsenko-Cushing's disease, with treatment with corticosteroids or adrenocorticotropic hormone, with disorders of the reproductive system ; eunuchoidism, post-castration syndrome, menopause, ovarian dysfunction, gynecomastia; with pseudohypoparathyroidism.

Obesity is one of the signs of adipose-genital-pituitary dystrophy and other hypothalamic syndromes, glycogenic disease, familial congenital absence of α-cells of the islets of Langerhans, Klein-Lewin syndrome, frontal hyperostosis, Moon-Laurens-Biedl-Bardet syndrome.

In all cases of obesity, it is necessary to treat the underlying disease, as well as resort to a low-calorie diet, stimulate mobility, activity, and reduce the number of hours of sleep. Medicines that increase basal metabolism and energy expenditure (thyroid drugs) should be recommended; diuretics and agents that suppress the reactivity of autonomic centers (reserpine).

Korovin method for determining obesity. An increase in the thickness of the base of the skin fold and subcutaneous fat layer in the epigastric region in men 18-50 years old over 2 cm indicates obesity, a decrease to 1 cm indicates exhaustion.

In the article we discuss grade 1 obesity. We will list the causes of excess weight gain, types, and stages of the disease. You will learn how to calculate BMI and recognize pathology in the initial stages. We will also pay attention to prevention methods and a special diet.

Obesity of the 1st degree is the accumulation of excess body weight in the form of subcutaneous fat. This pathology is diagnosed when weight increases by 20% of the average. According to medical statistics, women are susceptible to it 50% more often than the stronger sex. The peak development of pathology occurs between 30 and 60 years of age.

Treatment should include changes in eating behavior

The main reason for the formation of the disease is an imbalance between the amount of calories entering the body and their expenditure. Excess fat and carbohydrates are converted into fat cells, which are deposited in the subcutaneous layer.

Overeating and disordered eating behavior lead to nutritional obesity. Excessive, systematic consumption of large amounts of food provokes the replenishment of fat depots. The disease is also caused by impaired metabolism (5% of cases). At the same time, metabolism decreases and hormonal disturbances occur.

Weight gain can be triggered by a genetic predisposition or disruption of the endocrine system (insulinoma, hypothyroidism, Cushing's disease).

Disturbances in the functioning of the nervous system can also give impetus to the development of the disease: stress, depression, and insomnia cause psychological discomfort to “eat up.”

Types and stages of pathology

Based on the nature of fat deposits and their location, the following types of obesity are distinguished:

1. Femorogluteal— fat cells are formed mainly in the lower part of the body. This type is more common in women. The body takes on a pear shape. Accompanied by disturbances in the functioning of the veins of the lower extremities, joints, and spine.
2. Abdominal- characterized by accumulation of fat in the upper body. The abdominal area suffers the most. The figure takes on a spherical shape. This type of obesity is more common in men. The pathology is associated with the development of diabetes, stroke, and arterial hypertension.
3. Intermediate (mixed) type- characterized by an even distribution of fat deposits throughout the body.

Based on the rate of growth of the layer, a distinction is made between progressive and gradually increasing obesity. There are stable and residual stages of the disease. In the stable phase, primary weight gain occurs; in the residual phase, this is a consequence of sudden weight loss.

There are primary, secondary, endocrine types. Primary include pathologies caused by eating disorders, secondary include those based on genetic, hereditary diseases. The endocrine type is formed due to disruption of the endocrine glands.

How to calculate BMI

Body mass index (BMI) is used to classify the degree of obesity. To calculate it, you need to divide the patient's weight (kg) by the square of his height.

First signs and symptoms

The main symptom of the disease is a change in the patient’s appearance. Typical places for storing extra pounds are the stomach, thighs, buttocks, neck, and shoulders. Excess weight begins to cause dissatisfaction with one's own appearance among patients. Against this background, depressive disorders, increased irritability, and apathy often develop.

Due to the increased load on internal organs, most body systems malfunction. The gastrointestinal tract is most often affected. Heaviness in the stomach, nausea, and constipation appear.

Strongly increased weight provokes disorders of the musculoskeletal system. The patient may feel pain in muscles and joints. Peripheral edema appears.

Women are characterized by irregularities in the menstrual cycle. In later stages it can lead to amenorrhea.

Due to endocrine disorders, the condition of the skin and hair worsens. Severe sweating appears, skin oiliness increases, and the risk of developing skin diseases (eczema, furunculosis, pyoderma) increases.

Diagnostics

If you notice something is wrong, you will need consultations from different specialists (therapist, nutritionist, endocrinologist). It also wouldn't hurt to see a psychologist.

When diagnosing, a complete medical history is collected. The doctor draws up a genetic map, determines the minimum/maximum BMI indicators, and the duration of the period of weight gain. Particular attention is paid to the patient’s lifestyle and nutrition.

For successful diagnosis and subsequent choice of treatment, important attention is paid to calculating the body weight index. Among the necessary characteristics, the coefficient of distribution of adipose tissue is used. It is calculated based on the ratio of waist circumference to hip circumference. The abdominal type of disease is indicated by indicators exceeding 0.8 units for women and 1 for men.

Additionally, ultrasound, MRI, and CT are prescribed. Research allows you to more accurately determine the location and size of fat deposits. Through a blood test, the level of triglycerides, uric acid, cholesterol, and lipoproteins is determined. Be sure to determine glucose tolerance to exclude the development of diabetes mellitus.

Treatment methods

A nutritionist will help you create the right diet

The success of treatment directly depends on the patient’s wishes. Therefore, the competent work of a psychologist is important. A nutritionist develops an optimal nutrition system for the patient, and an exercise therapy instructor selects physical exercises to keep the body in good shape.

If the diet is ineffective within 12 days, they resort to drug intervention. Patients are prescribed drugs from the amphetamine group. They promote a quick feeling of fullness after eating.

If necessary, the doctor may prescribe fat-mobilizing drugs in combination with antidepressants (Adiposine, Fluoxetine). The drugs regulate eating behavior and help facilitate the process of weight loss.

Diet

Dietary nutrition consists of reducing the calorie content of food by 300-500 kcal. The main limitation is on carbohydrate foods and animal fats. Preference is given to boiled, steamed or stewed food. It is important to consume a sufficient amount of clean water - at least 1.5 l/day. Food is taken in small portions 5-6 times during the day.

The basis of dietary nutrition is non-starchy vegetables, lean meats and poultry, cereals, and fruits. Spicy, fried, salty foods and alcohol are strictly prohibited.

Prevention

To successfully prevent obesity, it is enough to monitor the balance of calories consumed and expended. To do this, you should adhere to proper nutrition and maintain minimal physical activity (sports).

If you are predisposed to the disease, you need to pay special attention to nutrition. Simple carbohydrates and fats should be excluded or limited. It is better to focus on fiber, protein, and plant foods.

To prevent the disease, specialist supervision is important. Once a year you need to visit an endocrinologist and nutritionist.

What to remember

1. If stage 1 obesity is suspected, the patient requires consultation with a therapist, nutritionist, endocrinologist, or psychologist.
2. Due to the increased load on internal organs, most body systems malfunction.
3. For successful prevention, it is enough to monitor the balance of calories consumed and expended.

E66 Obesity

Epidemiology

Since 1980, the number of obese people in some regions of North America, Great Britain, Eastern Europe, and the Middle East has tripled. Obesity rates in the United States increased by 100% during the same period. The African continent (sub-Saharan Africa) is the only region in the world where residents do not suffer from obesity.

According to WHO information, as of 2014, more than 600 million adults worldwide (accounting for 13% of the population) are obese. It is more often observed in women.

But experts from the International Association for the Study of Obesity (IASO) are particularly concerned about the increasing number of obese children. Almost 42 million children under the age of five are either overweight or diagnosed as grade 1, 2 or 3 obesity. The risk of childhood obesity is highest in Malta and the United States (25%), and lowest in Sweden, Latvia and Lithuania.

Even in Africa, the number of children in this age category who are overweight or grade 1 obese has almost doubled - from 5.4 million in 1990 to 10.6 million in 2014.

About half of these children live in Asian countries. For example, in China, every tenth urban child is obese. This is associated with increased consumption of carbohydrates rather than fats.

Causes of obesity 1st degree

Obesity is a complex heterogeneous disease, and increasingly doctors call it metabolic syndrome. Exogenous and endogenous risk factors for its development consist of excess food intake (unspent energy is stored in the body as fat), physical inactivity (lack of calorie-burning physical activity), endocrine disorders, genetic mutations and family (hereditary) predisposition.

Everything is clear with overeating and physical inactivity. Moreover, the expenditure of energy that food gives a person is of decisive importance, because, as it turned out, muscle loads contribute to the release of the membrane protein FNDC5 (irisin) from skeletal muscle tissue. It has been experimentally proven that irisin can regulate the participation of visceral adipose tissue and subcutaneous adipose tissue in thermogenesis, that is, it behaves like the hormone adiponectin, produced by white adipose tissue cells and involved in the regulation of glucose levels and the breakdown of fatty acids.

The key causes of stage 1 obesity lie in metabolic disorders of white adipose tissue, an excess of which is what characterizes this pathology. Adipose tissue is formed by adipocytes, which are enlarged in obesity due to increased levels of triacylglycerol (TAG) accumulated in them.

Two main processes occur in adipose tissue: adipogenesis (lipogenesis) - cell differentiation, as a result of which preadipocytes become full-fledged fat cells, and lipolysis - the breakdown of TAG contained in adipocytes. The products of this breakdown in the form of fatty acids are released into the vascular system for use as energy substrates.

Since white adipose tissue can normally perform its functions (accumulation of TAG and its remobilization) with a balance of both biochemical processes, the pathogenesis of obesity is associated with dysregulation of this balance. As a rule, this is a decrease in the intensity of lipolysis, which is regulated by numerous hormones, enzymes and polypeptide mediators.

The breakdown of triacylglycerol requires specific lipolytic (hydrolase) enzymes present in adipose tissue (ATGL, HSL, MGL) and encoded by certain genes. The body may lack these enzymes. Obesity is also caused by a deficiency of the already mentioned hormone adiponectin, for the sufficient synthesis of which the ADIPQTL1 gene is responsible. Problems in the FTO gene, which encodes dioxygenase enzymes of the hydrolase family that catalyze the breakdown of TAG, may be to blame for the accumulation of excess fat mass. Any mutations and polymorphism of these genes can cause a deficiency of substances that ensure the metabolism of fat cells. For example, people with two copies of the FTO gene allele weigh on average 3.5 kg more and have a higher risk of developing obesity and type 2 diabetes.

The same role was played by the discovery of the amino acid peptide ghrelin (secreted in the stomach and proximal small intestine), which increases appetite, glucose oxidation and lipogenesis. Ghrelin is the only substance that is released in response to a decrease in the contents of the gastrointestinal tract and is suppressed when it is replenished during eating. Already in grade 1 obesity, as in patients with insulin resistance, ghrelin levels are chronically low. At the same time, visceral adipose tissue is more sensitive to ghrelin deficiency than subcutaneous adipose tissue, which means that lipid deposition will occur predominantly in visceral fat depots. A connection between ghrelin deficiency and mutations in the G274A and GHS-R genes has been identified.

In addition, common causes of grade 1 obesity are endocrine disorders such as increased production of the pancreas enzyme lipase and the hormone insulin, insufficient levels of thyroid hormones (triiodothyronine). For example, when the level of glucose in the blood rises, endogenous insulin not only reduces it, but at the same time inhibits the secretion of the counter-regulatory hormone of the pancreas, glucagon, one of the functions of which is the stimulation of lipolysis. So insulin actually stops glucagon from fighting fat.

An equally important role in the pathogenesis of obesity is played by certain pathological changes in the functioning of certain brain structures, in particular the anterior lobe of the pituitary gland (adenohypophysis). Thus, low levels of the lipolysis-stimulating hormone somatotropin and increased production of adrenocorticotropic hormone (ACTH) prevent the breakdown of TAG. Due to excess ACTH, the adrenal cortex begins to produce more cortisol, which leads to an increase in blood sugar and inhibition of the breakdown of triacylglycerol.

Sex steroids (estrogen, testosterone), somatomedin (IGF-1, insulin-like growth factor-1), catecholamines (adrenaline, whose receptors are present in adipose tissue) are directly related to the process of accumulation and breakdown of adipose tissue cells. They are triggers of G-protein receptors, and their signals (passing through the adenylate cyclase signal transduction system) affect the activation of lipolytic enzymes in adipose tissue.

Obesity of the 1st degree is quite often observed in schizophrenia and schizoaffective disorders, prolonged depression, as well as in bipolar and panic mental disorders and agoraphobia (fear of open spaces and crowded places).

Drug-induced obesity can be provoked by atypical antipsychotics, tricyclic antidepressants, hypoglycemic agents of the thiazolidinedione group, sulfonylureas, steroids, some anticonvulsants and hormonal contraception.

Symptoms of stage 1 obesity

The first signs of obesity are extra pounds. A person's weight is considered normal with a body mass index (BMI) of 18.5-25. BMI is usually expressed in kilograms per square meter (kg/m2) and is calculated by dividing a person's weight by their height squared.

What is the easiest way to calculate it? Divide your weight in kilograms by your height in meters, and then divide the result again by your height. For example: if you weigh 70 g and are 1.75 m tall, you need to divide 70 by 1.75. The answer is 40. Then we divide 40 by 1.75 and get a body mass index of 22.9 (22.85). This is an excellent, that is, healthy BMI!

Weight is considered simply overweight when the BMI is 25-30, and a BMI equal to 30-35 indicates stage 1 obesity.

According to endocrinologists, in the absence of complications, symptoms of stage 1 obesity do not appear until the initial stage transitions to a progressive one. Then heaviness in the stomach, belching, flatulence, headaches, shortness of breath with tachycardia, attacks of weakness and hyperhidrosis may occur.

In general, the specifics of symptoms are determined by the types of obesity, which endocrinologists distinguish depending on the cause into exogenous and endogenous. And all of the above concerns primary obesity, that is, developing due to overeating and physical inactivity. This type of excess accumulation of adipose tissue has such variant names as alimentary obesity of the 1st degree, or alimentary-constitutional obesity of the 1st degree, or exogenous-constitutional obesity of the 1st degree.

All other causes of obesity are endogenous (see the previous section), and the pathology can be diagnosed as endocrine obesity (hormonal, pituitary, hypothyroid, diabetic, etc.), cerebral (hypothalamic) or hereditary. In short, the division of obesity into types is not strictly unified.

And according to where fat accumulates, they distinguish between types of obesity: abdominal (other terms - upper, central, android or male) with a characteristic increase in the volume of adipose tissue in the abdominal region (on the abdomen) - both under the skin and due to visceral (intra-abdominal) ) fat; femorogluteal (female or gynoid); mixed (most common with endocrinopathies).

Clinical practice has shown that stage 1 obesity of the abdominal type has more serious complications.

Obesity 1 degree in women

When characterizing grade 1 obesity in women, it should be noted the most important role of sex hormones in the regulation of energy balance. First of all, this is the ratio of androgens and estrogens.

Even with a relatively normal diet, women may have problems regulating adipose tissue homeostasis. Thus, with an excess of testosterone, hyperandrogenism develops, often associated with increased accumulation of visceral fat; The same thing happens in cases where women have polycystic ovary syndrome and during menopause.

Why is normal estrogen levels so important? Because the sex hormone of the female ovaries can activate the synthesis of the pituitary neuropeptide alpha-melanocyte-stimulating hormone, which induces a number of catabolic effects, including the breakdown of fat deposits. In addition, the action of estrogens in the hypothalamus increases the local activity of leptin, which inhibits food intake and increases energy expenditure.

Stage 1 obesity during pregnancy can occur as excessive gestational weight gain. Pregnant women gain 10-18 kg, and this is due to hormonal changes in the body and the biological and physiological needs of this condition. However, obesity of the expectant mother significantly increases the risk of intrauterine fetal pathologies and various obstetric complications.

Obesity 1 degree in men

Over the past 25 years, stage 1 obesity in men 20 years of age and older has become a problem for 15-18% of the male population in developed and developing countries.

This is grade 1 obesity of the abdominal type - with a thick belly and a swollen waist, and the fat layer in the armpits and pelvic area is also significantly thickened.

The thicker the waist in men after 30 years, the lower the level of testosterone in the body: according to foreign researchers, an increase in waist size by 10-12 cm reduces the production of male sex hormone by 75%, which leads to the development of erectile dysfunction. While the natural aging process reduces testosterone levels by an average of 36%. The reason for this is explained by the fact that adipose tissue produces estrogens (as discussed above). At the same time, the reproductive function of a man also suffers due to a low number of sperm and a decrease in their motility.

Many experts identify hypoventilation obesity syndrome (OHS) in men, which combines grade 1 obesity, hypoxemia (decreased oxygen levels in the blood) during sleep, hypercapnia (increased carbon dioxide in the blood) during the daytime - as a result of too slow or shallow breathing ( hypoventilation).

A frequent companion to obesity in men is kidney stones, benign prostatic hyperplasia, urinary incontinence, as well as changes in the metabolism of sex hormones, which can trigger the development of prostate cancer.

By the way, how do obesity of the 1st degree and the army combine? The list of diseases attached to the order of the Ministry of Defense “On military medical examination in the Armed Forces of Ukraine” does not include obesity, so the suitability or limited suitability of an obese guy for military service is determined on an individual basis.

Obesity 1 degree in children

Depending on age, gender and constitutional characteristics, the body weight of healthy children varies. A one-year-old child can weigh 9-12 kg with a height of 70-80 cm.

Stage 1 obesity in children is diagnosed when their weight exceeds the average age norm by 20-25%. And chronic overeating can be observed in a two-year-old child.

Thus, a one-year-old baby with a body weight of more than 12-13 kg can be obese; at the age of three - more than 18 kg; for five-year-olds - more than 24-25 kg; at seven years old - over 30-32 kg; at 10 years old - more than 45-47 kg, and at 16 - over 85 kg.

Domestic pediatricians are confident that the main causes of childhood obesity are associated with excess and poor nutrition (especially the habit of sweets, sweetened drinks and snacks), which disrupts metabolism, and a sedentary lifestyle, and problems of an endocrine or cerebral nature cause a fairly low percentage of obesity 1st degree in children.

Indeed, according to medical statistics, in 93% of cases, obesity in a child is considered idiopathic, that is, arising for an unknown reason. Only 7% of cases are associated with hormonal or genetic factors. And more often than other hormone deficiency conditions, hypothyroidism and growth hormone deficiency are observed. And the so-called syndromic obesity, diagnosed with congenital Cushing, Prader-Willi, Bardet-Biedl or Pechkrantz-Babinsky syndromes, is very rare.

Genetics plays a significant role in the development of childhood obesity: according to some data, 80% of children whose parents are obese also have significant excess body weight.

But it is impossible to completely exclude the influence of hypothalamic and pituitary disorders on the mechanism of development of obesity in children. In adolescence, mostly in girls, the initial degree of endogenous obesity may be a sign of hypothalamic syndrome of puberty (pubertal dyspituitarism) - one of the types of hormonal imbalances of the hypothalamic-pituitary-adrenal axis and general metabolism. Fat reserves are localized in a mixed type - on the buttocks, hips, chest, shoulders, and stripe-like atrophoderma (striae) appears there.

Complications and consequences

To have a general idea of ​​what consequences and complications are caused by excess fat in the body, even with stage 1 obesity, it is enough to note an increase in the level of low-density cholesterol (LDL) in the blood and the development of atherosclerosis, hypertension, heart failure, coronary heart disease and etc.

Obesity impairs the body's response to insulin and increases blood glucose levels: excess fat underlies 64% of diabetes cases in men and 77% of cases in women.

In addition, as a result of obesity, the following may occur: obstructive sleep apnea, cholelithiasis and urolithiasis, gastroesophageal reflux disease, fatty liver disease and fatty pancreatic necrosis, chronic renal failure, degenerative pathologies of the joints, lymphangiectatic edema of the lower extremities, menstrual disorders and infertility in women , erectile dysfunction in men.

And this is not a complete list of health problems that grade 1 obesity leads to. British Heart Foundation experts associate at least ten types of cancer that develop with excess weight.

And obesity in childhood and adolescence is associated with an increased risk of developing obesity in adulthood (up to 41-63%), with associated long-term health risks.

Diagnosis of obesity 1st degree

Diagnosis of stage 1 obesity begins with weighing, measuring height (to calculate BMI), as well as determining the ratio of waist to hip circumference (which makes it possible to clarify the location of fat deposits).

To determine the volume of adipose tissue and its distribution, instrumental diagnostics are performed using fluoroscopic absorptiometry (DEXA), ultrasound densitometry, and MRI to identify the amount of visceral fat.

Differential diagnosis

Differential diagnosis is necessary to identify possible pathologies: hypothyroidism, polycystic ovary syndrome (or Stein-Leventhal syndrome in women), tumor of insulin-producing cells of the pancreas (insulinoma), congenital tumor of the pituitary tract in children (craniopharyngioma), etc.

Treatment of obesity 1st degree

Today, dietary changes - a diet for stage 1 obesity with a reduction in calories - and exercise are generally accepted methods of treating stage 1 obesity.

Dietary quality can be improved by increasing dietary fiber intake and reducing intake of energy-dense foods such as fats and carbohydrates. But at the same time, the diet must contain products containing all the necessary vitamins, micro- and macroelements. The ultimate goal is to lose up to 5-10% of weight.

How to lose weight with stage 1 obesity, for more details see – Diet 8 for obesity. The same publication contains a list of foods that should be avoided and a sample diet menu for stage 1 obesity.

Dietary changes are also effective in limiting excessive weight gain during pregnancy.

Together with diet and exercise, medications can be used in the treatment of obesity, in particular, the drug Xenical, which suppresses lipase and reduces intestinal fat absorption (other trade names are Orlistat, Orlimax, Orsoten). This pharmacological agent is taken three times a day - one capsule before each meal. But it is contraindicated for use in the presence of kidney stones and high levels of oxalates in the urine, pancreatitis, cystic fibrosis and celiac disease. Possible side effects include nausea, diarrhea, flatulence, headaches, and sleep disturbances.

Surgical treatment

If diet, exercise, behavioral psychotherapy and pharmacology do not have an effect, resort to last resort and perform surgical treatment through bariatric surgery. This treatment has strict indications and is not intended for those who believe that they are simply overweight. As a rule, indications for surgical treatment of obesity arise with a BMI above 40. However, if the patient has problems such as type 2 diabetes, hypertension, varicose veins and problems with leg joints, indications arise already at a BMI of 35.

Surgical intervention occurs in the form of:

1. insertion of an intragastric balloon to reduce the volume of the stomach;
2. gastric bypass, in which the stomach is divided into two separate “compartments” of different sizes, leaving only the smaller part in a functioning state;
3. placing a band on the stomach, which slows down the passage of food;
4. sleeve gastroplasty (vertical excisional gastrectomy).

In case of obesity of the 1st degree, gastroplasty is mainly used, during which part of the stomach is removed, and a long and fairly thin “sleeve” is formed from the remaining one. In this case, the capacity of the stomach decreases approximately 10 times (to 150-200 ml).

Traditional treatment

Among the traditional treatments for obesity, green tea and celery root are considered the most effective. Tea can increase your metabolic rate and speed up the oxidation of fats, and by stimulating the nervous system, it can make you move more and, accordingly, burn more calories. And digesting dishes made from celery root requires a lot of energy

Treatment with herbs that have diuretic and laxative effects is categorically not recommended by doctors. But in order to suppress the appetite a little, herbalists advise eating plantain leaves. Plantain contains fiber that completely fills the stomach, which promotes a feeling of fullness and also normalizes blood glucose levels. In addition to plantain leaves, you can eat kelp seaweed, which enhances the functioning of the thyroid gland, dulling the feeling of hunger.

Abstract of the dissertationin medicine on the topic Functional changes in the cardiovascular system in persons with extreme degrees of nutritional-constitutional obesity who have undergone surgery to form a small ventricle

R G B OD

"^MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

MOSCOW MEDICAL ACADEMY named after. I. M. SECHENOVA

KOZLITINA Tatyana Viktorovna

FUNCTIONAL CHANGES IN THE CARDIOVASCULAR SYSTEM IN PEOPLE WITH AN EXTREME DEGREE OF NUTRITIONAL-CONSTITUTIONAL OBESITY WHO HAVE BEEN SUBJECT TO SMALL VENTRICLE FORMATION OPERATION

dissertation for the degree of candidate of medical sciences

x 7 Moscow - ¡994

As a manuscript UDC 616.1:613.24:616-089

The work was carried out at the Moscow Medical Academy named after. I. M. Sechenov.

Scientific supervisor: Doctor of Medical Sciences, Professor A. I. Ivanov.

Official opponents: Doctor of Medical Sciences,

Professor A. L. Syrkin Doctor of Medical Sciences, Professor B. Ya. Bart

Leading institution: Central Institute for Advanced Training of Physicians of the Ministry of Health of the Russian Federation.

The dissertation defense will take place in 1994

at _ o'clock at a meeting of a specialized Scientist

Council D.074.05.01 at the Moscow Medical Academy named after. I. M. Sechenov (Moscow, B. Pirogovskaya St., building 2).

The dissertation can be found in the academy library (Zubovskaya sq., building 1).

Scientific secretary of the specialized Academic Council,

Candidate of Medical Sciences, Associate Professor

V. I. POZZOL KOV

GENERAL DESCRIPTION OF WORK

Relevance of the topic. Available data in the literature indicate that a significant proportion of the adult population of economically developed countries is overweight. According to average data, the number of obese people is 20-30%. There has been a steady increase in this indicator (Samsonov M.A. et al., 1979, Beyul E.A. et al., 1986, Kuzin M.I. et al., 1988, Alexander J. et al. 1978).

Among the various forms of obesity, the most widespread is nutritional-constitutional obesity (ACO) according to the classification of D. Ya. Shurygin et al., 1980. Particularly close attention of researchers is attracted by extreme degrees of ACO: III degree (excess body weight (BMI) more than 50%) and IV degree (BMI more than 100%).

Obesity creates extremely unfavorable conditions for the life of the body, primarily for the functioning of the cardiovascular system (CVS). Patients experience a persistent increase in blood pressure (BP), atherosclerosis of the aorta (Ao) and coronary arteries, hypertrophy and dilatation of the left ventricle (LV), changes in contractility and electrical activity of the myocardium. However, among researchers there is no unambiguous assessment of such changes and their mechanisms (Barret-Connor E. L., 1985, Grossman E. et al., 1991, Messerli F. H. 1982, Nath A. et al., 1988, Zarioh S.W. et al., 1991). Excess body weight is one of the main risk factors in the development of sudden death in coronary heart disease (Alexander J. K. et al., 1962, Pelkonen R. et al., 1977). Obesity reduces the performance of patients and often causes early disability (Beyul E. A. et al., 1986, Alexander J. K., 1980).

In this regard, the intensive search for various methods of treating obesity is understandable. Widespread conservative therapy, which gives certain results in the early stages or with mild degrees of obesity, is not effective in patients with extreme ACO.

In recent years, surgical methods for treating obesity have become widespread. Under certain conditions, they turn out to be the most effective way to sustainably reduce body weight in patients with extreme ACO (Lebedev L.V. and Sedletsky Yu.I., 1987, Gomez O.A., 1980, Mason E.E., 1981). Among the proposed operations, the operation of forming a small ventricle (SVF) using synthetic

The traditional vascular prosthesis is becoming widespread and attracts more and more supporters because of its technical simplicity and the positive results achieved (Kuzin M.I. et al., 1987, 1988, 1991). The consequences of the operation can manifest themselves in changes in the functioning of various body systems, First of all, SSS. An accurate assessment of the state of the CVS before and after surgery for FMJ is extremely important to exclude independent pathology of the CVS, differentiated preoperative preparation, timely prevention of complications in the postoperative period and subsequent rehabilitation of patients.

The purpose of the study is to evaluate functional changes in the cardiovascular system in patients with extreme ACO before and after surgery for FMJ to clarify the indications for surgical treatment, predict its results, and improve the implementation of more effective rehabilitation measures.

Research objectives.

1. To study the effect of excess body weight in extreme ACO on the function of the cardiovascular system.

2. To develop objective echocardiographic criteria to distinguish true circulatory failure (CI) from circulatory disorders in extreme ACO.

3. Assess the results of FFM surgery and changes in cardiovascular function after weight loss.

4. Clarify the indications for surgical treatment of extreme ACO.

5. To determine the diagnostic capabilities of non-invasive methods for studying the CVS (echocardiography (EchoCG), Doppler echocardiography (DCG), electrocardiography (ECG) and differentiated ECG (ECGdif)) in patients with extreme ACO and give recommendations for their use.

Scientific novelty. Works devoted to a comprehensive study of the function of the cardiovascular system in persons with extreme degrees of ACO who have undergone FMF surgery have not been found in the literature available to us.

The study of cardiovascular function in patients with ACO is associated with the use of various surgical interventions for obesity. Publications on this topic reflect only narrow cardiological problems, and the study of the function of the cardiovascular system often occurs using invasive research methods (Alexan-

der J. K., 1980, Kaltman A. J. et al., 1976, Murray G. L. et al., 1991), which does not allow their repeated reproduction. Single studies on the use of echocardiography can be assessed as preliminary data (Messerli F. H., 1982, Alpert M. A. et al., 1985, Terry V. E., 1987). Data on the state of the cardiovascular system after weight loss are contradictory (Alpert M. A., 1985, Mac Mahon S. W. et al., 1986, Murray G. L. 1991), therefore they cannot serve as a key to accurate preoperative diagnosis or be used for predicting the results of surgery.

This work was carried out using unique clinical material (most patients had a BMI of more than 100%, and some patients had a BMI of more than 200%), the patients were subjected to a new effective treatment method with lasting results, for the first time in our country repeated studies were carried out three years after surgery FFM, which made it possible to objectively assess changes in the function of the cardiovascular system.

Practical significance. The data obtained on functional changes in the cardiovascular system in people with extreme degrees of ACO before and after FFM surgery made it possible to clarify the indications for surgery, improve the possibilities of postoperative management of patients, the results of rehabilitation and objectify the process of restoration of working capacity. Recommendations are given for examining patients before and after surgery using EchoCG, DCG, ECG and ECGdif, as the most accessible, informative and safe non-invasive methods for studying the cardiovascular system.

Implementation. The technique was introduced into practice at the Faculty Surgery Clinic named after. N. N. Burdenko MMA named after. I. M. Sechenov.

Approbation of the dissertation. The dissertation materials were reported and discussed at the interdepartmental scientific conference of the Department of Therapy of the Faculty of Medicine; Department of Surgery No. 1 of the 1st Medical Faculty of MMA named after. I. M. Sechenov and the Department of Cardiology of the Central Institute for Advanced Training of Physicians of the Ministry of Health of the Russian Federation on February 8, 1993; The main provisions of the work were presented at the conference of young scientists of the Faculty of Internal Affairs of the MMA named after. I. M. Sechenov on May 25, 1993 and at a meeting of the Moscow City Scientific Society of Therapists on April 27, 1994.

Structure and scope of the dissertation. The dissertation consists of an introduction, 4 chapters containing a literature review, own research, conclusions, practical recommendations, and a list of references. The list of references contains

46 domestic and 157 foreign sources. The dissertation is presented on 169 pages of typewritten text, illustrated with 10 drawings and 20 tables.

CHARACTERISTICS OF MATERIAL AND METHODS OF RESEARCH

To accomplish the assigned tasks, an examination and dynamic observation of 120 patients with extreme ACO were carried out before surgery for FMJ and within a period of 1 to 3 years after surgical treatment.

The clinical form and degree of obesity in each specific case were established on the basis of anamnesis, clinical data, laboratory and instrumental research methods in order to exclude obesity of other origins. At the same time, independent pathology from the CVS was excluded. All patients were diagnosed with grade III and IV ACO according to the classification of D. Ya. Shurygin et al. (1980). Proper body weight was calculated using Broca's method taking into account the correction factor.

The age of the subjects ranged from 19 to 57 years (average 36.6 ± 1.33 years). 89 people (74%) examined were female, 31 people (26%) were male. The body weight of the patients ranged from 100 to 280 kg, the average total body weight (TBM) of the examined patients was 150.6 ± 6.3 gk (BMI - 120 ± 4.01%).

All patients underwent an ECG study in conventional leads, recording of the first derivative and an echocardiographic study. However, for some of the subjects (37.5%), ultrasound research methods turned out to be impossible due to anatomical features and limited technical capabilities of ultrasound equipment.

In the remaining 75 patients, the study was completed in full. The average age of the study group was 36.6+ 1.82 years. Body mass of the subjects -145 ± 7.56 kg (BMI - 115.0 ± 4.9%), average height 166.7 + 1.92 cm. 55 (73.3%) examined were female, 20 (26.7 %) - male. The average duration of obesity was 16 + 0.4 years. The group of those fully examined was representative of the total group of 120 people, so further development was carried out using data obtained from the examination of this group.

Depending on the degree of obesity, groups were identified: with ACO III degree in the amount of 26 people (35%) and with ACO

IV degree in the amount of 49 people (65%). Patients were divided into groups depending on the duration of obesity. The first group included patients with a duration of obesity not exceeding 10 years (18 people or 24%), the second group included patients suffering from ACO from 11 to 20 years (40 people or 53.3%), the third group included patients with ACO more than 21 years (17 people or 22.7%). Also, all subjects were divided into groups depending on age. The age group up to 30 years old included 18 people (24%), the group 30-39 years old included 28 people (37.4%), the group 40-49 years old included 22 people (29.3%), the group 50 years old and older included 7 people (9.3%).

The most common complication of extreme ACO was arterial hypertension (AH) (60%), the second most common pathology was deforming osteoarthritis (58.7%). Among other diseases that significantly worsen the course of the underlying disease, it is necessary to note Pickwick syndrome (SP) (21.3%), diabetes mellitus (12%), cholelithiasis (16%).

Of particular interest were symptoms such as shortness of breath during exercise, noted in 63 patients (84%), swelling of the legs, occurring in 45 people (60%), and tachycardia, recorded in 40 patients (53.3%), which are signs of NC in patients with normal body weight. In patients with extreme ACO, certain difficulties arise in the differential diagnosis of NC and similar symptoms caused by obesity itself (the presence of so-called circulatory stagnation).

In order to identify differences in the genesis and course of hypertension, 20 patients with stage II hypertension (HD) with normal body weight were examined. The average age was 39.4 ± 2.38 years, the average body mass was 74.7 ± 2.08 kg.

The control group included 30 healthy people with normal body weight. Average age - 40.6 + 2.25 years, average body mass - 65.3 ± 2.08 kg.

The assessment of CV function was carried out using echocardiography in M-mode, using the recommendations of the American Society of Echocardiography using the MK-500 device from AT (USA). The following indicators were determined: LV end-diastolic size (DD), LV end-systolic size (Ds), thickness of the myocardium of the posterior wall of the LV in diastole (Tmd), thickness of the interventricular septum in diastole (IVD), amplitude of motion of the posterior wall of the LV (APW) and IVS (aIVD), anteroposterior size of the left atrium (LA), size of the right ventricle (RV), aortic diameter (Yes).

Based on the data obtained, evidence-based central hemodynamics were calculated: end-diastolic volume (EDV) and end-systolic volume (ESV) of the LV, LV stroke volume (SV), minute volume (MV), cardiac index (CI), stroke index (SI), total peripheral resistance (TPR), the degree of shortening of the anteroposterior dimension of the LV in systole (AS), the velocity of circular shortening of myocardial fibers (Vcf), ejection fraction (EF), and the mass of the LV myocardium (Mm) was calculated. Based on measurements of systolic (SAD) and diastolic (ADd) blood pressure, mean blood pressure (MBP) was calculated.

Using DCG in pulse mode (the sensor was located in the jugular fossa (the maximum flow velocity (vmax) > ejection time (VI), the integral of the flow velocity (ISP) was determined), VOdkg was calculated

The ECG study was performed using a Mingo-graph-82 polygraph from Elema (Sweden) in 12 standard leads. To standardize ECG waves, a millivolt (mV) equal to 10 mm was recorded. The tape transport speed was 50 mm/s. ECG signs of LV, RV and LA hypertrophy were detected. The QT interval was calculated in s; for comparison, tables of the maximum duration of the QT interval in normal conditions at different heart rates (HR) were used. Based on the data obtained, the relative electrical systole indicator was calculated.

The recording of the first derivative of the ECG was carried out using a differentiator at a time constant of 5 ml/sec. Differentiation of leads V5 and Ve was performed. Using the first derivative, we determined the ratio of maximum speeds (MSV) and the duration of the QT interval in s.

A repeat study of ACO patients was carried out 3 years after the FFM operation and the loss of most of the excess body weight. The most intensive reduction in excess body weight was observed during the first year after surgery (on average 38.9 ± 3.48 kg or 27.8% of initial body weight). 3 years after surgery, patients lost from 28 to 90 kg, an average of 49.8±4.15 gk or 34% of their initial body weight. OMT was completely normalized or grade I ACO remained, maximum grade II.

Statistical data processing was carried out using standard programs on an IBM personal computer - PC/AT.

MAIN RESEARCH RESULTS

1. The state of the myocardium and central hemodynamics in patients with extreme ACO according to echocardiography in M-mode and DCG in pulsed mode before FMF surgery

The examination revealed in all patients, regardless of the degree of obesity, in all age groups and with varying durations of extreme ACO, moderate hypertrophy of the LV myocardium, confirmed by increased Mm. These changes are more pronounced with increasing OMT (see Table 1).

No relationship was found between the duration of obesity and the magnitude of LV myocardial hypertrophy, so the maximum values ​​(TM1 = 1.1 ± 0.5 cm, IVS i = 1.03 ± 0.04 cm, Mm = - 192.8 ± 12.28 g ) were identified in the group with a duration of obesity of up to 10 years. In these same patients, LV dilatapia is maximally expressed. These changes in patients with relatively short periods of ACO can be explained by the fact that surgical methods of treatment have to be resorted to in cases of unsuccessful conservative treatment. Most often, this contingent of patients are patients with complications and concomitant pathologies who have a progressive course of ACO, which explains their early appeal to surgeons and more pronounced changes in the cardiovascular system obtained during the examination.

LV myocardial hypertrophy was insignificant in the age group under 30 years (Tid = 1.06 + 0.03 cm, the difference with the control group is significant, p< 0,005, МЖПД = 0,95 ± ±0,03 см, различие с контрольной группой недостоверно, р >0.05), with age there is a tendency to increase.

In addition to LV myocardial hypertrophy, dilatation of the heart chambers (LV, RV, LA) was detected in patients with extreme ACO. These changes also become more pronounced with increasing OMT (see Table No. 1). A dependence of dilatation, mainly of the left chambers of the heart, on age was revealed. After 30 years, these indicators increase, especially significant changes were noted in patients after 50 years (Dd = 5.7 ± 0.29 cm, Ds = 4.3 ± 0.3 cm, Lifespan = 2.3 ± 0.11 cm). The dynamics of changes in extreme ACO with age are similar to changes in myocardial thickness h of the internal dimensions of the heart chambers in healthy people, who also showed an increase in older age groups.

Reliable increase Yes (on average up to 3.5 + 0.1 cm, p< 0,05 по сравнению с контрольной группой и пациентами до 30 лет) и уплотнение стенок А0 у пациентов после 50 лет, мы склонны расценивать как ее атеросклеротическое поражение.

LV myocardial hypertrophy, confirmed by increased mm. in patients with extreme ACO cannot be explained by fatty infiltration alone. We adhere to the opinion that explains the development of LV myocardial hypertrophy and dilatation of the heart chambers by compensatory mechanisms. In obesity, excess adipose tissue and increased metabolism lead to an increase in blood MO. According to our observations, increased MO is the result of increased SV, since no changes in heart rate at rest were detected in our patients. This conclusion confirms other works (Backshap et al., 1973, \Voodard S.V. a1., 1978) and contradicts those studies in which tachycardia is considered an important factor that increases MO in obesity (Caitap A.L. , Oo1s1pp£ I.M., 1976). Our studies have proven an increase in EDV, ESR, as well as SV and MO in proportion to the increase in OMT and with age (in patients after 40 years). Cardiac output in patients with ACO increased regardless of the level of blood pressure.

Thus, compensation mechanisms due to increased LV work, mainly during volume overload, lead to compensatory LV hypertrophy. LA dilatation can also be explained by chronic volume overload and increased afterload due to stretching and increased tension of the LV wall. The changes are more noticeable with increasing OMT.

Average values ​​of the ASC, and especially the aIV, which exceeds the ADC and increases after 50 years with a duration of ACR of more than 2! years, confirm the presence of LV dilagation and volume overload, especially with a long course of the disease and in middle age.

Based on the data obtained, we came to the conclusion that cardiac changes in extreme ACO can be considered as eccentric myocardial hypertrophy.

Prolonged LV volume overload and increased workload ultimately lead to deterioration of LV systolic function. SI and UI indicators remained within normal limits in the age group under 30 years and in patients with normal blood pressure values. In other groups, we found a slight decrease in SI and UI. In some

In the works, the authors do not find a change in these indicators during ACO (Alexander J.K., 1978, 1985), but we are closer to the opinion of Messerli F.H., 1982, who considers these results to be false positive, and CI to be reduced, calculating this indicator per kg of mass bodies.

A decrease in myocardial contractility in extreme ACO is confirmed by reduced values ​​of Vcf, EF, and AS. These changes are more pronounced after 30 years and with an increase in body weight. Thus, as OMT increases, patients' risk of developing congestive heart failure increases.

Data regarding patients with “super-obesity” were studied separately. The average age of the group was 40 ± 4.22 years, the duration of obesity was only 10.5 ± 1.97 years, body mass was 228 ± 13.2 kg, BMI was 223.8 ± 15.7%. The results of the study of this group of patients are similar to those in ACO grades III and IV, but in patients with “super obesity” the heart rate on average was significantly higher than in the control group (82±4.78 beats per minute and 71.1+2 .19 beats per minute, respectively, p< 0,05), более выражены дилатация левых отделов сердца (в среднем Дд = 6,4±0,48 см, Дс = 5,1 ±0,56 ем, ЛП = 4,75 ± 0,45 см) и гипертрофия миокарда ЛЖ Тыд = = 1,23 ± 0,14 см и МЖПЛ= 1,1 ±0,08 см), Мм увеличена до 233,9± 31,22 г в среднем. Не выявлено увеличения УО и МО. При «сверхожирении» снижается -сократительная функция миокарда, что выражается в снижении СИ и УИ (2,25 ± ± 0,34 л/мин/м2 и 27,5 ± 4,67 мл/м2 соответственно) и таких показателей как Vcf- ФВ, AS (0,57 ± 0,25 С"1, 40,5 ±6,09% и 20,5 + 3,74% в среднем соответственно).

Pronounced dilatation of the left chambers of the heart, left ventricular myocardial hypertrophy, reduced SV and MO, a tendency to increase heart rate, a decrease in SI and SI values, sharply reduced values ​​of SVr, EF, AS, suggest the presence of true NC in patients with excess body weight of more than 200% of due. This is also confirmed by clinical manifestations.

All of the above CV disorders in patients with extreme ACO without independent heart pathology can be explained as congestive heart failure caused by cardiomyopagia of obesity. This term is still controversial, but in our opinion, it fully reflects the pathogenesis of the disease. A number of researchers use it in their works (Alexander J.K., 1985, Braunwald E., 1980).

It is also necessary to address changes in the cardiovascular system in ACO of extreme complications. In our studies, hypertension was detected in 45 people (60%) with extreme ACO.

Table 2. Blood pressure indicators in different groups (M±m).

Blood pressure, mmHg Art. I group II group III group

AKO cr. sg. with hypertension (n = 45) stage II hypertension (n = 210) Control group. (n = 30)

AD 141.1 ±2.02*** 154.3+ 2.48* 1:13.5 ± 2.25

ADD 91.0 + 1.74* 92.0 + 0.68* 68.0 ±0.9

ADer 107.7 ± 1.95* ** 112.8 ±0.93* 88.0 ± 1.44

* - 1 asterisk indicates significant differences between the groups with ACO, HD and the control group (p< 0,00(1) .

** - 2 asterisks indicate significant differences between the groups with ACO and HD (p<0,05).

As follows from Table 2, with extreme ACO there is an increase in blood pressure, mainly blood pressure, but in comparison with the indicators of patients with stage II hypertension, it is moderate.

Hypertension is more often registered in patients with stage IV ACO, that is, it is directly dependent on OMT. In addition, hypertension is a more frequent complication with increasing duration of ACO. Average blood pressure values ​​in all age groups are increased compared to the control group, but blood pressure tends to increase with age.

To clarify the mechanisms of increased blood pressure in ACO, the results of a study of a group of hypertensive patients were used as a comparison. In hypertensive patients, pronounced hypertrophy of the LV myocardium, lack of dilatation of the heart chambers (concentric type of hypertrophy) and a significantly increased TPS were revealed. SV and MO in these patients did not differ from normal values, myocardial contractility did not change. Based on the data obtained, it was concluded that the leading mechanism for increasing blood pressure in hypertension is an increased TPS.

In the group of patients with extreme ACO and hypertension, LV myocardial hypertrophy is less pronounced than in

GB (Tmd = 1.08 ± 0.02 cm and Tmd = 1.26 + 0.05 cm, respectively, p<0,05) н не отличалась от показателей в группе АКО без АГ. Мм также меньше, чем при ГБ (186 + 6,48 г) и 190,1 + ±10,85 г соответственно, р<0,05). Однако дилатация камер сердца и увеличенные КДО, КСО, УО и МО были значительно выражены. ЧСС не отличалась от нормальных "показателен. ОПС у пациентов с АГ было несколько выше, чем у пациентов без АГ, но не отличалось от показателей в контрольной группе. Следовательно, повышение АД при АКО крайней степени происходит преимущественно за счет увеличения сердечного выброса при гиперкинетическом типе кровообращения. В пашем исследовании в отдельных случаях МО достигал 11,8 л/мин. Учитывая некоторое увеличение ОПС, при этом, .следует отметить увеличение постнагрузки за счет увеличения ОПС у пациентов с АКО и АГ. Таким образом, сочетание АКО и АГ, за счет различных механизмов, создает высокую пред- и постнагрузку на сердце, увеличивая работу ЛЖ. Это ухудшает сократительную способность миокарда ( сниженные показатели Vcf >EF and AS) and increases the risk of developing NC.

A serious complication of extreme ACO is SP. We did not find any dependence of the occurrence of SP on age, duration of obesity, body mass or BMI. Due to the difficulty of visualizing the anterior wall of the pancreas, we cannot speak with complete certainty about the nature of pancreatic myocardial hypertrophy. RV dilation "with SP in our work did not differ from the dilation of the RV with extreme ACO without SP. In the left parts of the heart, changes in SP were of the same nature as with extreme ACO. However, in these patients there was a significant increase in DD, EDV and MO, that is, the LV volume load is even more pronounced and the contractility of the LV myocardium is significantly reduced. Therefore, it can be assumed that patients with extreme ACO with SP do not experience “pure” right ventricular failure and isolated damage to the RV.

Examination of patients with extreme ACO is not always possible using the M-method of EchoCG. In this regard, it was of particular interest to conduct DCG in pulsed mode and calculate CVD and other indicators of central hemodynamics based on the obtained data. A pulsed study performed in parallel with the M-method of EchoCG and DCG showed that the stroke volume determined by various methods does not differ significantly.

In addition, by the blood flow in the ascending section of A0, an indirect assessment of myocardial contractility is possible. With a decrease in myocardial contractility, Vmax decreased. Our work shows the relationship between Vmax and AS. Thus, in cases where visualization of the heart through parasternal access is not possible, pulsed DCG examination should be recommended.

2. State of electrical activity of the myocardium

according to ECG data in conventional leads and differentiated ECG in patients with extreme ACO before FFM surgery

A study of the electrical activity of the myocardium, performed in 120 patients with extreme ACO in the preoperative period, allowed us to conclude that the ECG in this pathology in most cases does not differ from the ECG of healthy people; we did not find a significant decrease in the ECG voltage as noted in some studies (Lebedev L.V. and Sedletsky Yu.N., 1987, Eisenstein I. et al., 1982). In our work, low voltage was detected in 6 people (5%), while normal voltage was found in 114 people (or 95%). All patients had sinus rhythm and only in 2.5% of cases (3 people) rhythm disturbances were detected. In two cases it was a single atrial extrasystole, in one patient it was a single ventricular extrasystole. Thus, we cannot say that in patients with extreme ACO, a regular ECG study reveals frequent rhythm disturbances, as stated by Messerli F. N. et al., 1987. Perhaps the method would be more acceptable to confirm these data Holter 24-hour monitoring.

The location of the electrical axis of the heart (EOS) in extreme ACO is presented in Table 3. The horizontal position of the EOS and deviation of the EOS to the left occurred in 70% of cases. An explanation for this may be the presence of LV hypertrophy, which occurs in 53.3% of patients with ACO, as well as the horizontal position of the heart in the chest cavity, when the dome of the diaphragm rises due to excessive obesity.

Heart rate did not differ significantly from normal values, but with “super obesity” there was a tendency to increase.

It should be noted that with normal average values ​​of the duration of the PO interval, the width of the P wave and the complex (P, the values ​​of the latter two were significantly higher (p< 0,001), чем аналогичные в контрольной группе, причем с увеличением ОМТ отмечена тенденция к их росту.

Conduction disturbances also occur more frequently with increasing BMT. Of the 36 people (30%) with conduction disorders, 1 patient had incomplete blockade of the right bundle branch, 19 patients had blockade of the anterior left branch of the His bundle, 7 patients had incomplete atrioventricular block of the first degree, and 9 patients had nonspecific changes , expressed in jaggedness of the ventricular complex in various ECG leads.

Signs of LA hypertrophy were recorded in 24 patients with ACO (20%). An echoCG study in all cases showed an increase in the internal dimensions of the left atrium, therefore, we can talk about either hypertrophy of the left atrium myocardium or an overload of the left atrium. However, with an echocardiography study, an increase in the left atrium was noted in 93.3% of cases, that is, the information content of the ECG is low .

Signs of LV hypertrophy based on quantitative criteria were identified in 10 out of 120 patients with extreme ACO, which is only 8.3%. Signs of pancreatic hypertrophy were not found in any of the patients. The possibilities for diagnosing hypertrophy of various sections are limited, which may be due to their moderate severity, as well as changes in the electrical conductivity of surrounding tissues due to excessive development of subcutaneous fat.

The average duration of the OT interval, determined by the normal ECG, did not differ from the indicators in the control group. In most cases, the duration of the WC interval corresponded to the heart rate, as evidenced by a normal WC (see Table 3).

Since our work, when analyzing a regular ECG, did not reveal an increase in the duration of the interval (WT), we analyzed 1 derivative of the ECG in these same patients. The average duration of the T interval, determined by this method, also corresponded to normal values ​​(see Table 3). Only in In 18 people (15%), the OT interval was increased to an average of 0.39 ± 0.007 s with an average heart rate of 79.9 ± 1.7 beats per minute and significantly higher than normal values ​​(p< 0,001), показатель ОТ в среднем равнялся 1,12±0,01, что превышало норму. Среди этих пациентов у 13 человек (72,2%) при ЭхоКГ-исследоваяни выявлена гипертрофия миокарда ЛЖ.

However, out of 75 patients with extreme ACO who underwent echocardiography, 40 people (53.3%) had LV myocardial hypertrophy and only 13 of them (32.5%) had an increased QT interval. At the same time, the average values ​​of the QT interval duration in patients with LV hypertrophy were 0.38 ± 0.006 s and did not differ from the data in the control group. The QT indicator was also within normal limits, averaging 1.06 ±0.02. Thus, an increase in the duration of the QT interval occurs in approximately 1/3 of patients with extreme ACO and LV hypertrophy.

In our work, we did not find an increase in the compulsory medical mass in patients with ACO, and there were no differences in the average values ​​of the compulsory medical mass in extreme cases of acute hypertrophy and concomitant hypertension. Separately, we calculated the average values ​​of the compulsory medical mass in patients with proven LV hypertrophy, but, with a tendency to increase this indicator, no significant differences were found compared to the control group.

The use of the ECGdiff method is justified due to its higher sensitivity (determining the duration of the QT interval), despite the fact that speed parameters (VMP) with moderate LV myocardial hypertrophy turned out to be uninformative.

3. The state of the myocardium and central hemodynamics in patients with extreme ACO after FFM surgery according to echocardiography in M-mode and DCG in pulsed mode

The literature provides data regarding changes in the function of the cardiovascular system after weight loss in patients with ACO over a period of 4 to 34 months, but some of the studies were performed using invasive methods, while others concern radiographic research methods, and the decrease in body weight was not always significant and “It has always been associated with surgical treatment (Alexander J.K., 1985, Alport M.A., 1985, Mac Mahon S.W. et al., 1986). Researchers have not come to a consensus regarding changes in the cardiovascular system.

In our work, a repeat study of the CVS in patients with extreme ACO was carried out in 18 patients (25%) 3 years after the FMJ operation, which allows us to draw certain conclusions.

The needs of the body, which has significantly reduced metabolism as a result of a decrease in body mass, are sharply reduced and this is reflected in hemodynamics. All patients have adequate

SV and MO decrease correctly. The decrease in MO is directly proportional to the decrease in OMT. Maintaining adequate blood flow requires less expenditure, which explains the decrease in heart rate in the postoperative period and, although we did not find a significant decrease in heart rate in these patients, the tendency to bradycardia is beyond doubt (heart rate in some patients was 50 beats per minute).

In all patients, DD, DS, LA, and RV decreased significantly, which reflects a decrease in volume load. This is confirmed by the significantly decreased EDV and ESV, therefore, we can talk about a decrease in LV filling pressure. We cannot agree with the conclusions of Alexander J. K., 1972, who reports a decrease in LV size in only 7% of cases. A decrease in LV size occurs in all cases with a decrease in body mass, but this decrease depends on the initial body weight (i.e., the degree of ACO) and the duration of obesity. Our work shows that in patients with grade III ACO and a duration of obesity of up to 10 years, the LV dimensions return to normal, while in patients with grade IV ACO and a duration of obesity of more than 10 years, they only approach those. This fully applies to the size of the pancreas. The LA dimensions do not differ from normal in all cases.

No changes were found in TMD and IVD even 3 years after surgery and weight loss. Confirmation of the persisting moderate hypertrophy of the LV myocardium is an increased Mm, significantly different from normal values. The only exception was the group of patients with stage III ACO, whose postoperative data did not differ from the norm (see Table 1).

There was a decrease in aIVS and an increase in AD after a decrease in body weight, which, together with a decrease in the size of the left atrium, suggests a decrease in diastolic dysfunction. There is no doubt about the improvement in LV systolic function in all patients. Vcf indicators. > EF and AS after weight loss were practically no different from those in the control group. SI and UI also did not differ significantly from normal. In patients with obesity for more than 10 years, systolic function was restored worse. With repeated studies, Vcf, EF and AS in these patients tend to decrease.

A study of blood flow in the ascending Ao showed that Vma increases in both groups after surgery. In the case of grade IV ACO, the indicators do not differ from normal

(78.5±2.6 cm/s), and in the group with grade III ACO they even exceed normal (91.8 ±4.23 cm/s, p<0,05).

In all cases, with a decrease in OMT, patients experience a decrease in blood pressure, both ABP, ABP and ABP. Blood pressure is normalized in almost all patients, and this is associated with a decrease in MR, and therefore SV. A decrease in heart rate plays a small role in this. In this case, OPS increases slightly and does not differ from the values ​​in the control group. It should be noted that the decrease in blood pressure with a decrease in body mass occurred without restriction of salt in the diet.

4. State of electrical activity of the myocardium

according to ECG data in conventional leads and differentiated ECG in patients with extreme ACO after FM surgery

An ECG performed after weight loss demonstrated a significant decrease in heart rate compared to the group of patients before surgery and the control group, which may be one of the mechanisms for reducing MR.

In 2 patients, a change in EOS from a horizontal to a normal position was noted, which can be explained by a change in the topography of the heart relative to the chest and diaphragm with a decrease in body mass and a decrease in heart size.

Conduction disturbances in the postoperative period were noted in 23.3% of cases: in 5 patients (16.7%) there was blockade of the anterior left branch of the His bundle, in 2 patients (6.6%) there were nonspecific changes.

The duration of the PQ interval and the width of the P wave did not change. Signs of LA hypertrophy were noted in 4 patients (13.3%), in 11 patients (36.6%), the width of the P wave decreased compared to the preoperative period, and the “bihump” disappeared. The width of the QRS complex did not change compared to preoperative values. Signs of LV hypertrophy were not detected in any of the patients either before or after surgery. The duration of the QT interval tended to increase, but did not differ significantly from the values ​​in the control group. The QT index, on the contrary, significantly decreased compared to the preoperative data, which also did not allow us to assert that the QT interval was increasing to a significant extent. When recording the first derivative of EKGL„f, we received the values<ЗТДНф не отличающиеся от средних значений в дооперационной группе (см. таблицу 3).

The postoperative study revealed a significant decrease in the average values ​​of the compulsory medical insurance compared to the preoperative group (p<0,05), в то же время эти показатели не отличались от данных в контрольной группе. Для уточнения подобных изменений были вычислены значения ОМС у этих пациентов до операции. Средние значения ОМС до операции в этой группе составили 0,98 ± 0,05, что позволило расценить эти изменения, как «первичные» нарушения репо-ляризации, вызванные кардиомиопатией олшрения и, возможно, атеросклерозом, так как возраст пациентов этой группы в 50% случаях превышал 40 лет. После операции у этих больных выявлено достоверное увеличение ОМС до 1,1 ±0,03 в среднем (р<0,01). Следовательно, в действительности можно говорить не об уменьшении показателей ОМС, а об их увеличении после снижения ОМТ, а также об обратимости кардиомиопатии ожирения если предположить, что снижение ОМС при АКО крайней степени вызвано именно этой причиной.

1. With extreme nutritional-constitutional obesity, obesity cardiomyopathy occurs, characterized by moderate hypertrophy of the left ventricular myocardium, dilatation of the heart chambers and a decrease in myocardial contractility; with increasing body weight, age and duration of obesity, these changes are more pronounced.

2. Changes in central hemodynamics are associated with an increase in stroke volume and cardiac output, which increase preload on the heart and are the main mechanism for increasing blood pressure in extreme alimentary-constitutional obesity.

3. In case of true circulatory failure, an echocardiography study reveals a decrease in stroke volume and minute volume and a sharp decrease in myocardial contractility, which distinguishes this pathology from circulatory disorders in extreme alimentary-constitutional obesity.

4. With a decrease in body weight as a result of the operation of forming a small ventricle, the stroke volume and minute volume, the internal dimensions of the chambers of the heart are reduced, myocardial contractility is restored, blood pressure is normalized, but hypertrophy of the left ventricular myocardium remains. Improving the function of the cardiovascular system up to complete normal

malization was noted in patients with alimentary-constitutional obesity of the third degree, a short history of the disease and under the age of 40 years.

5. Methods of EchoCG and DCG in pulsed mode allow for safe, repeated and accurate examination of the cardiovascular system, while ECG and ECGDI did not reveal specific changes, which suggests their low information content compared to ultrasound methods.

1. The selection of patients with extreme alimentary-constitutional obesity for surgical treatment must be carried out with the mandatory use of EchoCG and ECG, which makes it possible to exclude independent pathology from the cardiovascular system and identify functional changes caused by the underlying disease.

2. When selecting for surgery, preference should be given to patients with grade III nutritional-constitutional obesity under the age of 40 years and a disease duration of up to 10 years, since in this group in the postoperative period the function of the cardiovascular system completely returns to normal.

3. In diagnosing hypertrophy of various parts of the heart, the EchoCG method in M-mode should be used, as it is the most informative in comparison with ECG.

4. The EchoCG method in M-mode and the indicators of central hemodynamics obtained on its basis make it possible to distinguish true circulatory failure from circulatory disorders caused by extreme alimentary-constitutional obesity. With true circulatory failure, the stroke volume and minute volume of blood decrease, the contractility of the left ventricular myocardium is sharply impaired (decrease in the ejection fraction of the left ventricle, the degree of shortening of the anteroposterior size of the left ventricle, stroke and cardiac indices).

5. The use of Doppler echocardiography in pulsed mode with the sensor located in the jugular fossa is advisable if it is impossible to conduct EchoCG in M-mode due to the anatomical features encountered. Indicators of central hemodynamics obtained on the basis of Doppler echocardiography closely correlate with indicators obtained by the M-method of EchoCG.

b. Pulsed Donple echocardiography is recommended to be used to calculate central hemodynamic parameters in cases of severe dilatation of the heart chambers and associated regurgitation, as the most accurate method.

1. Functional changes in the cardiovascular system in patients with alimentary-costigudional disorders! extreme obesity after surgical treatment. - Dep. in State Central Scientific Library, D-24105, 03/30/94 (together with M. M. Romanov, L. Yu. Churganovop, N. M. Kuzin, V. K. Marko, Vym, A. I. Ivanov).

2. Duration of the ECG interval in patients with extreme alimentary-constitutional obesity before and after surgical treatment, - Dep. in State Central Scientific Library, D-24106, 03.30.94 (together with L. Yu. Churganova, M. M. Romanov, N. M. Kuzin, A. I. Ivanov).

Table 1. Dependence of Echo CG indicators on the degree of ACO (M±m)

(asterisk - significance of differences with the control group, p< 0,05)

ACO stage III (group 1) ACO stage IV (group 2) Control group (n = 30)

Indicators before FMF after FMF before FMF after FMF

(n = 26) (n = 7) (n = 49) (n = 1.1)

OMT, kg 129.6 ±3.54* 78.0 ± 4.53* 154.1 ±4.33* 88.1 + 6.0* 65.3 ± 2.08

BMI, %" 77.4 ± 2.56* 13.0 ± 6.06* 134.9 ±5.32* 33.0 ± 5.3* -

Tmd, cm 1.05 ± 0.02* 1.0 ±0.02* 1.1 ±0.02* 1.1 ±0.06* 0.9 + 0.02

IVD, cm 1.0 ±0.03* 1.0 ±0.04* 1.03 ±0.03* 1.0 + 0.04* 0.9 ± 0.03

mm, g 170.9 ±5.47* 127.6 ± 11.3 189.3 ±5.88* 176.9 ±15.83* 123.4 ± 3.88

dd, cm 5.57 ±0.11* 4.9 ±0.15 5.9 ±0.09* 5.2 ±0.19* 4.8 + 0.06

Dc" cm 3.9 ±0.12* 3.1 ±0.11 4.2 + 0.12* 3.4 ± 0.12* 2.9 ± 0.06

EDV, ml 153.8 ± 6.82* 119.9 + 8.51 175.9 ±6.1* 138.3 ± 10.58* 105.3 ± 3.37

ESR, ml 71.4 ±5.05* 48.5 ± 7.53 84.6 ±5.58* 65.3+9.99* 334.5 ± 1.52

LA, cm 3.98 ± 0.09* 3.4 ±0.15 4.28 ± 0.07* 3.6 ±0.14 3.3 ± 0.08

RV, cm 2.38 ±0.09 1.9 ± 0.08 2.39 ± 0.08* 2.2 ±0.11* 1.9 ± 0.07

OPS, din. cm-6 1639.5 ±161.7 1691.5 ± 158.3 1348.8 ± 56.63 1709.0 ± 112.6 1499.1 ± 79.44

SV, ml 78.6 ± 6.21 67.0 ± 7.9 91.4 ±3.54* 73.1 ±7.1 70.9 ± 2.61

MO, l/min 5.82 ±0.45 4.4 ± 0.25 6.82 ± 0.28* 4.5 ±0.40 5.06 ± 0.26

EF, % 53.2 ±2.69* 63.7 ±4.11 53.3 ± 1.93* 61.9 ±3.0. 67.6 ±1.07

Usr, s-1 1.04 ± 0.08* 1.4 ±0.19 1.07 + 0.06* 1.1 ±0.03* 1.3 + 0.05

DB, % 28.4 + 1.83* 32.5 ± 2.78 28.9 ± 1.29* 33.9 ± 2.0 37.7 ±0.78

SI, l/min/m2 2.43 ±0.19* 2.9 ± 0.8 2.72 ±0.11* 2.6 + 0.4 3.16 ±0.18

UI, ml/m2 34.3 ±2.19* 41.0 + 3.3 36.4 ± 1.29* 40.4 ± 2.42 44.1 + 1.72

Table 3. Results of an ECG study after surgery for FMJ (M±m)

Indicators of extreme ACO before FMF (n = 120) Patients after FMF (n = 30) Control group (n = 30)

Heart rate, beats per minute 76 ± 1.04 63 ± 1.13%* 71 ±2.19

normally located 36 (30%) 12 (40%) 20 (66.6%)

horizontal 61 (50.8%) 12 (40%) 5 (16.7%)

deviated to the left 4 (3.3%) 1 (3.3%) -

sharply deviated to the left 19 (15.9%) 5 (16.7%) -

vertical - 5 (16.7%)

R<Э, с 0,16 ±0,002 0,16 ±0,03 0,16 ±0,02

P, s 0.09 ± 0.01 0.09 ± 0.003 ** 0.08 ± 0.001

Rate, s 0.07 ±0.001 0.07 ± 0.002 «« 0.06 ± 0.002

<ЭТ с 0а36 ±0,03 0,37 ± 0,04* 0,36 ± 0,004

show<ЗТ 1,01 ±0,007 0,98 ±0,01* 0,96 ± 0,004

Signs of hypertrophy

LP 24 (20%) 4 (13.3%) -

Signs of LV hypertrophy 10 (8.3%) _ _

C^T diff., s 0.38 ± 0.003 0.38 ± 0.004 0.36 ± 0.004

Compulsory medical insurance 1.2 ±0.03 i 1.1 ± 0.03* 1.2 ±0.05

*-1 asterisk indicates significant differences between patients with extreme AK.0 before FFM surgery and patients after FFM surgery (p< 0,05).

¡¡¡¡2 asterisks indicate significant differences between patients after FMJ surgery and the control group (p<0,05).

Alimentary obesity (exogenous-constitutional) is a type of metabolic pathology in which hereditary factors do not play a significant role. External causes play a leading role in the development of this disease, but the influence of the initial state of the body on the process should not be excluded.

All factors contributing to the development of nutritional obesity can be divided into external and internal. External symptoms include regular overeating, the presence in the diet of large amounts of food rich in fats and simple carbohydrates (baked goods, sweets, pasta, fatty meat dishes, etc.), incorrect eating habits (not eating according to the schedule, eating high-calorie and heavy foods at night) . Today, the problem of a sedentary lifestyle as one of the key links in the pathogenesis of obesity is particularly relevant. Internal factors include metabolic diseases (diabetes mellitus, etc.). A special group consists of hormonal imbalances with excessive or insufficient function of the gonads that occur during pregnancy and lactation, and during menopause in women. In the anamnesis of almost every obese person there are relatives suffering to one degree or another from metabolic pathology, which indicates the invariable role of genetic predisposition to the disease.

According to UN estimates, the countries with the highest percentage of obese populations include the United States (32.8%), Mexico (31.8%) and Syria (31.6%). Russia occupies 28th place in this ranking, the level of the population with excess body weight is 24.9%.

Existing classification

Classification of degrees of obesity:

1. Excess body weight is 10-29%.
2. Excess weight – 30-49%.
3. Excess weight – 50-99%.
4. The actual body weight of a person exceeds the norm by 100%.

Types of obesity based on the location of adipose tissue:

1. Android (male) obesity is sometimes called central obesity. This type is characterized by the deposition of fat masses in the abdomen, armpits, lower back and back.
2. Gynoid (female) obesity - fat deposits occur in the chest, buttocks and thighs, and lower abdomen.
3. Mixed – relatively equal distribution of fat throughout the body.

The deposition of adipose tissue in the body is a genetically determined process that is controlled by sex hormones. With hormonal dysfunction in men or women, redistribution of adipose tissue may occur according to the type of the opposite sex.

Particular attention should be paid to the process of obesity of internal organs. With a slight excess body weight, its percentage is low, but the higher the degree of obesity, the more fat is distributed around the internal organs. Pathologies of fat metabolism may develop, leading to inclusions of fat drops between the functional cells of organs, which leads to the development of dystrophies of the latter (“tiger” heart, fatty liver, etc.). Any dystrophy is accompanied by disruption or insufficiency of the organ, which leads to the appearance of concomitant diseases.

Clinical picture

In addition to fat deposits, nutritional obesity is characterized by some secondary symptoms. These include shortness of breath and respiratory failure, palpitations during exercise, and increased sweating. They arise due to an increase in the volume of circulating blood along with adipose tissue, but the heart has difficulty coping with such a load and requires the activation of compensatory mechanisms. Shortness of breath may be partly due to the increased size of the internal organs and the greater omentum, which press on the diaphragm from below, thus compressing the lungs. Against the background of a constant excess of lipoproteins in the blood, atherosclerotic vascular lesions develop, which underlies the development of coronary heart disease. Excess fat tissue can lead to the development of type 2 diabetes. Every fat person is a potential diabetic.

Striae may appear on the skin (white or red stripes, similar to scars, appear when a person recovers quickly, but the elasticity of his skin does not allow him to accommodate the sharply increased volume of tissue). Excessive sweating creates favorable conditions for the proliferation of pathogenic bacteria in the folds, which leads to pustular skin diseases. Constant excess pressure on the spine can lead to deformations and curvatures.

Diagnosis of obesity

The international standard for diagnosing obesity is body mass index. It is calculated using the formula: BMI = body weight (kg)/height² (m), (kg/m).

This indicator is very subjective, since it does not take into account the weight of a person’s muscle mass. Based only on body mass index, one can mistakenly assume that an athlete with well-developed muscles is overweight.

During inspection, the following indicators are determined:

1. The thickness of the skin fold on the abdomen, at the angle of the shoulder blade, and shoulder (the norm is up to 1.5-2 cm).
2. Waist circumference. For a man this figure should be less than 101-102 cm, for a woman - less than 87-88 cm.
3. Type of constitution (hypersthenics – people with a strong, stocky build) are most prone to obesity.

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Necessary treatment

In order to reduce or get rid of obesity, a complete reorganization of lifestyle is required. The nutritionist prescribes such a patient a strict diet with limited fats and carbohydrates, gradually reducing the calorie content of the daily diet. Nutritional obesity is by no means cured by fasting. Meals are fractional, in small portions, up to 5-6 times a day. The patient is recommended to have moderate physical activity: walks in the fresh air, therapeutic exercises and physical education. If you feel well, the load can be increased.