Modern approaches to obesity prevention

Obesity, which is a pathological increase in body weight due to excessive accumulation of adipose tissue, is an independent chronic disease and at the same time the most important risk factor for insulin-independent diabetes mellitus, arterial hypertension, atherosclerosis, cholelithiasis and some malignant neoplasms. Evidence of a causal relationship between obesity and serious metabolic disorders and cardiovascular diseases determines the importance of this problem for modern healthcare and allows us to talk about obesity as a serious threat to public health.

The prevalence of obesity is steadily increasing worldwide. It has been shown that the main role in this is played by environmental factors, such as excessive consumption of high-calorie foods rich in fats and easily digestible carbohydrates, chaotic diets with a predominance of abundant food in the evening and at night, and low physical activity. People tend to overeat fatty, high-calorie foods, since such food tastes better due to the increased content of fat-soluble aromatic molecules and does not require thorough chewing. Active promotion of high-calorie products on the market also plays an important role.

There are many instrumental methods that allow determining the content of adipose tissue (bioelectrical impedance, dual-energy X-ray absorptiometry, determination of the total water content in the body), but their use in wide clinical practice is not justified. A more practical and simple method of screening for obesity is the calculation of the body mass index (BMI), reflecting the ratio between weight and height (weight in kilograms is divided by the square of height in meters):

• less than 18.5 - underweight;
• 18.5-24.9 - normal body weight;
• 25-29.9 - overweight;
• 30-34.9 - obesity of the 1st degree;
• 35.0-39.9 - obesity stage II;
• > 40 - obesity stage III.

It has been proven that even moderately elevated BMI leads to the development of hyperglycemia, arterial hypertension and dangerous complications. At the same time, determining BMI is a fairly simple manipulation that ensures the timely prevention of these conditions. In general medical practice, it is recommended to determine BMI in all patients with subsequent measures to reduce or maintain its normal level.

Waist circumference (WC) is also important in assessing abdominal obesity. Many researchers believe that this indicator plays an even greater role in predicting cardiovascular complications and especially diabetes. Abdominal obesity is characterized by a special deposition of fatty tissue in the upper part of the body in the abdominal area.

Abdominal obesity is defined as WC > 102 cm for men and > 88 cm for women (according to more stringent criteria - > 94 cm for men and > 80 cm for women).

Obesity prevention is considered a primary prevention measure that is carried out among healthy people. These measures are most effective when they are aimed at the entire population. They are based on the principles of healthy eating. Healthcare workers play a leading and coordinating role in these measures.

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Primary prevention of obesity

Primary prevention of obesity should be carried out in cases of genetic and family predisposition, predisposition to the development of diseases associated with obesity (type 2 diabetes mellitus, arterial hypertension, ischemic heart disease), in the presence of risk factors for metabolic syndrome, with a BMI > 25 kg/m2 ^, especially in women.

Secondary prevention of obesity

Secondary prevention also requires the active participation of family doctors. Their involvement of dietitians, nutritionists, endocrinologists should facilitate early detection of obesity and prevention of its consequences and complications.

When overweight and obese individuals lose weight, their shortness of breath during physical exertion decreases, their physical performance increases, they have a hypotensive effect, their mood, work capacity, and sleep improve, which generally improves the quality of life of patients. At the same time, the severity of dyslipidemia decreases, and in the presence of diabetes, the blood sugar level decreases. Thus, as a result of losing weight, the prognosis for life improves and the risk of developing cardiovascular diseases decreases.

The basis of the method of reducing excess body weight is a balanced diet in terms of caloric content. It is necessary to explain to the patient the rules of a balanced diet both in terms of caloric content and composition. Depending on the severity of obesity and taking into account the patient's condition and professional activity, a hypocaloric diet is prescribed at 15-30% below the physiological need.

Patients should be taught to differentiate between low-calorie, moderately calorie, and high-calorie foods. Products recommended for unlimited consumption should provide a feeling of satiety (lean meats, fish), satisfy the need for sweets (berries, tea with a sugar substitute), and create a feeling of fullness in the stomach (vegetables). The diet should be enriched with products with lipolytic properties (cucumber, pineapple, lemon) and those that increase thermogenesis (green tea, non-carbonated mineral water, seafood).

Weight loss programs should include not only dietary interventions but also mandatory aerobic exercise training to improve or maintain patients' quality of life. The most effective interventions for obesity correction include a combination of active nutritional counseling, diet, and exercise with behavioral strategies to help the patient acquire appropriate skills.

The duration and intensity of the exercises depend on the state of the cardiovascular system. It is necessary to examine the patient and determine tolerance to physical activity. The most accessible and simple method of physical activity is measured walking or measured running at a moderate pace. In this case, regularity of exercise is especially important, which requires willpower and psychological attitude.

It has been shown that physical activity leads to a moderate increase in energy expenditure and contributes to a change in energy balance. But sometimes physical activity, despite its undoubted benefits, does not provide a significant reduction in body weight, which is explained by the redistribution of fat mass (it decreases) towards an increase in muscle mass. However, despite a slight overall decrease in body weight with increased physical activity, the amount of visceral fat decreases, which is extremely important for reducing the risk of developing concomitant pathology and improving the life prognosis of obese patients.

The proposed primary goal is a 10% weight loss over 6 months, which results in a 10% reduction in overall mortality. In almost 95% of cases, it is not possible to reduce weight for a long time, since obesity is still perceived by many patients and, unfortunately, doctors as a cosmetic rather than a medical problem. This is why most obese patients self-medicate. According to the International Obesity Task Force (IOTF), every third obese patient tries to reduce their weight on their own, but without significant effect.

Both the nutrition system and physical exercise require careful, well-thought-out and strictly individual dosing. But often, when a doctor expresses a wish to lose weight, he does not make specific recommendations, leaving the wish to lose weight as nothing more than a wish. It is also not fully realized that the treatment of obesity, like, incidentally, the treatment of any other chronic disease, should be continuous. That is, a set of measures aimed at actively reducing excess body weight should in no case end with the patient returning to his and his family's usual diet and lifestyle. It should smoothly transition into a set of measures aimed at maintaining the achieved result.

Mandatory measures for the prevention of obesity

1. Regularly assess the body weight of all patients, determine the waist circumference. If these indicators are within the normal range or decrease, the patient should be informed and his behavior should be approved.
2. An assessment of the nature of nutrition and eating habits that are prognostically significant for the development of obesity, which is desirable for all patients regardless of the BMI value.
3. Informing patients about the dangers of being overweight, especially the risk of developing cardiovascular diseases.
4. Patients with a BMI over 30 should be advised to reduce their body weight to 27 or less as a long-term goal. The weight loss should not exceed 0.5-1 kg per week. If dietary changes are not effective enough, a low-calorie diet is recommended.
5. Continuous monitoring and support of the patient during obesity treatment. It is advisable to re-measure the BMI weekly or at least every two weeks, check the food diary, express approval and encouragement to the patient, monitor the increase in physical activity and exercise.

List of topics to discuss with patients in order to successfully change eating behavior

1. Keeping a food diary.
2. Losing weight is a long-term lifestyle change.
3. Changing eating habits.
4. The role of physical activity in the treatment of obesity and ways to increase it.
5. Analysis of situations that provoke overeating and finding ways to eliminate them.
6. Why is it so important to plan your daily menu?
7. How to read food labels correctly.
8. The influence of stress and negative emotions on appetite.
9. Food as a way to deal with negative emotions, finding alternative ways to deal with them.
10. The ability to control feelings and emotions.

Medication therapy is promising for secondary prevention and treatment of obesity. Treatment of obesity is no less difficult than treatment of any other chronic disease. Success is largely determined by persistence in achieving the goal of not only the patient but also the doctor. The main task is a gradual change in the patient's unhealthy lifestyle, correction of the disturbed food stereotype, reduction of the dominant role of food motivation, elimination of incorrect connections between emotional discomfort and food intake.

Secondary prevention of obesity: medications

Drug therapy is indicated for BMI > 30 kg/m2, if the effectiveness of lifestyle changes over 3 months is insufficient, as well as for BMI > 27 kg/m2 in combination with risk factors (diabetes mellitus, arterial hypertension, dyslipidemia), if there is no positive effect of lifestyle changes on the body weight of patients over 3 months. Drug therapy allows to increase adherence to non-drug treatment, achieve more effective weight loss and maintain reduced body weight over a long period. Weight loss solves a number of problems that an obese patient has, including reducing the need for drugs, antihypertensive, lipid-lowering and antidiabetic.

The main requirements for drugs used to treat obesity are as follows: the drug must have been previously studied in an experiment, have a known composition and mechanism of action, be effective when taken orally and be safe for long-term use without the effect of addiction. It is necessary to know both the positive and negative properties of drugs prescribed for weight loss, and the source of such information should not be advertising brochures, but multicenter randomized studies.

To reduce body weight, drugs are used that affect the absorption of fats in the intestine (orlistat) and act through the central nervous system. However, after stopping taking these drugs, body weight returns to its original level unless a low-calorie diet is followed.

Orlistat may result in modest weight loss that may be maintained for at least 2 years with continued use. However, there are no data on the efficacy and safety of long-term (more than 2 years) use of the drugs, and therefore it is recommended that pharmacological treatment of obesity be used only as part of a program that includes actions aimed at changing lifestyle.

Surgical interventions

Surgical interventions such as vertical band gastrectomy, adjustable band gastrectomy have been proven to be effective in achieving significant weight loss (28 kg to 40 kg) in patients with stage III obesity. Such interventions should only be used in patients with stage III obesity, and in stage II obesity with at least one obesity-related disease.

The difficulties are not so much in losing weight, but in maintaining the achieved result over a long period of time. Often, having achieved success in losing weight, patients gain weight again after some time, and sometimes this happens repeatedly.

WHO recommendations for obesity prevention include keeping a healthy lifestyle diary for people with risk factors. The diary is recommended to record the dynamics of changes in key indicators (BP, BMI, WC, blood glucose and cholesterol levels), daily physical activity, and diet. Keeping a diary disciplines and promotes lifestyle modification in order to prevent obesity.

Many doctors judge the effectiveness of a particular treatment method only by the number of kilograms lost in a certain period of time and consider the method to be more effective the more kilograms it allows you to lose in a week (two weeks, a month, three months, etc.).

However, it makes sense to talk about the effectiveness of a particular method of treating obesity only if it maximally preserves the quality of life and is tolerated by the majority of patients, if even its long-term use is not accompanied by a deterioration in health, and its daily use does not cause great inconvenience and difficulties.

The realization that obesity, perhaps more than any other disease, has a distinctly familial nature opens up new opportunities for medicine to prevent and treat it, as well as to prevent and treat diseases causally related to obesity. Indeed, measures aimed at treating obesity in some family members will simultaneously be measures to prevent the accumulation of excess body weight in other family members. This is due to the fact that methods of treating obesity are based on the same principles as measures of its prevention. In this regard, medical personnel in working with obese patients and their family members must take into account the following points:

• the presence of obesity in some family members significantly increases the likelihood of its development in other family members;
• treatment of obesity is a necessary component of treatment of diseases causally related to it (arterial hypertension, coronary heart disease, diabetes mellitus);
• both for the treatment of obesity and for its prevention, it is necessary to have a rational diet and a more active lifestyle;
• Measures aimed at both treating and preventing obesity should, in one form or another, concern all family members and be continuous.

Obesity cannot be cured without the participation, active cooperation and mutual understanding between the doctor and the patient, so to achieve a good effect it is simply necessary for patients to correctly understand the doctor, the logic and validity of certain recommendations.

Thus, today it is obvious that only moderate and gradual weight loss, elimination of risk factors and/or compensation for obesity-related diseases, individualization of prevention and therapy against the background of a comprehensive approach, including non-pharmacological and pharmacological methods, will allow achieving long-term results and preventing relapses.

Prof. A. N. Korzh. Modern approaches to obesity prevention // International Medical Journal - No. 3 - 2012