Modern approaches to the prevention of obesity

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 the causal relationship of obesity with serious metabolic disorders and cardiovascular diseases determine the importance of this problem for modern health care and allow talking about obesity as a serious threat to public health.

Worldwide, there is a steady increase in the prevalence of obesity. It is shown that the main role in this is played by environmental factors, such as excessive intake of high-calorie foods, rich in fats and easily digestible carbohydrates, a chaotic diet with a predominance of abundant nutrition in the evening and night, and low physical activity. People are prone to overeating fatty high-calorie food, because such food is tastier due to the higher content of fat-soluble aromatic molecules and does not require thorough chewing. An important role is played by the active promotion of high-calorie products in the market.

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

• less than 18.5 - deficiency of body weight;
• 18,5-24,9 - normal body weight;
• 25-29.9 - excess body weight;
• 30-34,9 - obesity of the I degree;
• 35,0-39,9 - obesity of the II degree;
• > 40 - obesity of the third degree.

It is proved that even moderately elevated BMI leads to the development of hyperglycemia, arterial hypertension and dangerous complications. At the same time, the definition of BMI is a fairly simple manipulation, which ensures the timely prevention of these conditions. In general medical practice, it is recommended that BMI be determined in all patients, followed by measures to reduce or maintain its normal level.

The waist circumference (OT) is also important in assessing abdominal obesity. Many researchers believe that this figure plays an even greater role in the prognosis of cardiovascular complications, and especially diabetes. Abdominal obesity is characterized by a special deposition of adipose tissue in the upper part of the trunk in the abdominal region.

Abdominal obesity is noted at OT> 102 cm for men and> 88 cm for women (according to more stringent criteria -> 94 cm for men and> 80 cm for women).

Prevention of obesity is referred to as primary prevention measures that are carried out among healthy people. These measures are most effective when directed at the entire population as a whole. They are based on the principles of healthy eating. Medical workers in these events have a leading and coordinating role.

[1], [2], [3]

Primary prophylaxis of obesity

Primary prophylaxis of obesity should be carried out with genetic and family predisposition, with a predisposition to the development of diseases associated with obesity (type 2 diabetes, arterial hypertension, coronary heart disease), with metabolic syndrome risk factors, with a BMI> 25 kg / m ², especially in women.

Secondary prophylaxis of obesity

Secondary prevention also requires the active involvement of family doctors. Involvement of nutritionists, nutritionists, endocrinologists should promote early detection of obesity and prevention of its consequences and complications.

With a decrease in body weight in persons with excessive weight and obesity, dyspnea decreases with exercise, physical performance improves, hypotensive effect is observed, mood, work capacity, sleep improves, which generally improves the quality of life of patients. Simultaneously, the severity of dyslipidemia decreases, and in the presence of diabetes mellitus, blood sugar levels decrease. Thus, as a result of weight loss, the life expectancy is improved and the risk of developing cardiovascular diseases is reduced.

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

Patients should be taught to distinguish between low-calorie, moderately high-calorie and high-calorie foods. Products recommended for consumption without restriction should provide a feeling of saturation (low-fat varieties of meat, fish), satisfy the needs for sweet (berries, tea with sugar substitute), create a feeling of filling the stomach (vegetables). The diet should be enriched with products with lipolytic properties (cucumber, pineapple, lemon) and increasing thermogenesis (green tea, still mineral water, seafood).

In programs to reduce body weight, you need to include not only dietary correction, but also mandatory aerobic physical training, which will improve or preserve the quality of life of patients. The most effective interventions aimed at correcting obesity include a combination of active nutrition counseling, diet and exercise with behavioral strategies to help the patient acquire appropriate skills.

The duration and intensity of exercise depends on the state of the cardiovascular system. It is obligatory to examine the patient, determine the tolerance to physical exertion. The most accessible and simple method of physical activity is dosed walking or dosed running at a moderate pace. At the same time, the regularity of classes is especially important, which requires strong-willed efforts and a psychological attitude.

It is shown that physical activity leads to a moderate increase in energy consumption and contributes to a change in the energy balance. But sometimes physical loads with undoubted advantage do not give a significant reduction in body weight, which is explained by the redistribution of the fat content (it decreases) in the direction of increasing 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 expectancy of obese patients.

As a primary goal, it is proposed to reduce body weight by 10% for 6 months, which leads to a 10% reduction in total mortality. Practically in 95% of cases it is not possible to reduce body weight for a long time, since obesity is perceived by many patients and, unfortunately, by doctors, still, as a cosmetic, and not a medical problem. That is why most obese patients are self-treated. According to the International Group on Counteracting Obesity (IOTF), one in three obese patients tries to reduce their body weight independently, but without significant effect.

Both the power system and physical loads need careful, well thought out and strictly individual dosing. But often, when a doctor expresses a desire to lose weight, he does not make specific recommendations, leaving the desire to lose weight is nothing more than a wish. Not fully realized that the treatment of obesity, as, incidentally, and the treatment of any other chronic disease, should be continuous. That is, a set of measures aimed at actively reducing excess body weight, in no case should result in the patient returning to a normal diet for him and his family and a way of life. He must smoothly move into a set of measures aimed at maintaining the achieved result.

Obligatory measures for the prevention of obesity

1. Regular assessment of body weight of all patients, determination of waist circumference. If these values are within normal limits or are reduced, the patient should be informed and approved of his behavior.
2. Assessment of the nature of nutrition and eating habits, prognostically significant for the development of obesity, which is desirable to be carried out by all patients regardless of the magnitude of BMI.
3. Informing patients about the dangers of overweight, especially about the risk of developing cardiovascular diseases.
4. Patients with a BMI above 30 should be recommended to reduce their body weight to 27 or lower as a long-term goal. At the same time, a decrease in body weight should not exceed 0.5-1 kg per week. If the changes in nutrition are not effective enough, it is recommended to introduce a low-calorie diet.
5. Constant observation and support of the patient during the treatment of obesity. It is advisable to repeatedly measure BMI every week or at least once every two weeks, check diet diary, express approval and encouragement to the patient, observe the increase in motor activity and physical activity.

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

1. Keeping a food diary.
2. Decreased body weight - a change in lifestyle for a long time.
3. Changing eating habits.
4. The role of physical activity in the treatment of obesity and ways to increase it.
5. Analysis of situations provoking overeating, and the search for ways to eliminate them.
6. Why is it so important to plan the menu for the day.
7. How to correctly read labels on products.
8. The influence of stress and negative emotions on appetite.
9. Food as a way to combat negative emotions, to find alternative ways to deal with them.
10. Ability to own feelings and emotions.

For secondary prevention and treatment of obesity, drug therapy is promising. Treatment of obesity is no less difficult task than treating any other chronic disease. Success in this case is largely determined by the persistence in achieving the goal not only of the patient himself, but also of the doctor. The main task is a gradual change in the patient's wrong lifestyle, correction of the disturbed foodstoreotype, a decrease in the dominant role of nutritional motivation, and the elimination of the wrong connections between emotional discomfort and eating.

Secondary prophylaxis of obesity: medications

Drug therapy is indicated with a BMI> 30 kg / m2, if the effectiveness of lifestyle changes for 3 months. Insufficient, as well as with a BMI> 27 kg / m2 in combination with risk factors (diabetes mellitus, hypertension, dyslipidemia) if within 3 months. There is no positive effect of lifestyle changes on the body weight of patients. Pharmacotherapy makes it possible to increase adherence to non-drug treatment, to achieve more effective weight loss and to maintain a reduced body weight for a long period. Losing weight solves a number of problems that are present in the obese patient, including reducing the need for the use of medicines, antihypertensive, lipid-lowering and anti-diabetic.

The main requirements for drugs used to treat obesity are as follows: the drug should be previously studied in the experiment, have a known composition and mechanism of action, be effective when taken orally and safe for prolonged 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 leaflets, but multicenter, randomized studies.

To reduce body weight, use drugs that affect absorption in the intestine of fats (orlistat) and acting through the central nervous system. However, after the end of taking these medications, the body weight returns to the original, if not to comply with a low-calorie diet.

Orlistat may lead to a moderate weight loss, which can persist for at least 2 years with continued use of the drug. However, data on the efficacy and safety of long-term (more than 2 years) use of drugs are not available, and therefore it is recommended to use pharmacological treatment of obesity only as part of a program that includes actions aimed at changing the lifestyle.

Surgical interventions

The effectiveness of surgical interventions, such as vertical gastroplasty with ribbon, regulated gastric banding with ribbon, has been proven, which allows a significant reduction in weight (from 28 kg to 40 kg) in patients with grade III obesity. Such interventions should only be used in patients with grade 3 obesity, as well as in obesity of grade II, with at least one disease associated with obesity.

Difficulties are not so much in reducing body weight as in maintaining the result achieved for a long time. Often, having achieved success in reducing body weight, after a while, patients regain weight, and sometimes it repeats repeatedly.

WHO recommendations for the prevention of obesity include maintaining a diary of a healthy lifestyle for people with risk factors. In the diary it is recommended to record the dynamics of changes in the main indicators (BP, BMI, OT, blood glucose and blood cholesterol level), daily physical activity, the nature of nutrition. Keeping a diary disciplines and promotes lifestyle modification in order to prevent obesity.

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

However, it makes sense to talk about the effectiveness of a method of treating obesity only if it maximizes the quality of life and is tolerated by the majority of patients, even if prolonged use is not accompanied by a deterioration in health, and its daily reproduction does not cause great inconveniences and difficulties .

The realization that obesity, like no other disease, has a clearly expressed family character, opens up new opportunities for medicine in its prevention and treatment, as well as the prevention and treatment of diseases caused by obesity. Indeed, measures aimed at treating obesity in some family members, will simultaneously be measures to prevent the growth of excess body weight from other family members. The reason is that the methods of treating obesity are based on the same principles as the measures for its prevention. In this regard, medical personnel in working with obese patients and their family members should consider 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 an essential component of the treatment of diseases causally associated with it (arterial hypertension, coronary heart disease, diabetes mellitus);
• both for the treatment of obesity, and for its prevention, it is necessary that the diet be rational, and the way of life is much more active;
• activities aimed at both treating obesity and its prevention, in one form or another should concern all family members and be continuous.

Obesity can not be cured without participation, active cooperation and mutual understanding between the doctor and the patient, so to achieve a good effect, it is simply necessary that patients correctly understand the doctor, the logic and validity of these or other recommendations.

Thus, it is now clear that only moderate and gradual reduction in body weight, elimination of risk factors and / or compensation of obesity-related diseases, individualization of prevention and therapy against the background of an integrated approach involving non-pharmacological and pharmacological methods will lead to long-term results and prevent relapses.

Prof. AN Korzh. Modern approaches to the prevention of obesity / / International Medical Journal - № 3 - 2012