Treatment of obesity

The main direction of treatment of obesity is to reduce or prevent weight gain with a mandatory reduction in the risk of obesity-related diseases. With existing diseases, adequate monitoring of already developed disorders is important. This can be achieved if the caloric content of the food taken is lower than the daily energy expenditure. The basis of nutrition is the use of a balanced hypocaloric diet by reducing the intake of fats below 30% of the caloric content of the daily diet, sufficient protein intake (15% of daily caloric content) and carbohydrates (55-60% of the daily caloric intake), vitamins and minerals according to the daily need for them. Important is the restriction of sugars, foods rich in fast-digestible carbohydrates (melons, grapes, bananas, dates); Exclusion of flavorings and extractives; the use of foods high in fiber, contributing to rapid saturation, accelerating the passage of food through the intestines and thereby reducing the absorption of nutrients. It is necessary to include vegetable fats, fractional meals - 5-6 times a day. Application of unloading days: fruit and vegetable, fish, meat, kefir, etc.

Reduced diets containing 500-800 kcal, for example, with a sharp restriction of carbohydrates, high protein or fat content, do not have advantages over a well balanced low-calorie diet. Reduced diets, diets with sharply reduced caloric intake are recommended to be prescribed for a short time and in hospitals. In outpatient settings, the estimated estimated body weight loss should be 800-1000 g / week.

Fasting is applied only in a hospital in cases of severe obesity under careful medical control because of the possibility of developing serious complications: a decrease in body defenses and frequent intercurrent infections, a significant loss of protein mainly muscle tissue, pronounced vegetovascular changes, anemia, nervous and emotional disorders , violations of the liver and kidneys.

The initial loss of body weight with a low-calorie diet is due to increased metabolism of carbohydrates and fluid loss. With further reduction in body weight, most of the body's energy expenditure is absorbed by the acceleration of fat metabolism. Therefore, there are, as it were, two phases of its loss: Phase I - rapid loss caused by the catabolism of glycogen, protein and water excretion; II phase - slow - due to fat catabolism.

Against the backdrop of restrictive diets, there is a decrease in basic metabolism, which contributes to the conservation of energy and the reduction of the effectiveness of dietary measures. Therefore, in the course of treatment, recalculation is periodically required to reduce the daily calorie content of food. An indispensable condition for effective treatment is the use of physical exercises to increase the basal metabolism by increasing the mobilization and metabolism of fat, preserving and even enhancing protein synthesis in skeletal muscles while slowing down its destruction, enhancing the effectiveness of insulin action.

Drug therapy is an important component of treatment and is used in combination with hypocaloric nutrition against the background of increased physical activity. The use of drug therapy facilitates compliance with dietary guidelines and promotes faster and more intensive weight loss. And also helps to keep the body weight achieved and prevent its growth. Drug therapy is indicated for patients with obesity (BMI> 30 kg / m ² ), as well as patients with a BMI> 27 kg / m ² in combination with abdominal obesity, a hereditary predisposition to diseases that accompany obesity, and those who have a high risk of developing or already developed concomitant diseases (dyslipidemia, hyperinsulinemia, type II diabetes, arterial hypertension, etc.). Conducting drug therapy is not recommended for children, pregnant and lactating women. On the mechanism of action, drugs for obesity can be divided into three groups:

1. reducing food intake;
2. increasing energy consumption;
3. reducing the absorption of nutrients.

Preparations of the first group (phentermine, mazindol (teronak), fenfluramine (miniphage), dexfenfluramine (insipan), sibutramine, fluoxetine, phenyl-propanolamine (trimix)) exert an influence mainly on the serotonergic system, stimulating the release of serotonin into the synaptic space and / or inhibiting it reverse capture. Stimulation of serotonergic structures leads to suppression of appetite and a decrease in the amount of food eaten. Preparations of the second group (ephedrine / caffeine, sibutramine) increase the activity of the sympathetic nervous system. Sibutramine has a combined effect and stimulates not only serotonergic, but also adrenergic activity. Therefore, taking the drug is accompanied by a decrease in appetite and an increase in energy expenditure. Possible side effects of these drugs are dry mouth, nausea, diarrhea, irritability, dizziness, sleep disturbance, primary pulmonary hypertension (dexfenzhluamine), valvular heart disease (fenfluramine / phentermine), a slight increase in blood pressure and an increase in the heart rate (sibutramine ). The drug of the third group (xenical), being a specific long-acting inhibitor of gastric and pancreatic lipases, prevents the splitting and subsequent absorption of fats of food. The drug has a therapeutic effect within the gastrointestinal tract and does not have a systemic effect. Side effects of xenical: oily discharge from the anus, fatty stool, frequent or urge to defecate. These effects are manifestations of the mechanism of action of the drug and occur, usually in the early stages of treatment (the first 2-3 weeks), are directly related to the amount of fat consumed by patients with food. The drug is contraindicated in patients with chronic malabsorption syndrome and hypersensitivity to xenical or drug components.

Thyroid hormones are indicated mainly in patients with signs of hypothyroidism. In other cases, the question of prescribing thyroid medications is decided individually, taking into account age and concomitant diseases. Given the decrease in the level of endogenous T ₃ in patients with a low calorie diet, the appointment of thyroid hormones can be considered in many cases justified. Usually, large doses are used (thyroidin 0.3 g, triiodothyronine 60-80 μg, thyreotum 2-3 tablets per day), but only in the hospital, by monitoring the pulse and examining the ECG. It should be remembered that a decrease in body weight with the administration of large doses of thyroid hormones can occur due to their catabolic action.

In some women, the function of the ovaries is restored independently on the background of a decrease or normalization of body weight. More often medical therapy is required, aimed at normalizing the menstrual cycle and ovulation. The most difficult treatment for women with obesity and with polycystic ovary syndrome. Therapy is performed under the supervision of a gynecologist and tests of functional diagnostics (rectal temperature).

To restore ovulation clomiphene-citrate (klostilbegit) is used at 50-150 mg per day from the 5-7th day of the cycle for 5-7 days. Evaluation of the effectiveness of treatment is conducted after 6 consecutive courses. To stimulate ovulation, in addition to clomiphene, FSH-containing drugs are prescribed: menopausal human gonadotropin-pergonal-500. The use of exogenous lylyberyrin is effective.

Synthetic estrogen-progestin preparations (bisekurin, non-ovolon, ovidone, and figevidone) were widely used in the treatment of polycystic ovaries in women with overweight, from the 6th day of spontaneous or induced menstruation, 1 tablet daily for 21 days. In some cases, these drugs can contribute to weight gain. Progesterone and synthetic gestagens (narcotics) are also used.

With the aim of reducing hirsutism, the use of antiandrogen, androkura in combination with estrogens, is the drug "Diana". A certain action can be obtained with the use of veroshpiron at 150-200 mg / day, which in order to avoid the appearance of acyclic secretions is assigned only in the second phase of the menstrual cycle.

In the absence of the effect of conservative treatment, wedge resection of both ovaries is performed.

Men with overweight and sexual dysfunction in some cases justified the appointment of a chorionic gonadotropin 1000-1500 units per day in a day for 1-1.5 months with interruptions of 4-6 weeks.

Patients with excessive body weight and violation of tolerance to carbohydrates without concomitant cardiovascular pathology are assigned biguanides (met-formin), which reduce insulin resistance and glucose production by the liver, which have a weak anorexigenic effect.

The question of the use of diuretics is decided individually. In the presence of concomitant complications prescribe symptomatic therapy. Liquid intake is limited to 1.2-1.5 l / day. Assign laxatives. With obesity of the fourth degree, surgical methods of treatment are used.

Forecast, work capacity. In patients with obesity III-IV degree of work capacity is reduced. In most cases, the prognosis for significant improvement, weight loss is favorable. With the progression of the disease and severe concomitant diseases, the outlook is unfavorable.