Treatment of obesity

The main direction of obesity treatment is to reduce or prevent weight gain with mandatory reduction of the risk of obesity-related diseases. In case of existing diseases, adequate control of already developed disorders is important. This can be achieved by reducing the caloric content of food intake below the daily energy expenditure. The basis of nutrition is the use of a balanced hypocaloric diet by reducing fat consumption below 30% of the daily caloric content of the diet, sufficient consumption of proteins (15% of the daily caloric content) and carbohydrates (55-60% of the daily caloric content of the diet), vitamins and minerals according to the daily requirement for them. It is important to limit sugars, products rich in easily digestible carbohydrates (melons, grapes, bananas, dates); exclude flavorings and extractive substances; use products with a high fiber content, which promotes rapid saturation, accelerates the passage of food through the intestines and thereby reduces the absorption of nutrients. The inclusion of vegetable fats, fractional meals - 5-6 times a day are mandatory. The use of fasting days: fruit and vegetable, fish, meat, kefir, etc.

Reduced diets containing 500-800 kcal, for example with a sharp restriction of carbohydrates, increased protein or fat content, have no advantages over a well-balanced low-calorie diet. Reduced diets, diets with a sharply reduced calorie content are recommended for short periods and in hospitals. In outpatient settings, the recommended estimated weight loss should be 800-1000 g/week.

Fasting is used in a limited manner, only in hospitals in cases of severe obesity under careful medical supervision due to the possibility of developing serious complications: a decrease in the body's defenses and frequent intercurrent infections, significant loss of protein primarily by muscle tissue, severe vegetative-vascular changes, anemia, nervous and emotional disorders, and impaired liver and kidney function.

Initial weight loss when following a low-calorie diet occurs due to increased carbohydrate metabolism and fluid loss. With further weight loss, most of the body's energy expenditure is covered by accelerating fat metabolism. Therefore, there are two phases of weight loss: Phase I - rapid loss due to glycogen and protein catabolism and water excretion; Phase II - slow - due to fat catabolism.

Against the background of restrictive diets, there is a decrease in the basal metabolism, which contributes to the conservation of energy and a decrease in the effectiveness of dietary measures. Therefore, during the treatment, it is periodically necessary to recalculate towards a decrease in the daily caloric 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, maintaining and even increasing the synthesis of protein in skeletal muscles while simultaneously slowing down its destruction, increasing the effectiveness of insulin.

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

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

The drugs of the first group (phentermine, mazindol (teronac), fenfluramine (minifage), dexfenfluramine (izolipan), sibutramine, fluoxetine, phenylpropanolamine (trimex)) affect mainly the serotonergic system, stimulating the release of serotonin into the synaptic space and/or inhibiting its reuptake. Stimulation of serotonergic structures leads to appetite suppression and a decrease in the amount of food eaten. The drugs 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 drugs in these groups: dry mouth, nausea, diarrhea, irritability, dizziness, sleep disturbance, primary pulmonary hypertension (dexphenfluramine), heart valve disease (fenfluramine/phentermine), slight increase in blood pressure and heart rate (sibutramine). The drug in the third group (Xenical), being a specific long-acting inhibitor of gastric and pancreatic lipases, prevents the breakdown and subsequent absorption of fats in 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, increased frequency or urge to defecate. These effects are manifestations of the mechanism of action of the drug and usually occur in the early stages of treatment (first 2-3 weeks) and 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 components of the drug.

Thyroid hormones are indicated mainly for patients with signs of hypothyroidism. In other cases, the question of prescribing thyroid drugs is decided individually, taking into account age and concomitant diseases. Given the decrease in the level of endogenous T3 _in patients on a low-calorie diet, the prescription of thyroid hormones can be considered justified in many cases. Large doses are usually used (thyroidin 0.3 g, triiodothyronine 60-80 mcg, thyrotom 2-3 tablets per day), but only in a hospital, monitoring the pulse and ECG. It is necessary to remember that weight loss with the introduction of large doses of thyroid hormones can occur due to their catabolic effect.

In some women, ovarian function is restored on its own as body weight decreases or normalizes. More often, drug therapy is required to normalize the menstrual cycle and ovulation. The treatment of women with obesity and polycystic ovary syndrome is most difficult. Therapy is carried out under the supervision of a gynecologist and functional diagnostic tests (rectal temperature).

To restore ovulation, clomiphene citrate (clostilbegit) is used at 50-150 mg per day from the 5th-7th day of the cycle for 5-7 days. The effectiveness of the treatment is assessed 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 luliberin is effective.

Synthetic estrogen-gestagen drugs (bisecurin, non-ovlon, ovidon, rigevidon) are widely used in the treatment of polycystic ovary syndrome in overweight women - 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 (narcolut) are also used.

In order to reduce hirsutism, it is effective to use an antiandrogen - androcur in combination with estrogens - the drug "Diana". A certain effect can be obtained by using veroshpiron at 150-200 mg / day, which, in order to avoid the occurrence of acyclic discharge, is prescribed only in the second phase of the menstrual cycle.

If conservative treatment is ineffective, wedge resection of both ovaries is performed.

In some cases, it is justified to prescribe chorionic gonadotropin to men with excess body weight and sexual dysfunction at a dose of 1000-1500 IU intramuscularly every other day for 1-1.5 months with breaks of 4-6 weeks for 1-1.5 months.

Patients with excess body weight and impaired carbohydrate tolerance without concomitant cardiovascular pathology are prescribed biguanides (metformin), which reduce insulin resistance and glucose production by the liver and have a weak anorectic effect.

The question of using diuretics is decided individually. In the presence of concomitant complications, symptomatic therapy is prescribed. Fluid intake is limited to 1.2-1.5 l/day. Laxatives are prescribed. In case of obesity of the IV degree, surgical methods of treatment are used.

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