Approximate unloading diets.

Methods for correcting overweight and treating obesity can be classified into:

Medication - carried out in combination with non-drug methods by specialist doctors (nutritionist, endocrinologist, etc.) or in conjunction with attending doctors or doctors of offices / departments of medical prevention, health centers;

Surgical - are carried out according to special indications in a surgical hospital by surgeons together with doctors, nutritionists, endocrinologists, etc.

The goal of overweight correction is to reduce the Quetelet index to 25 kg / m, waist circumference for men less than 94 cm, for women less than 80 cm.

An intermediate goal for obesity, especially with a significant degree - the Quetelet index is below 30 kg / m, the waist circumference for men is less than 102 cm, for women - less than 88 cm.

The target weight loss in obesity is determined individually, but it is desirable to strive (in the absence of contraindications) to the general target level. Consideration of the total cardiovascular risk is important.

The primary method is focused on determining the indications for correcting excessive MT and choosing tactics, including clarifying the type of obesity, intensity and duration, and concomitant pathological conditions.

The initial examination should include an assessment of the pattern of preventive behavior. The concept of "models of preventive behavior" includes an assessment of the patient's attitude to the revealed excess MT (obesity), the desire to reduce MT and the willingness to follow medical prescriptions and advice. The experience of scientific research shows that the predicted success in reducing excess MT is more often observed in patients with an active attitude to their health, who have a desire for health improvement, but who need medical care. they understand that it will not be easy for them to cope with the problem on their own (model of the perceived need for medical care).

The primary admission of a patient with overweight / obesity can be carried out both by the attending physician and in the medical prevention office / health center.

The majority of patients with excess MT express a desire to normalize their weight, but not in all cases this desire is realized and is associated with a desire to "act". Such patients may be shown to consult a psychologist (if possible). At the same time, a medical prophylaxis physician should have the basic skills of conducting motivational consultations with a preventive aim of increasing an awareness of the health and recovery of patients with behavioral risk factors, which include eating habits (eating behavior). In this connection, at the initial admission, attention should be paid to the assessment of the patient's desire to reduce excess MT, which is established by a simple questionnaire method. If the patient does not have such a desire, then at the first stage he needs to conduct at least a brief counseling, in which it is important to give information about the need to control body weight and maintain it at an optimal level. On the basis of the examination, persons with absolute and relative contraindications are excluded already at the initial admission. These patients (or their relatives) are interviewed and presented with health education materials in the form of memos, leaflets, brochures, reference materials, etc. Individuals with normal MT are also given short advice on healthy eating and weight control. Patients who wish to reduce excess MT, but have a number of contraindications, can be offered, if possible, individual tactics.

Persons who are practically healthy, but overweight (BMI in the range of 25.0-29.9), who do not additionally have other RFs (smoking, dyslipidemia, impaired carbohydrate tolerance, etc.) are invited for group counseling (health schools) or they are encouraged to visit again, the content of counseling on a return visit is similar to the topic of the lesson in the School of Health with excessive MT.

Persons with BMI> 30.0 with a diagnosis of obesity and persons with excessive BMI (BMI 25.0-29.9) with concomitant RF are scheduled for repeated visits, with them repeated supportive counseling and body weight control.

Perhaps the appointment of an additional (strictly according to indications) against the background of diet therapy, drug and / or surgical treatment. If necessary, consultations of other specialists are prescribed: endocrinologist, psychotherapist, reflexologist, exercise therapy doctor, surgeon, etc. Self-control of MT is recommended for all patients.

Medical correction of obesity
The use of medicines is indicated for:

Ineffectiveness of diet therapy and other methods of non-drug intervention;

Complicated forms of obesity (treatment of concomitant pathology);

With an MT index of more than 30 kg / m or more in any case and an index of 27 kg / m or more in the presence of AO or risk factors and concomitant diseases. You can immediately prescribe drug therapy against the background of a diet.

Secondary obesity, when there is a pathology from the endocrine system (treatment of the underlying pathology).

All drugs prescribed for obese patients are used strictly according to indications and contraindications. Contraindications for drug treatment are: children's age; pregnancy; a history of serious side effects when using drugs of a similar type; simultaneous use of drugs with a similar mechanism of action

Medicines used for obesity are divided into the following groups:

Directly used for obesity

Hormonal, improving metabolism

Vitamins, amino acids and minerals to help balance a reduced diet

Symptomatic drugs: antihypertensive, diuretic, laxative, hepatotropic, antidiabetic, hypolipemic, etc.

According to the mechanism of action, the drugs of the 1st group for the treatment of obesity can be conditionally divided into 2 subgroups:

Central actions that reduce appetite: anorectics, acting on adrenergic serotonergic structures (specific drugs and their dosages are determined by the attending physician, since there are contraindications to the use of each of them)

Reducing food absorption - means of gastrointestinal effects: orlistat - an inhibitor of pancreatic lipase. Reduces fat absorption by 30%. It is prescribed by a doctor in an individual dose for each patient.

Orlistat treatment can be continued for up to 6 months under medical supervision. Repeated courses are possible. From the point of view of evidence-based medicine, there is no information about their effective and safe long-term use.

Surgical methods of correction for obesity.

Invasive conservative (plasmapheresis, hemosorption, etc.) and surgical (gastroplasty, formation of a "small" stomach, bowel resection, etc.) are most often used for strictly defined health indications, when there is high obesity, with a body mass index of more than 35 and concomitant risk factors and / or diseases that cannot be corrected conservatively and / or occur with typical complications (secondary endocrine disorders, hernia of the spinal column, severe coxoarthrosis, etc.).

More gentle operations of liposuction, liporesection with plastic surgery of the abdominal wall, etc. have more cosmetic value and can be carried out in the absence of well-known general surgical contraindications, at the request of the patient.

It is known that the physical development of a person as a process of change and formation of morphological and functional properties depends both on heredity and on living conditions, as well as on physical education from the moment of birth. Of course, not all signs of physical development are equally amenable to correction at student age: the most difficult is height (more correctly, body length), much easier - body weight (weight) and individual anthropometric indicators (chest circumference, hips, etc.) ).

In this work, we will consider what means and methods of physical culture each student who wishes can correct and maintain their anthropometric indicators, in particular, body weight.

Prospects for the formation of an ideal figure depending on the type of physique

wellness physique physical regimen

Unlike height, body weight (weight) lends itself to significant changes, both in one direction and the other, with regular engagement in certain physical exercises or sports (with a balanced diet).

Before you start training, you need to accurately assess your data: general health, heart readiness for physical activity and body type. People with different body types respond differently to the same training system. What gives great results for one may not work for another.

As you know, the norm of body weight is closely related to the growth of a person. The simplest height-weight indicator is calculated by the formula: height (cm) - 100 = weight (kg). The result shows the body weight normal for a person of a given height. However, this formula is suitable only for adults with a height of 155-165 cm.When a height of 165-175 cm, 105 must be subtracted, with a height of 175-185, 110 must be subtracted.

You can also use the weight and height indicator (Ketley index). In this case, by dividing body weight (in g) by height (in cm), the quotient is obtained, which should be about 350-420 for men and 325-410 for women. This indicator indicates excess body weight or lack of it.

The directional change in body weight is quite accessible at a student age. The problem is different - it is necessary to change the usual way of life. Therefore, preventing or treating obesity is largely a psychological problem. But whether or not you need to significantly change your body weight, you decide for yourself when assessing the proportionality of your body. It remains to choose the types of sports (exercises) for regular exercise, especially since some types contribute to weight loss (all cyclic - running for middle and long distances, cross-country skiing, etc.), others can help "gain" body weight (weightlifting , athletic gymnastics, kettlebell lifting, etc.).

The true anthropometric proportionality of the human body, recognized by both anatomists and biodynamicists, is based on the views of the ancient Hellenes, in whom the cult of the human body was quite high. This is especially clearly reflected in the classical proportions of the works of ancient Greek sculptors. The basis for their development of body proportions were taken units of measure, equal to one or another part of the human body. This unit of measure, called the modulus, is the head height. According to Poliklet, the height of the head with a normal figure of a person should fit eight times in the height of the body. So, according to the "square of the ancients", the range of outstretched arms is equal to the height of the body. The length of the thigh fits four times in the height of the growth, etc.

Basic body types

  • * asthenic (ectomorphic);
  • * hypersthenic (endomorphic);
  • * normosthenic (mesomorphic).


First of all, the correction of physique by means of physical culture implies the regulation of body weight. During physical education, excess adipose tissue is consumed to generate the required amount of energy for exercise. As a consequence, there is a decrease in excess weight. At the same time, it goes without saying that our physique will certainly change towards a slender figure. An increase in body weight can also lead to an improvement in body type, but only when this is due to the growth of muscle tissue. You can achieve a significant increase in muscle tissue by such means of physical education as weightlifting and bodybuilding. However, for the vast majority of women, this is probably not the most suitable option, since in this case the physique of the fair sex will acquire masculine features. A much more successful option for correcting the physique by means of physical culture are classes in various types of athletics. Each sport of this category forms certain features of the figure, which, quite possibly, will be the desired results of body correction. How do different types of light gymnastics affect anthropometric characteristics?

When jogging, women form a correct posture and a symmetrically developed body. Correcting the physique through jumping exercises can reduce body weight, lead to strong chest development, and increase the leg-to-body ratio. When correcting the physique with the help of such a means of physical culture as gymnastics, a small body weight, long thin legs, a narrowed pelvis are achieved, which together gives a slender athletic figure. Synchronized swimming or figure skating will allow you to correct your physique through the formation of a strictly symmetrical body, correct beautiful posture, slender legs, and development of the chest.

It should also be borne in mind that the best results when correcting physique by means of physical culture can be achieved in childhood and adolescence. During this period, the body is still developing, so unwanted body traits can be corrected quite easily. In adulthood, it is much more difficult to correct the physique, since the body has already been formed, the growth has stopped, the growth zones of the bones are already "closed" for exposure to the means of physical culture. However, physique correction by reducing excess body weight (i.e., reducing excess body fat) during physical education can be carried out at any age (of course, in the absence of contraindications to physical activity). In addition, some body flaws can be completely hidden by practicing plastic and beautiful movements. This, again, is achieved at the expense of physical education.

You can do body correction not only in fitness clubs, but also independently (evening and morning jogging in stadiums or parks, jumping rope, performing general physical exercises at home).

Osteoarthritis (OA) is the most common joint disease, accounting for more than 70% of adults aged 55 to 78 years. The widespread prevalence, chronic pain syndrome and a high percentage of the development of temporary and permanent disability in OA have a negative impact on the lives of patients and society as a whole.

Today, OA is called a heterogeneous group of diseases of various etiologies with similar biological, morphological, clinical manifestations and outcomes, which are based on the defeat of all components of the joint, primarily cartilage, as well as the subchondral bone, synovial membrane, ligaments, capsule, periarticular muscles.

Currently, joint diseases are considered not only from the standpoint of local pathology, but also from the standpoint of the violation of many metabolic factors. Along with obesity in patients with gonarthrosis, pathology of the cardiovascular system (CVS) is especially often revealed, including arterial hypertension (AH), coronary heart disease (IHD), cerebrovascular disorders, up to stroke. Special attention should be paid to the fact that there is a double increase in the incidence of ischemic heart disease in persons with gonarthrosis compared with the corresponding contingent of patients without signs of gonarthrosis.

Due to the complex combination of various causes and mechanisms of the development of OA and taking into account the high frequency of comorbid diseases, the treatment of OA is a difficult task. Classical drug therapy for OA leads to a variety of adverse drug reactions. Surgical treatment of OA in patients of the older age group is not always possible due to the presence of contraindications (risk of thromboembolic complications, instability of the endoprosthesis, infectious complications). Early endoprosthetics for joint diseases also has a number of disadvantages. In proportion to the age of the operation, the need to replace an artificial joint or one of its components increases. In this regard, great importance is attached to the methods of non-drug therapy of OA. In particular, in the recommendations of the International Society for the Study of Osteoarthritis (Osteoarthritis Research Society International, OARSI) 2014, non-drug therapy is considered as the "core" of the methods of treating this disease. These include: doing exercises on land and in the water, strength training, using educational programs for the sick, and correcting excess body weight.

The treatment of obesity in OA seems to be especially important, since, according to modern data, it is a risk factor for the development of not only OA, but also many other diseases associated with metabolic disorders. Up to 44% of cases of diabetes mellitus (DM), 23% of coronary artery disease and up to 41% of hypertension are due to overweight and obesity. It is important to note that in Russia at present more than 25% of the population is diagnosed with obesity, and 55% are overweight.

Joint dysfunctions and disabilities, usually accompanying OA, in turn lead to an increase in body mass index (BMI) and induce the development of cardiovascular diseases and diabetes mellitus. Currently, the role of overweight in the onset and progression of OA is recognized by most authors. At the same time, the excess of body weight by 5.1% is significant. The fact that OA often develops in joints that are not related to the direct mechanical effect of excess weight suggests that there are some other mechanisms associated with obesity that can alter the metabolism of cartilage and bone tissue and lead to the development of the disease.

According to the literature, a decrease in body weight by 5-10% from the initial level is accompanied by a decrease in pain syndrome in OA, as well as a significant improvement in the course of diabetes, hypertension, ischemic heart disease. Weight loss is undeniably based on changing dietary habits. First of all, it is recommended to reduce the caloric content of food due to foods rich in fats and light carbohydrates, enrich the diet by replacing meat and sausages with fish, introducing a sufficient amount of fiber-rich foods (fresh vegetables, fruits, a sufficient amount of leafy greens). It is necessary to remember about the mode of food intake, fractional meals in small portions are useful.

Dietary measures for correcting body weight must be combined with physical activity. The main problem in recommending weight loss to patients with OA is associated with low motor activity in this group of patients for a number of factors: increased pain in the joints with increased motor activity, exacerbation of cardiovascular diseases and pain syndrome when exercising in health groups. In this regard, patients with comorbid pathologies should be recommended a number of specially selected rehabilitation measures. It is better to start physical therapy in the mode of individual lessons with frequent repetition of exercises during the day and a gradual increase in load, expansion of the range of motion in all joints. When performing a 30-40 minute exercise without exacerbating the pain syndrome, group exercises are recommended.

In order to increase the effectiveness of the therapy, it is necessary to apply a comprehensive program of rehabilitation treatment, including various means of rehabilitation (physical exercises, hydrokinesis therapy, position correction, therapeutic massage, post-isometric muscle relaxation, physiotherapy, etc.), depending on the period of the disease and the severity of joint dysfunction. In the initial stages of OA without signs of joint instability, it is possible to recommend walking with a gradual increase in the load from 5 to 30 minutes 3 days a week. Aerobic exercise (walking, cycling, swimming, pool exercise) and isometric exercise lead to increased muscle strength and endurance, as well as a decrease in body weight, which in turn leads to less stress on the joint. The inclusion of isometric exercises in the complex of physiotherapy exercises allows you to strengthen endurance and muscle strength. With a pronounced degree of OA with the formation of joint contractures, the maximum unloading of the affected joints is shown in combination with measures aimed at improving the mobility of the joints and increasing the daily activity of the patient. You can control the effect of the load on the affected joints using orthopedic shoes, periodically - a cane when walking, in case of significant joint damage - elbow crutches "Canadian type" or walkers and orthoses for joints. So, for example, in OA of the hip joints, walking with a cane reduces the load by 50%.

Physical exercises in water, hydrokinesis therapy allow to engage in physiotherapy exercises for patients with heavy weight, combined pathology of load joints and spine, CVS diseases. In the pool, movements are greatly facilitated, which reduces the load on the axial skeleton, at the same time practically all muscle groups are involved in the work, the blood circulation of organs and tissues improves, which is accompanied by increased energy consumption. As a result of the high heat capacity of water, metabolic processes in adipose tissue are enhanced. It must be remembered that treatment sessions should take place in cool or moderately warm water for no more than 45 minutes with a preliminary 10-15-minute warm-up on land. To improve the general aerobic condition of the muscles, patients with OA and obesity are advised to walk on level ground at a moderate pace with a gradual increase in duration to 30-60 minutes. With pain syndrome that does not allow long walks, "Scandinavian" (or Nordic) walking is indicated - a highly effective and accessible form of physical activity, which uses a certain walking technique and special sticks to evenly distribute the load on the muscles of the whole body. Unlike running, cycling or just walking, "Nordic walking" simultaneously stimulates the muscles of the shoulder girdle, arms and abdomen, while unloading the hip, knee, ankle joints and lumbar spine, burns 46% more calories than normal walking. At the same time, the use of this technology of rehabilitation treatment allows, without exerting a significant effect on hemodynamic parameters, to increase exercise tolerance and improve the quality of life of patients with CVS pathology by increasing their vital activity, mental health, role functioning due to physical and especially emotional state. All controlled studies have shown that exercising increases exercise tolerance, and that physical and social activity of patients is behind this. Regular exercise allows you to improve coordination of movements and strengthen the muscle corset, which leads to a decrease in the risk of falls, outdoor exercise promotes the active synthesis of vitamin D3, significantly reducing the risk of osteoporosis and its complications (fractures) in the elderly. Thus, the use of non-drug methods of therapy for OA is an important component of the treatment and rehabilitation of patients with this disease.

The aim of this work was to investigate the effectiveness of correction of increased body weight in the treatment of primary OA.

Materials and research methods

We observed 80 patients with primary OA. The diagnosis was established in accordance with the criteria of the American College of Rheumatology (ACR), 1986, 1991, Institute of Rheumatology, Russian Academy of Medical Sciences (1993). All patients were examined at least twice, at the time of visiting a doctor and after 3 months. At the initial visit, a complete clinical and laboratory examination was carried out.

The WOMAC functional indices were used to assess the dynamics of the pain syndrome level in patients with OA of the knee and hip joints. Patients with primary OA were between the ages of 38 and 78 years, of which there were 52 (65%) women (mean age 52.08 ± 1.58 years) and 28 (35%) men (mean age 54.07 ± 2.0 years).

The study recruited patients with increased body weight. All patients were recommended a hypocaloric diet with a low content of animal fats, physiotherapy exercises in a gentle mode without support on their legs, if possible - "Scandinavian walking", classes in the pool. Positive dynamics for a decrease in body weight by 5 kg or more in 3 months was achieved by 18 patients (23%).

To study the effect of weight loss on the clinical manifestations of OA, the patients were divided into two groups. The first group consisted of patients who managed to reduce body weight by 5 kg or more (18 people), the second - patients whose body weight loss was less than 5 kg, and patients without weight loss (62 people). As a result of the study, the dynamics of clinical manifestations of OA was assessed, as well as the dynamics of blood pressure, carbohydrate and lipid metabolism in these groups of patients. The data are presented in table.

The table shows that against the background of a decrease in body weight of more than 5 kg, there was a significant decrease in the severity of clinical manifestations of OA (a decrease in the level of pain syndrome according to the visual analogue scale (VAS) at rest and while walking, the total indicator according to WOMAC), C-reactive protein. At the same time, a decrease in metabolic disorders was noted (a decrease in the level of glycemia and an improvement in the parameters of the lipid profile).

Currently, the concept of the relationship between chronic inflammation and diseases associated with obesity has become widespread. It is assumed that with an increase in the mass of adipose tissue, the number of macrophages infiltrating it increases. These data formed the basis for the hypothesis that the inflammatory process in adipose tissue is the cause of systemic metabolic and vascular disorders. It has been shown that white adipose tissue is an active endocrine organ due to the synthesis of pro-inflammatory factors by its cells, such as interleukin-1 and tumor necrosis factor-α, as well as a large number of adipokines, which can take an active part in the development of degenerative changes in the joints in patients. with obesity.

Thus, the study of the functions of adipose tissue, the biology of cytokines and adipokines, their active interaction and participation in immunopathological processes contributes to a better understanding of the effect of body weight on the course of pathogenetically interrelated diseases. As a result of regular physical activity, the quality of life of patients increases, their social activity is maintained. Reducing body weight by following dietary recommendations and including various types of physiotherapy exercises in the complex treatment of OA makes it possible to improve the patient's functional capabilities by restoring his physical, psychological and social status to the optimally achievable level determined by the capabilities of the body's adaptive mechanisms.

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Yu. V. Polyakova 1
L. E. Sivordova, Candidate of Medical Sciences
Y. R. Hakhverdyan, Candidate of Medical Sciences
B. V. Zavodovsky, Doctor of Medical Sciences, Professor
A. B. Zborovsky,Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences

Obesity and overweight have become a global epidemic with an increased risk of developing clinically important comorbidities, as announced by WHO in 1997. The prevalence of obesity is increasing among adults and children of all ages. Over the past 40 years, the prevalence of obesity in the United States has increased from 13 to 31%, and the number of overweight people in the population has increased from 31 to 34%.

A.V. Kaminsky, MD, PhD, Senior Researcher, Department of Radio-Induced General and Endocrine Pathology; Scientific Center for Radiation Medicine of the Academy of Medical Sciences of Ukraine, Kiev

Studies in the United Kingdom and the United States show a consistent increase in obesity prevalence with age in both men and women. Our pilot studies in 2003 showed that in Ukraine the prevalence of obesity among people over 45 years old can be 52%, and overweight - 33% (obesity + overweight is 85%). Normal body weight is observed only in 13% of the adult population of Ukraine.

Obesity is a complex chronic disorder of lipid metabolism with excessive accumulation of fat (triglycerides) in different parts of the body, accompanied by an increase in body weight and the subsequent development of various complications.

Obesity is the result of an excess of the intake of calories in the body with food over the expenditure of calories, especially with a deficit of movements, that is, the result of maintaining a positive energy balance for a long time.

Obesity is a disease and is not currently viewed as a psychological problem characterized by low discipline or weak willpower. Only recent studies have partially explained the biochemical and genetic factors involved in the etiology of obesity, pointing the way towards more effective treatments for it.

In the United States alone, more than 400,000 people a year die from the effects of obesity. The medical costs and disability costs associated with obesity are more than $ 100 billion annually. The total economic harm due to obesity exceeds that in comparison with cancer. In obese women, a moderate loss of body weight (by 10% of the original) leads to a decrease in disability by 20%.

Overweight and abdominal obesity determine the risk of developing type 2 diabetes mellitus (2-3 times more often), arterial hypertension, dyslipidemia, coronary heart disease, hyperlipidemia, atherosclerosis and its clinical manifestations, varicose veins, thrombophlebitis, cholelithiasis, arthritis, osteochondrosis, flat feet, gout, Pickwick's syndrome (attacks of hypoventilation and drowsiness up to sleep apnea), hepatic steatosis, etc. Obesity is an independent risk factor for cardiovascular diseases. Body weight is a more reliable predictor of coronary heart disease than blood pressure, smoking, or impaired glucose tolerance. Morbidity and risk of premature death are directly related to the amount and type of distribution of excess fat.

Excess visceral fat is closely correlated with various pathologies and occurs in:

  • 57% of patients with type 2 diabetes;
  • 30% - with diseases of the gallbladder;
  • 75% - with arterial hypertension;
  • 17% - with coronary heart disease (IHD);
  • 14% - with osteoarthritis;
  • 11% - with cancer of the breast, uterus and colon.

Prospective studies have shown that obesity is the main risk factor for the development of type 2 diabetes. According to the latest surveys conducted in the United States, the risk of diabetes increases by 9% for every additional kilogram of excess body weight. The risk of developing type 2 diabetes in obese patients increases in direct proportion to body weight and the duration of obesity. Large demographic studies in Sweden have shown that abdominal obesity is the main risk factor for developing diabetes.

Obesity in diabetic patients increases cardiovascular risks and mortality. Compared with people with normal weight, the relative mortality rate is 2.5-3.3 times higher for people with diabetes and obesity (overweight 20-30%), 5.2-7.9 times higher for overweight body by more than 40%. A mass index exceeding 30 kg / m 2 is critical for the onset of type 2 diabetes, and an increase in body weight within 5-10 years precedes its manifestation. At a younger age, critical body weight is maximally associated with the development of diabetes in the future, the risk is especially high with rapid weight gain in the period of 20-30 years.

The results of the Finnish Diabetes Prevention Program (3200 patients with increased body weight and impaired carbohydrate tolerance) showed that even a slight decrease in body weight (by 7%) leads to a significant decrease in the negative consequences and risk of developing diabetes mellitus.

In general, weight loss reduces the risk of overall mortality by 25% and the risk of mortality from cardiovascular disease by 28%.

Obesity classification

Obesity is defined as being over 25% overweight for men and over 35% overweight for women compared to ideal weight for height.

The World Health Organization (WHO) has proposed a unified indicator for assessing body mass - body mass index (BMI). It is currently the most important criterion for obesity. BMI is an important indicator for controlling health risk factors and depends to some extent on ethnicity. The formula for calculating this index is as follows: BMI (kg / m 2) = the ratio of body weight (in kg) to height (in m 2). In many Western countries it is called the Quetelet index (Table 1).

Obesity is considered to be an excess of BMI of more than 29.9 kg / m 2 (normal limits are 18.5-25 kg / m 2), which is divided into three degrees.

Waist circumference is also an important indicator of risk for abdominal obesity. For men, it corresponds to more than 102 cm, for women - more than 88 cm.

Another risk factor for complications is the degree of weight gain throughout life. Thus, an increase in body weight after 18-20 years by more than 5 kg increases the risks of developing diabetes mellitus, arterial hypertension and coronary heart disease.

The diagnosis of obesity should include not only anthropometric data, but also anamnesis of the disease, a study of health status, health risks, laboratory tests, and an assessment of the psychological status of patients.

Height, body weight, BMI, form of fat distribution (gynoid or android), presence of thyroid pathology, cardiovascular pathology, arterial hypertension, cancer, diabetes mellitus and dyslipidemia should be assessed.

Obesity treatment

The goal of obesity treatment is to gradually reduce body weight to real values, as well as prevent subsequent morbidity and mortality associated with obesity.

The goals of body weight correction:

  • preventing further weight gain;
  • decrease in body weight by 10-15% (from the initial values);
  • maintaining the achieved weight values ​​for a long time;
  • reducing risk to improve quality and increase life expectancy.

Maintaining the achieved values ​​of body weight is more difficult task than losing weight itself. It requires lifelong lifestyle adjustments, behavioral responses, and dietary therapy. Therefore, weight management programs should emphasize the continuity of such therapy throughout life.

The mainstay of obesity treatment is restricting caloric intake and increasing physical activity, achieving energy balance, which is part of the concept of lifestyle.

However, it should be understood that only 42% of obese patients will comply with the doctor's recommendations. For most obese patients, the target body weight loss should be up to 10-15% / year.

The treatment of overweight and obesity is a multi-step process that includes a series of studies, lifestyle changes, drug therapy and, in some cases, surgery. It should not be forgotten that drug therapy for obesity is recommended as an adjunct to lifestyle modification.

Lifestyle change

Lifestyle changes include attitudes toward your diet, physical activity, and body weight. Patients should keep a daily self-control log, weigh food and assess their calorie content. Emotional control complements diet therapy and may include periods of relaxation, meditation, and others. Also, patients can participate in closed support groups (10-20 people), which are designed to create positive emotions, promote self-affirmation, and visually assess the success of other patients. The spouses should be included in the treatment process. Lack of interest in losing weight in a spouse increases the likelihood of abandoning the weight loss program.

The principles of dietary therapy for overweight and obesity are based on several important rules.

  1. Calorie restriction of food.
  2. Significant reduction in fat intake, especially of animal origin.
  3. The maximum reduction in food intake in the evening.
  4. Food should be taken at least four times a day.
  5. All dietary restrictions of the patient must apply to the entire family. There should be no products at home that are "forbidden" to the patient. You should eat slowly.

Calorie restriction

Diet restriction in obese patients can be moderate or significant, depending on the possible health risk. There are two levels of calorie restriction - a low-calorie diet (LCD; calorie intake is 800 to 1800 kcal / day), which is acceptable for most obese patients, and a specialized ultra-low-calorie diet (VLCD; food intake is 250-799 kcal / day) prescribed to patients with a high level of health risk.

Successful weight loss depends largely on adherence to a low-calorie diet, when energy expenditure per day is greater than the number of calories received from food. The use of a low-calorie diet can reduce body weight by 10%. However, only 15% of patients follow such a diet.

The NHLBI and NAASO recommend a low-calorie diet of 1000-1200 kcal / day for women and 1200-1600 kcal / day for men (as well as for women who regularly exercise or weigh less than 75 kg) as a standard.

In the presence of concomitant pathology (diabetes mellitus, hyperlipidemia, arterial hypertension, etc.), in addition to the nutritionist, doctors of the relevant specialties should take part in the preparation of the menu. Making a menu without a dietitian is unacceptable!

Drug therapy

One of the reasons many doctors refuse to treat obesity is that they do not have in their arsenal sufficiently effective and safe means to reduce body weight. Currently, only two drugs have been approved by the FDA for long-term use: sibutramine and orlistat. At the same time, only orlistat is recommended for long-term use - safety was assessed in the XENDOS study for 4 years, and the intake of sibutramine is limited to 1 year of admission.

As monotherapy, any drug can reduce body weight by no more than 8-10% per year, from baseline values. However, to minimize the risks of obesity and diabetes, weight loss should be greater than 12%. This is a goal that cannot be achieved through drug monotherapy alone.

Medicines are recommended to be prescribed to obese patients only as part of a comprehensive program that includes diet therapy, physical activity, behavior correction and diet, which accelerates the process of weight loss and is carried out under the supervision of experienced doctors (endocrinologist, therapist, family doctor).

Principles of drug therapy for overweight and obesity.

  1. The use of drugs approved by the FDA for long-term use.
  2. The drugs can only be used as part of a comprehensive diet and exercise program.
  3. The drugs should not be used alone.
  4. Drug therapy is indicated for patients with a BMI of 30 or higher without associated risk factors for obesity.
  5. Drug therapy is indicated for patients with a BMI of 27 or higher with concomitant risk factors for obesity (hypertension, dyslipidemia, type 2 diabetes, rest asphyxia).

Modern official medicine gives preference to drugs, the clinical efficacy of which has been proven by many multicenter, placebo-controlled and randomized studies using the principles of evidence-based medicine

Medicines used to reduce body weight are divided into two main groups: drugs to reduce appetite and drugs that reduce the absorption of nutrients (fats, carbohydrates, etc.) - dietary correctors. A number of other drugs are also distinguished, including trace elements, vitamins, amino acids, peptides, hormones, etc. In particular, ADA and AACE recommend the use of drugs that have passed full clinical trials and approved by the FDA.

Not all drugs are equally safe. Centrally acting drugs (noradrenergic drugs), such as phentermine, are approved by the FDA, but are only recommended for short-term treatment as an adjunct to mainstream obesity treatment. When taking drugs based on benzfetamine or phendimetrazine, there is a high risk of abuse of these drugs.

In general, we propose to divide drugs for weight loss into several groups (Table 2). All of them allow you to change eating behavior. Effective drugs for weight loss are those that reduce the original weight by at least 5% / year.

Central-acting drugs that raise serotonin levels have previously been widely used for weight loss, but have serious side effects. For example, fenfluramine was removed from the US drug market because of the damage to the valvular heart. Serotonin reuptake inhibitor drugs similar to fluoxetine have not shown long-term efficacy. Therefore, the FDA has not registered any of the noradrenergic drugs for the long-term treatment of obesity. Centrally acting drugs with amphetamine-like action, although approved for use in a number of countries, their use is significantly limited.

Sibutramine showed long-term efficacy in reducing body weight and reducing blood fat metabolism, however, in some patients, there was a statistically significant increase in blood pressure, increased heart rate (and therefore they could not continue taking the drug). Frequent side effects such as xerostomia, constipation, headache and insomnia, plus limited effectiveness, prevent its widespread use.

The FDA has approved the only drug to reduce fat absorption, orlistat (Xenical). This drug is a lipase inhibitor and blocks the absorption of some of the fat from food. Xenical is the most studied and safest drug for correcting body weight; it does not have a negative effect on the cardiovascular system.

Comparative characteristics of the efficacy and safety of orlistat and sibutramine are shown in Table 3.

Since July 1998, when Xenical was approved for use in Europe, 20 million patients have received orlistat worldwide. The drug is approved for use in 140 countries. In the United States, it is approved by the FDA for the treatment of obesity on April 26, 1999.

Orlistat (Xenical) is a synthesized stable substance (tetrahydrolipstatin), which is similar to the waste product of the bacteria Streptomyces toxytricini - lipstatin. The molecular weight of Xenical (C 29 H 53 NO 5) is 495.74. The drug has a high lipophilicity, dissolves well in fats, and its solubility in water is very low.

The drug has no systemic effect, is practically not absorbed from the intestine. Xenical mixes with drops of fat in the stomach, blocks the active center of the lipase molecule, preventing the enzyme from breaking down fats (triglycerides). Due to the structural similarity of Xenical with triglycerides, the drug interacts with the active site of the enzyme - lipase, covalently binding to its serine residue. The binding is slowly reversible, but under physiological conditions, the suppressive effect of the drug during the passage through the gastrointestinal tract remains unchanged. As a result, about 30% of food triglycerides are not digested or absorbed, which allows you to create an additional calorie deficit compared to diet alone, equal to about 150-180 kcal / day. Undigested triglycerides cannot enter the bloodstream and are excreted in the feces, which creates an energy deficit and contributes to weight loss. Xenical does not affect the hydrolysis and absorption of carbohydrates, proteins and phospholipids.

An orally taken dose of Xenical is almost completely (about 97%) excreted in the feces, with 83% being eliminated as an unchanged drug.

More than three quarters of patients taking Xenical and following a diet achieved a clinically significant decrease in body weight after 1 year (more than 5% of the initial body weight). When taking Xenical and following a diet after 1 or 2 years of treatment, more than 10% of the initial body weight lost twice as many patients than when following a diet and taking a placebo. It can be predicted that patients who strictly adhere to the recommendations received (as can be judged by a decrease in body weight by more than 5% in 3 months), by the end of the first year of treatment, will greatly reduce their body weight (by 14%). After the initial weight loss, the patients receiving the placebo and diet regained twice as much as the patients receiving the diet and Xenical.

It is preferable to prescribe Xenical to all obese patients who have an addiction to fatty foods. When analyzing the content of fats in the patient's diet, one should keep in mind not only animal, but also vegetable fat, not only explicit, but also hidden fats (T.G. Voznesenskaya et al.).

In addition to its weight loss mediated effects, Xenical has an additional beneficial effect on total and LDL cholesterol levels. The use of Xenical reduces the amount of free fatty acids and monoglycerides in the intestinal lumen, reduces the solubility and subsequent absorption of cholesterol, and helps to reduce hypercholesterolemia. The LDL / HDL ratio of a well-known predictor of cardiovascular risk after 1 and 2 years of treatment with Xenical significantly improved (p< 0,001 и р < 0,001 соответственно по сравнению с группой плацебо). Достоверное улучшение за 2 года лечения Ксеникалом было отмечено и со стороны апоВ- и липопротеина – двух хорошо известных сердечно-сосудистых факторов риска.

Xenical reliably reduces high blood pressure. The decrease in body weight after 1 and 2 years was accompanied by a decrease in both systolic (SBP) and diastolic (DBP) blood pressure. In high-risk patients (baseline DBP 90 mm Hg), Xenical treatment reduced it by 7.9 mm Hg. Art. by the end of the first year, while taking placebo, the decrease in DBP was 5.5 mm Hg. Art. (p = 0.06). Similar results were obtained for SBP in high-risk patients (baseline SBP 140 mmHg). At the same time, in patients receiving placebo, it decreased by 5.1 mm Hg. Art., and for those who received Xenical - more than 10.9 mm Hg. Art. (R< 0,05). Таким образом, полученные результаты показывают, что Ксеникал в сочетании с диетой более эффективно снижает артериальное давление у больных ожирением и артериальной гипертензией, чем только диетотерапия. Снижение артериального давления уменьшает степень сердечно-сосудистого риска.

The 4-year Swedish study XENDOS, which was conducted in 3277 obese adult patients, examined the efficacy of orlistat in metabolic syndrome. It was found that about 40% of obese patients had all the signs of metabolic syndrome (NCEP ATPIII). Weight loss with orlistat led to an equivalent improvement in body weight, blood pressure, fasting glucose, blood lipids and others in 60% of obese patients who did not have metabolic syndrome.

Obese individuals have an increased risk of developing type 2 diabetes. Several studies have shown that the use of Xenical can prevent the development or slow the progression of type 2 diabetes. Among patients with initially normal oral glucose tolerance test results who received Xenical for 2 years, none developed diabetes. At the same time, during the same period in the placebo group, diabetes manifested itself in 1.5% of patients (p< 0,01). Кроме того, количество больных, у которых в ходе наблюдения развилось нарушение толерантности к глюкозе, в группе плацебо было вдвое больше (12,4%), чем в группе Ксеникала (6,2%, р < 0,01). Среди пациентов, уже исходно имевших нарушение толерантности к глюкозе, диабет за 2 года наблюдения в группе плацебо развивался более чем в 4 раза чаще, чем в группе Ксеникала (7,5% и 1,7%, р < 0.05). Положительная роль модификации образа жизни пациентов при приеме орлистата проявилась и в предотвращении манифестации СД 2 типа. Поэтому его рекомендуют применять лицам с высоким риском развития СД 2 типа наряду с препаратами акарбозы и метформином.

A retrospective analysis of 7 multicenter, double-blind studies showed that a 12-month course of treatment with orlistat plays a significant role in reducing carbohydrate tolerance, systolic and diastolic blood pressure, HbA1c and fasting blood glucose (XEDIMET, Sweden). The effectiveness of Xenical in combination with diet exceeds that of placebo in combination with diet in preventing the development and slowing the progression of type 2 diabetes mellitus.

Xenical significantly reduces the level of fasting glycemia. In patients with initially high fasting glycemia (more than 7.77 mmol / L), Xenical reduced it by 0.47 mmol / L, and placebo use was accompanied by an increase in glycemia by 0.36 mmol / L. A multicenter (12 centers) placebo-controlled 57-week study of orlistat, conducted in the USA on 391 patients who received hypoglycemic sulfonamides, showed a decrease in weight compared with placebo by 6.2 kg versus 4.3 kg, a decrease in waist circumference by 4.8 cm against 2.0 cm, respectively. Patients receiving orlistat achieved a significantly greater effect when using lower dosages of antihyperglycemic drugs than patients receiving placebo, which resulted in the normalization of glycated hemoglobin (- 0.28 versus + 0.18%), fasting glucose (- 0.02 versus + 0.54 mmol / l) and insulin levels (-5.2 versus + 4.3%). Similar results were obtained in a study in the USA and Canada among 503 patients with a BMI of 28–43 who received orlistat + metformin or orlistat + metformin + sulfanilamide for one year.

Taking Xenical reduces the concentration of insulin in the blood on an empty stomach. In patients at risk with hyperinsulinemia (initially 90 pmol / l), by the end of the 4-week induction phase in the group randomized for the future use of Xenical, insulin concentrations decreased by - 17.8 pmol / l, while in in the group randomized to follow-up placebo, only -9.4 pmol / L. After the start of therapy in the Xenical group, a further significant decrease in the level of insulinemia was observed, the amplitude of the difference between the groups was 19.7 pmol / l (p = 0.021). By the end of the second year, the difference became even more pronounced (30 pmol / L, p< 0,017). Таким образом, Ксеникал снижает концентрации инсулина более чем на 30%.

The safety and efficacy of orlistat was evaluated in 375 adolescents 12-16 years old, whose average age was 13.5 years, who received 120 mg of the drug 3 times a day. Placebos were given to 182 teenagers. There was a more frequent (in 27% of patients) weight loss due to visceral fat (more than 5% of the weight) in the group receiving orlistat than in the group receiving only diet and placebo (in 16% of patients), in which weight loss took place after account of bone demineralization. This allowed the FDA to approve Xenical in the United States on December 15, 2003 for adolescents in the 12-16 age group. It is currently the only weight management drug approved for use in adolescents.

Orlistat is taken with every meal with water. The presence of lipases in the gastrointestinal tract is necessary for the manifestation of the Xenical effect. Since lipase secretion is stimulated by the presence of food in the gastrointestinal tract, Xenical should be taken with meals. The effectiveness of Xenical is optimal when the drug is taken during or within 1 hour after a meal containing less than 30% of calories from fat. As the fat content of food increases, the total amount of fat excreted in the feces increases. When taking orlistat, it is recommended to use multivitamin preparations (supplements).

A number of studies have found that the fat content in food is directly related to the frequency and severity of adverse events from the gastrointestinal tract with each dose of Xenical. Xenical's tolerance is inversely correlated with the amount of fat in food. When using it, there are general negative effects in the form of increased stool frequency and steatorrhea, which was noted in a three-year study among patients receiving various combinations of orlistat with antihyperglycemic drugs and a moderate diet containing about 30% fat. It should be noted that these side effects were the result of excessive fat consumption and, of course, indicate the high effectiveness of the drug. Xenical should be used with a moderately hypocaloric diet containing no more than 30% of calories in the form of fats. In this case, intestinal discomfort is usually not observed.

Xenical does not interact with alcohol. Xenical increases the bioavailability of pravastatin by 30%. When Xenical is prescribed in combination with pravastatin, the lipid-lowering effect is enhanced.

Based on the foregoing, we consider the most appropriate treatment regimen for moderate obesity or overweight:

  1. Reducing the calorie content of food to 1200 kcal / day (for women) or 1500 kcal / day (for men), mainly due to a decrease in fat in food (up to 30%) and simple carbohydrates (products made from sugar and / and wheat flour).
  2. Increase in physical activity (30 min / day of active movements or brisk walking daily or at least 4 times a week).
  3. Changing the regimen of food intake (4-5 times a day in small portions up to 18-19 hours), the use of third-generation sweeteners (based on aspartame, etc.).
  4. Xenical is used to further reduce the caloric content of food against the background of a low-calorie diet and to correct lipid metabolism disorders by reducing intraintestinal lipid absorption.
  5. Trial treatment with Xenical for 1 month at a dose of 120 mg 3 times a day with each main meal, in combination with the antidepressant fluoxetine at a dose of 20 mg 1 time per day in the morning 1 hour before meals or 2 hours after meals.
  6. With the effectiveness of trial treatment with Xenical (decrease in body weight by 2-4 kg / month), long-term therapy for several years in order to further reduce body weight (10-15% / year) and keep it at the level of the achieved values.

For more detailed information on the use of Xenical (orlistat) for the treatment of obesity and overweight, you can visit the website www.xenical.com.ua or call the hotline: 8-800-50-454-50 (all calls are Free of charge for Ukraine).

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