OBESITY

From Big Medical Encyclopedia

OBESITY (Latin. adipositas) — excess adjournment of fatty tissue in an organism.

The lake can be an independent disease (primary O.) or the syndrome developing at various diseases of c. N of page and hemadens (secondary O.). Distinguish also O. the general and local. Local O. is characterized by an adiposity in the form of lipomas, hl. obr. in hypodermic cellulose (see. Derkuma disease , Madelunga syndrome ).

The lake is known from an extreme antiquity. In Hippocrates's treatise «About a healthy lifestyle» there is a section «How to Lose Weight». K. Galen in the works states dietary recommendations for patients with obesity. Caelius Aurelianus recommended corpulent a limited diet, bystry run, short rutting, bathtubs. In «A canon of medical science» of Ibn-Sina it is told about moderation in food and other ways of fight against the Lake.

The systematized studying of a problem O. and lipometabolism began 18 at the end — the beginning of 19 century and included both overseeing by patients, and pilot studies. Monographs Shandler-Barlaya (1884) and at the beginning of 20 century of Noorden were the fullest works about O. last century (Page H. Noorden).

In Russia the problem O. found reflection in works V. F. Kallash (1822), M. I. Gilyarova (1852), A. N. Lebedeva (1885), P. A. Polyakov (1894), etc.

In Soviet period the problem O. gained considerable development in M. I. Pevzner, M. N. Egorov and L. M. Levitsky's works; A. A. Pokrovsky, etc.

O. belongs to the most widespread diseases. O.'s prevalence increased with 40 — the 50th there are 20 century in all countries with high the level of m of economic development. According to WHO data (1972), apprx. 30% of the population in economically developed countries has the weight (weight) of a body exceeding norm for 20% and more. The researches conducted in a number of districts of our country showed that 26% inspected suffer from O. Otmecheno that O. is more often observed at women and in age groups 50 years are more senior. So, according to the Czech researchers Oshantsova and Geyda (To. Osancova, S. Hejda, 1972), was observed by O. almost at 30% of men and 50% of women. Similar data are obtained in GDR and Germany. Rees (W. Ries, 1970) notes that in groups of the population 50 years are more senior O. is observed in 50% of cases. There are instructions on big prevalence of O. for country people. The lake is risk factor of such diseases as atherosclerosis, an idiopathic hypertensia, a diabetes mellitus. Among the persons suffering from O., mortality higher and comes in earlier years. The lake increases risk of death especially in a combination with cardiovascular diseases and a diabetes mellitus. As an illustration of it serve these tables 1.

Similar data are provided in a row epidemiol. the researches executed in England, the USA, Germany and other countries. So, in the USA it is established that exceeding of weight over normal for 10% increases mortality on average by 30%. Due to these these O. it is necessary to consider as a serious medico-social problem.

Classification

is not present the Standard classification of O. The most widespread is the classification allocating primary, or alimentary and exogenous, O. which is characterized in the absence of any diseases, exceeding of an indicator of ideal body weight owing to accumulation of fat. It is the most widespread and makes more than 75% of all cases of the Lake.

Secondary O. is caused by endocrine and cerebral diseases (endocrine and cerebral a form O.). The given classification is simplest and is widely applied in clinic.

The etiology and a pathogeny

O.'s Aetiology is defined by many factors. Primary O. develops at surplus coming to an organism from poor energy in comparison with necessary power expenses. It leads to disturbances of a lipometabolism. O. conducting in development is the alimentary imbalance caused by the excess caloric content of food, hl. obr. at the expense of fats of animal origin and carbohydrates (in 60% of cases of primary O.); disturbance of food — the use of the main share of daily caloric content in the evening; rare, but plentiful meals (apprx. 40% of all cases of primary O.). However the factor of overconsumption of food is not obligatory for all forms O. There are patients, at to-rykh in a daily diet there is no exceeding of caloric content of food, but small physical activity creates excess accumulation of energy in an organism and promotes increase in body weight. The reduction of a metabolic cost connected with a scientific and technological revolution is the important reason of the accruing O.'s frequency, in particular at safety of habits concerning food. It is not necessary to revaluate also a role of insufficient physical activity in O. Nesomnenno's development, the main is the excess caloric content of food. It is proved that excess food in the first months of life of the child and even in the embryonal period (excess food of the woman during pregnancy) can exert negative impact on formation of the systems defining features lipometabolism (see) during all life.

An important role in O.'s emergence is played by a factor of heredity. Quite often O. has family character. According to Günter and Gottshalk (O. of Gunther, To. Gottschalk, 1962), 56% of children get sick with O. if one of parents suffered from it. However Rees (1970) at a research of enzygotic twins did not find enough certain data indicating value of heredity. Possibly, family character of O. is reflection of the general eating habits and a way of life. Without excess food even at genetic predisposition of O. it is shown seldom. The constitutional factor was considered as one of leaders earlier, however the statement about value of the pyknic constitution in O.'s development is not always confirmed though O. also is observed more often at picnics.

Endocrine forms of secondary O. meet at hypothyroidism (see) owing to the lowered expenditure of calories an organism; at to an insuloma (see) because of the polyphagia developing in connection with a hypoglycemia and strengthening of processes of a lipogenesis; as result of a disease of Itsenko — Cushing, characterized by strengthening glyukoneo-and a lipogenesis (see. Itsenko — Cushing a disease ).

A cerebral form of secondary O., e.g. O. at Laurence's syndrome — Muna — B and for (see. Laurence — Muna — Bidlya a syndrome ), Prader's syndrome — Willie, adiposogenital dystrophy (see), it is connected with development of a polyphagia as a result of disturbance of the central regulation of a food reflex. Similar patol. mechanisms develop at injuries of a brain, tumors and inflammatory diseases of c. N of page. It is undoubted that the excess caloric content of food and in secondary O.'s cases is of great importance.

The pathogeny

O.'s Pathogeny comes down to disturbance of regulation of balance of energy, disturbance of interstitial exchange with increase in ability to formation of fat from is exogenous the entered fats and carbohydrates, to its adjournment in fat depos and to difficulty of mobilization of fat from fabrics. All listed mechanisms are closely connected with each other. Fatty tissue is highly active in the course of a metabolism and is in continuous interaction with other compound components metabolism and energy (see). At excess receipt of energy the lipogenesis exceeds a lipolysis that leads to the strengthened adjournment of triglycerides in lipoblasts — lipocytes. The number of lipocytes at the adult is constant therefore strengthening of adjournment of triglycerides leads to increase in the sizes of lipocytes. The hypertrophy of lipocytes is the main factor of the Lake. By means of measurement of number and volume of lipocytes it was succeeded to allocate two pathogenetic types O., to-rye differ in hormonal and metabolic features — giperpla-sticheski-hypertrophic and hypertrophic. Faulkhaber (J. - D.Faul-haber) et al. (1969), Lish (N. of J. Lisch) et al. (1970) and W. Leonhardt et al. (1972) established that the volume of lipocytes closely correlates with an indicator of body weight. However weight cannot increase beyond all bounds and reaches a maximum, to-ry exceeds norm by 3 times. At extreme degree of O. the mass of fat in an organism can increase by 10 times. In these cases it is observed both a hypertrophy, and a hyperplasia of lipoblasts.

Thermogenesis at sick O. is not broken, but muscular work of sick O. demands big, than normal, energy consumptions. Primary O. leads to considerable metabolic and exchange disturbances. It is characterized by a giperinsuli-nizm and disturbance of tolerance to glucose, the insulinrezistent-nost which is defined by disturbance of insulinretseitorny relationship; increase in contents free fat to - t in blood, bent to a ketogenesis at starvation, to a gipertriglitseridemiya. At O. activity of liggoliti-chesky enzymes in fatty tissue, in particular lipases of triglycerides goes down that leads to their accumulation, and lipoproteidlinaza in this connection splitting of lipoproteids decreases. Hypertrophied lipocytes are weaker, than giperplazirovanny, react to adrenaline, noradrenaline and other lipolytic substances. Features of a pathogeny of secondary O. are defined by a disease, at Krom it arises — see. Adiposogenital dystrophy , Hypothyroidism , Itsenko — Cushing a disease , Laurence — Muna — Bidlya a syndrome .

The pathological anatomy

Primary O. is characterized by an excess adiposity in hypodermic cellulose, an epicardium, a mesentery of small bowels, retroperitoneal space; fatty infiltration of a liver can be observed. More often than at persons with a normal weight, atherosclerosis of various localization, inflammatory processes in a gall bladder, bilious channels, a pancreas are observed. Features patol, are stated to secondary O.'s anatomy at the description of the corresponding nosological forms, at to-rykh it is observed.

The clinical picture

Primary obesity depending on expressiveness can be 4 degrees: The I degree — excess weight exceeds normal for 15 — 29%; II \for 30 — 49%; III \for 50 — 100%; IV \more than 100%. The lake develops gradually. At the beginning of a disease the health of the patient does not change; with development of a disease fatigue, weakness, sometimes apathy, an asthma, drowsiness, the increased appetite appear, polydipsia (see). Already at early children's age it is possible to find various disturbances biochemical, indicators of blood. Many complaints are connected with diseases, to-rye are, as a rule, combined with O. (atherosclerosis, hron, cholecystitis, osteochondrosis, an osteoarthrosis, etc.). Dryness or perspiration of skin, sometimes a hyperkeratosis is observed (Bør's symptom, see. Hypothyroidism ), fungus and inflammatory diseases of skin, disturbance of a trophicity, intertrigo.

Excess deposits of fatty tissue at early stages of O. are observed on a trunk, in shoulders, a stomach, on hips, a face, during the progressing — in forearms and shins. At sharply expressed O. skin folds in a stomach, spins have an appearance of the hanging-down sites of skin with hypodermic cellulose of big thickness.

The expressed changes are observed from cardiovascular system. The earliest and widespread damage of heart is dystrophy of a myocardium (see. Myocardial dystrophy ), also coronary disturbances, defeats of vessels of a brain and the lower extremities are noted (see. Atherosclerosis ).

Often they are combined with arterial hypertension (see. arterial hypertension ).

At sick O. are more often observed varicosity (see), thrombophlebitis (see).

Dysfunction of a respiratory organs is characterized respiratory insufficiency (see). It reduction of respiratory capacity of lungs as a result of high standing of a diaphragm and reduction of its mobility, because of an excess adiposity can be the cause.

Sick O. have acute respiratory diseases because of decrease in mechanisms immunol, protection more often. They to a thicket have pneumonia, hron, bronchitis, a pneumosclerosis.

Disturbances of digestive organs are characterized by hypersecretion of a gastric juice which is followed hyperacidity (see) and morfol, changes of a mucous membrane of a stomach.

Fatty infiltration of a liver is observed rather often, sometimes it is followed patol, hepatic tests (see. Liver ). However find hron more often. cholecystitises (see) and cholangites (see) which reason disturbances of cholesteric and purine exchange, and also dysfunctions of a gall bladder are. More often than at persons with a normal weight, are found pancreatitis (see).

Nocturia (see) it is observed approximately at 2/3 patients, and at a half of them it is followed isosthenuria (see). Increase ud is often noted. weight of urine. Manifestations nephrolithiasis (see) are connected with disturbances of a lipometabolism and bigger frequency of inflammatory processes in kidneys and urinary tract. Changes of a musculoskeletal system at sick O. are characterized arthroses (see), connected with increase in load of joints and exchange disturbances.

In most cases several joints are surprised. Often small joints of hands (osteoarthrosis) both metatarsophalangeal and interphalangeal joints groan are surprised that is caused not only by disturbance of exchange, but also weight loading. Are observed defeat and large joints, in to-rykh radiological reveal surface semicircular defects in an epiphysis of bones, deformation of joints and adjournment of lime in them. Often sick O. have dislocations and incomplete dislocations that is connected with inadequacy of loads of ligaments of joints. Spondylarthrosis (see) — an everyday occurrence at patients O. Chem is higher O.'s degree, especially changes in joints are expressed.

Disturbance of a water salt metabolism is clinically shown by pastosity, hypostases (see. Swelled ). The reasons of a delay of liquid at sick O. are insufficiently clear. Consider that the delay of liquid is promoted by the giperinsulinemiya which is observed at sick O.; however it is not the only mechanism explaining a delay of liquids.

Primary O. has significant effect on funkts, a condition of hemadens that is most brightly shown by a giperin-sulinemiya, a hypercorticoidism (level of cortisol in blood never reaches such values, as at Itsenko's disease — Cushing), decrease in secretion of somatotropic hormone, at women also ginofunktsiy ovaries with disturbances of a menstrual cycle.

All changes stated above have reversible character and at effective treatment can disappear completely.

Displays of secondary obesity are defined by a basic disease. Distinguish from endocrine forms of secondary O. pituitary, adrenal, hypothyroid, gipoovari-alny and climacteric.

Pituitary O. (Itsenko's disease — Cushing) is characterized by quickly progressing increase of weight with typical redistribution of hypodermic cellulose (excess adjournment on a face and a trunk at thin extremities). Skin is usually thin, with the expressed trophic disturbances (red and white strips of stretching, as a rule, on a stomach, hips, in axillary areas, sometimes on a back and buttocks; folliculites, sharp dryness). The focal or total alopecia, persistent arterial hypertension (rise in diastolic pressure), an amenorrhea or falloff of a potentiality and libido, dysfunction of other hemadens are characteristic a matronizm (a round red face against the background of the general O.), sometimes. Excretion with urine 17 of oxycorticosteroids is sharply raised, the maintenance of cortisol in blood is higher than norm by 2 — 3 times.

Adrenal O. is defined by existence of a tumor of bark of an adrenal gland (see. Androsteroma , Kortikosteroma ) or AKTG-produtsrfuyushchy tumor of various localization. On a wedge, adrenal O. is close to a current to pituitary, however the content of hormones of bark of an adrenal gland in blood and their excretion with urine is usually much higher. The hypertrichosis, the expressed dysfunctions of gonads are typical.

The hypothyroid form of secondary O. is connected with decrease in lipolytic activity of fatty tissue and weakening of all exchange processes as a result of insufficiency of thyroid hormones that is observed at an idiopathic hypothyroidism or after a strumectomy at radiation or traumatic injury of tissue of thyroid gland. Wedge, symptoms of a hypothyroidism are combined with O., a cut is characterized by uniform excess adjournment of fatty tissue.

Hypoovarian O. develops at 30 — 60% of women after removal of ovaries. In a wedge, a picture is the most expressed postkastratsionny syndrome (see), typical distribution of hypodermic cellulose (on a stomach, hips, sometimes breasts).

Climacteric O. is, as a rule, combined with vegetovascular and psychological disturbances (see. Menopausal syndrome ); it is close to the hypoovarian Lake.

The cerebral form of secondary O. is characterized by bystry progressing, excess adjournment of fatty tissue is observed on a trunk and extremities.

The Yules (M. of Julesz, 1963) points to «fancifulness» cerebral C). in respect of distribution of hypodermic cellulose that depends in some cases on defeat of certain segments of a spinal cord or departments of century of N of page.

At this form of obesity of a strip of stretching are observed seldom though trophic defeats meet often. Skin looks cyanochroic, the hypothermia which is replaced by subfebrile condition is quite often observed.

A peculiar form of cerebral O. is Barraker's disease — Simmons (see. the Lipodystrophy progressing ), characterized by excess adjournment of a fatty tissue of hl. obr. on hips and legs in the form of riding breeches at sharply expressed leanness of an upper half of a trunk and person.

The diagnosis

the Diagnosis of various forms O. comes easy. The main indicator at inspection is body weight. At O.'s diagnosis use tables of normal weight. The lake is diagnosed at exceeding of normal weight more than for 15%. For determination of normal weight the main indicator is the ratio of growth and body weight. Use also various formulas based on the principle of relationship of growth and weight — Brock's formula, Breytman (see. Body weight ), definition of an indicator of body weight and determination of thickness of a skin fold special device kaliper. At the person normal fatty weight averages 15%, at O. it increases and can reach 50%. It is reasonable to use the following scheme of establishment of the diagnosis of the Lake. First of all on the basis of the anamnesis, survey, consultations of the endocrinologist and neuropathologist and carrying out additional hormonal, X-ray and functional inspections it is necessary to allocate secondary forms O. (endocrine and cerebral) and its degree. Then reveal associated diseases and complications of the Lake. This scheme allows the practical doctor to appoint the most adequate treatment. For diagnosis, a cut first of all clinical manifestations of O. are the cornerstone, are carried out a lab. a blood analysis and urine, a glucose tolerance test, a research of content of fats in blood and fractions of lipoproteids, increase to-rykh has direct dependence on increase of degree of the Lake.

At the same time rather low content of phospholipids is noted.

Carry sometimes out definition of types of giperlipo-proteinemias across Fredrikson (see. Lpoprteida ); at primary O. the II—V types most often meet. However this research malospetsifichno.

Treatment

Treatment always complex. Its purpose — creation in an organism of the negative energy balance by sharp restriction of caloric content of food and strengthening of physical activity for perhaps more expressed weight reduction of a body. The comparative characteristic reduced (reduced on caloric content) the diets recommended at sick O.' treatment in a hospital is provided in tab. 2. The main option of a diet can be used as well at treatment in out-patient conditions.

At the choice of option of the reduced diet it is necessary to consider age of the patient with primary O., associated diseases and complications with O. Predel of the reduction of caloric content of a diet which is not reflected in a condition of the patient, the diet in 600 kcal appointed only in the conditions of a hospital is. The close check behind proteinaceous structure of a diet since at sick O. decrease in specifically dynamic effect of protein of food is established is necessary. At reduction of content of fats in a diet it is necessary to increase amount of vegetable oils which ratio with animal fats shall make 1:1. Sharply limit the products containing carbohydrates and digestible (sugar, honey, confectionery, etc.) are excluded completely. The amount of bread is also limited. A daily set of the products recommended for sick Lakes is given in tab. 3.

Completely exclude the spices increasing appetite from food. Technology of preparation of dishes usual. The use of weak beef-infusion broths is allowed (2 — 3 times a week). Food is made without salt, and patients add some salt to it to taste (to 5 g of salt a day) during food. Special attention is paid on additional administration of vitamins. Food shall be fractional, 5 — 6 once a day; in intervals between the main meals (a breakfast, a lunch, a dinner) additional receptions of low-calorie food (2 — 3 times) are important. For sick O. with associated diseases or complications carry out the corresponding correction of a diet. To the carried-out dietotherapy, the diet with the maximum reduction of caloric content, to 800 — 700 kcal is appointed especially resistant sick primary O. (no more than 2 — 3 weeks and only in the conditions of a hospital). However at any diet process of a lose of weight is slowed down over time therefore 2 — 3 are appointed fasting day (see) in a week.

Primary O.'s treatment by starvation is hardly reasonable, though is applied in separate institutions. In case of sharply increased appetite in the first half of day by sick O. appoint anorexigenic means (Phepranonum, Desopimonum, etc.) taking into account contraindications (glaucoma, increase in intraocular pressure, psychoneurological frustration, arterial hypertension, a heart and renal failure, a hyperthyroidism). Their use is contraindicated because of exciting action on c in the evening. N of page. Treatment by anorexigenic drugs is carried out usually 2 — 3 weeks. Among zhiromobilizuyushchy medicines it is necessary to specify on Adiposinum (see), received from a hypothalamus of cattle. Its use for patients with primary O. is rather effective, however it is necessary to be careful in the presence at sick O. of the accompanying allergic states and heart failure. Quite often in primary O.'s treatment drugs of thyroid hormones are used — Thyreoidinum (see), triiodothyronine (see), especially when there are instructions on depression of function of a thyroid gland. Because of easier portability preference is given to triiodothyronine; its dosage at the same time makes 20 — 60 mkg a day, drug is appointed in the morning and during the lunchtime. Treatment is carried out by courses under control of pulse and the ABP, sometimes an ECG. However data on efficiency of treatment of primary O. by means of these drugs are contradictory. In primary O. and O.'s treatment which is followed by a diabetes mellitus, broad use was found guanyl guanidines (see). They promote weight reduction of a body, reduction of absorption of food in intestines, to strengthening of its mobility, anorektichesky effect, decrease in a giperin-sulinemiya, suppression of a gluconeogenesis in a liver. Use of butylguanyl guanidine (Buforminum) and dimethylguanyl guanidine (Glukofagum, Metforminum) is the most reasonable.

Use of drugs of fenetil-guanyl guanidine (Phenforminum) dangerously because of a possibility of development lactacidemia (see). They are not applied at purpose of most reduced diet. Usually doses of Buforminum make 100 — 200 mg a day, Metforminum of 800 — 1600 mg. Efficiency of treatment by guanyl guanidines comes to light a year later after the beginning of therapy.

Efficiency of treatment of secondary forms O. depends first of all on efficiency of therapy of a basic disease. Dietary treatment is carried out as well as at primary forms O. Anorexigenic means are applied with care in the same doses, as at primary Lake. Operational treatment of secondary forms O. is carried out seldom. Usually beam or operational treatment of a disease of Itsenko — Cushing, an oncotomy of bark of adrenal glands renders positive effect and on the Lake. Replacement therapy of a hypothyroidism drugs of thyroid hormones is effective and in treatment planning of O. Znachitelno it is more difficult to achieve success in O.'s treatment at cerebral forms of secondary O. Obychno removal of tumors of a brain, radiation and antiinflammatory therapy along with a complex of the medical actions applied at primary O. lead to weight reduction and its stabilization.

One of the most important conditions of efficiency of treatment of any form O. is the psychotherapy. In an initiation of treatment the detailed discussion with the patient about need of strict observance of all appointments of the doctor is led, the number of the calories consumed by the patient, errors of the previous food, eating habits are investigated. It is necessary to install belief in efficiency of treatment in the patient, to convince him of need of continuous treatment. Soft admonitions, persistent searches of errors in a diet, issue of the printed schemes of a diet make small success and, as a rule, in such cases efficiency of treatment is low. Tactics of the doctor shall be flexible, optimistic and at the same time offensive. Only in this case the patient will believe it.

Medical physical culture at O. is considered as a component of complex therapy. It is shown at all forms and O.'s stages both at adults, and at children when on a condition of cardiovascular system it is possible to expand degree of physical activity. Lech. action of physical exercises is based on significant increase eiyergotrat, normalization of all types of exchange, strengthening of lipolytic processes in various bodies, improvement of function of all bodies and systems, increase in fitness and general efficiency of the patient.

Most successfully LFK is applied in resorts and in sanatoria; considering duration (throughout all life) fight against O. to lay down. the physical culture is recommended also in house conditions.

The type of physical exercises, volume, intensity of loading and a form of training depend from a wedge, O.'s manifestations, associated diseases (hl. obr. cardiovascular system), age, sex and physical training of the patient. For patients of young and middle age without diseases of cardiovascular system exercises on endurance (walking, run, swimming, rowing, walking on skis, etc.) and sports are especially shown. High-speed exercises are exigeant for patients and do not cause sufficient increase in energy expenditure. Exercise stresses should not be given it is concentrated, in a short span, it is necessary to distribute them for day (a method of fractional loadings).

The course of treatment of LFK usually is divided into 2 periods. In the first period of the patient adapts to moderately raising exercise stresses. Generally gymnastic exercises in the form of morning a gigabyte are used. and to lay down. gymnastics and the dosed walking. At improvement funkts, conditions of cardiovascular and respiratory system (disappearance of an asthma and heartbeat during the performance of physical exercises) can be passed to the second period, Krom in addition joins walks, tourist campaigns, the dosed run, walking on skis, swimming, rowing and other exercises, and also occupations in groups of health.

At primary O. LFK is most effective, edges it is carried out it is long (one occupation lasts 45 — 60 min. and more). Exercises for large muscular groups are generally used; they in p spinning tops N I yut with a big amplitude of movements are also alternated to respiratory. Moves, roundabouts in large joints, exercises with moderate burdening and with various objects (balls, maces, gymnastic sticks) are widely applied. Much attention is paid to exercises for muscles of a prelum abdominale, to self-massage. For increase in an emotional background it is recommended to include outdoor games in occupations. Each occupation includes walking and run. Whenever possible use physical exercises in water (pool). It is necessary to observe strictly gradualness in increase in speed and number of separate exercises, and also duration of walking and run.

At endocrine O. the general loading in occupations is regulated depending on a wedge, displays of a disease. In bigger quantity, than at primary O., exercises are applied to average muscular groups and breathing exercises. Rate of performance of exercises slow and average, duration of occupation is 25 — 30 min.

For sick O. with strongly expressed changes in cardiovascular system or in other bodies of LFK it is carried out by the technique applied at diseases of these systems and bodies taking into account the phenomena of the Lake.

The general massage is not method of treatment of O. and can be used in combination with a physical training. Also work therapy is recommended.

Operational treatment of O. was begun at the end of 19 century by Kelly (N. A. Kelly, 1899), to-ry for the first time applied excision of fatty accumulations in hypodermic cellulose of a front wall of a peritoneum, however this operation did not gain distribution as gave only cosmetic and short-term effect.

Since 50th 20 century began to apply operation of an intestinal bypass for the purpose of reduction of the soaking-up surface of intestines by creation of an eyunotransverzo-anastomosis. Clear weight reduction was noted in most cases. However at a part of patients the dysphagy, exhaustion, anemia, a hypoproteinemia were observed further. in this connection this operation did not gain distribution. In the 70th operation of an intestinal bypass was offered in the way enteroenteroakastomoza (see), to-ry more often than other operative measures, the positive effect gives. Indications to operational treatment are obesity of the III—IV degree, lack of effect of conservative treatment, falloff of working capacity; contraindications — the age is more senior than 60 years, associated diseases. Results of operations are estimated differently. Performing conservative treatment in the postoperative period is obligatory.

Prevention

Prevention includes actions for preservation of normal body weight — carrying out the wide measures directed to rationalization of food and overcoming a hypokinesia. Prevention of progressing of O. shall be promoted by widespread introduction in retail chain stores of specialized products or sets of dishes with precisely considered reduction of calories and high biological value. It is necessary to emphasize importance of production for this purpose of confectionery with a smaller sugar content and fat, confectionery on sorbite and xylitol, bakery products with the reduced maintenance of an animal fat and replacement with its vegetable oil; uses of low-calorie butter, the sour cream and fermented milk products enriched on linenasyshchenny fat to-tami.

The problem of preservation of normal weight is closely connected with overcoming a hypokinesia at all population, especially at middle-aged persons and elderly people. Therefore it is necessary to create favorable conditions for involvement of these contingents in exercises, and first of all the most elementary, easily accessible sports, to use country recreation areas for exercises and sport more widely.

Obesity at children

O.'s Prevalence at children makes from 10 to 30%. O.'s etiology at children does not differ significantly from O.'s etiology at adults; the overeating, inf can play a role. diseases, traumatic injuries of a brain, birth trauma, genetic defects, etc. There are various classifications of O. at children's age (Yu. A. Knyazev and A. V. Kartelishev, 1974), however they differ from O.'s classification at adults a little. From secondary forms O. at children

O. Klien is more often observed cerebral, primary O.'s picture is characterized by an excess increase in weight at early children's age and a wavy current. Allocate the simple or uncomplicated, transitional and complicated phases. Simple, uncomplicated, the phase usually corresponds to I (15 — 25%) or II (26 — 50%) to O.'s degrees; distribution of fat uniform, does not affect health of the child.

Sharp increase in weight is necessary on fiziol, growth periods and development: are observed increase in appetite with shift of peak on the second half of day, passing disturbances from century of N of page (periodic perspiration, thirst, weakness, nausea, headaches, dizziness, heartbeat, decrease in attention, etc.), to-rye carry funkts, character. With O.'s progressing (a transitional phase) there is unstable arterial hypertension, disturbances from outside V.n.s become frequent., changes of skin (folliculites, pigmentation, acne, a hypertrichosis) are noted. At the complicated phase O. all symptomatology becomes a constant, and O. progresses to the III—IV degree (surplus of weight for 51 — 100% and more). In this phase strips of stretching on a stomach, buttocks, hips, mammary glands can be observed that is combined with increase in excretion of corticosteroids. The complicated phase develops usually with 9 — 10-year age.

Secondary O. at children is connected with dysfunction of hemadens and c. N of page. In these cases into the forefront symptoms of a basic disease act.

O.'s complications at children are caused by a complex of secondary adaptation hormonal and exchange frustration. To them first of all decrease in tolerance, the giperinsulinemiya, inversion of biorhythms of function of bark of adrenal glands, disturbances of fatty and protein metabolism belong to glucose. Children, sick O., are irritable, easily vulnerable, are sometimes embittered. It is necessary to emphasize the frequency of the mental disorders connected with vulnerability of children in connection with their «singularity» in comparison with peers. On this factor it is necessary to pay special attention at - inspection and treatment of children with the Lake.

The diagnosis is based on anamnestic data and a wedge, inspection.

O.'s treatment at children essentially does not differ from O.'s treatment at adults. Its basis is the dietotherapy. Food 5 — 6-times. The last meal no later than 18 hours. Protein content in a diet shall meet age standards, carbohydrates and fats are limited. It is necessary to watch that the diet in enough contained vitamins and microelements. In the presence of complications the corresponding treatment is appointed. Anorexigenic drugs to children are appointed seldom. An operative measure is not applied. The great value is attached to LFK, especially exercise stresses. At children depending on age and O.'s degree is wider, than at adults, use various imitating exercises, mobile and sports, a hardening of an organism. Activation of the motive mode in hours and days, free from study is provided (under control of parents).

At secondary forms O. first of all carry out treatment of a basic disease, however the dietotherapy and exercise stresses keep the value.

Children with the increased risk to O.'s development shall be under special dispensary observation.

Tables

Table 1. DEPENDENCE of MORTALITY AT DISEASES of CORDIAL and VASCULAR SYSTEM FROM BODY WEIGHT: NUMBER of DEATHS ON 100 000 POPULATION [according to Dablin and Marx (L. Dublin, H. Marks), 1951]


Table 2. OPTIONS of the DIETS REDUCED ON CALORIC CONTENT FOR PATIENTS with OBESITY


Table 3. A DAILY SET of PRODUCTS FOR the DIET of PATIENTS with OBESITY




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M. A. Samsonov, E. A. Beyul, A. G. Mazowiecki, D. Ya. Shurygin; V. N. Moshkov (to lay down. physical.); G. A. Pokrovsky (hir.), A. V. Kartelishev, Yu. A. Knyazev (ped.).

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