Overweight and obesity is a medical problem, not a cosmetic one

Resume. The article covers the issues of epidemiology, considering the classification of obesity, the risks of development of various somatic diseases related to overweight and obesity. The results of clinical studies of orlistat use in the treatment of obese patients are reported. Key words: obesity, overweight, body mass index, orlistat, Orsoten.

It is well known that overweight often lies at the basis of a person’s psycho-emotional dissatisfaction. Over the years, in the overwhelming majority of cases, it turns into obesity, which increases the risk of adverse health effects and the development of many diseases, becoming a source of extra costs not only for the individual, but and societies.

The ratio of official medicine to obesity has changed significantly over the past quarter century, although since ancient times it has been known to have a negative effect on the body. Even 2500 years ago, Hippocrates wrote that "... sudden death is more characteristic of fat than of thin." Overweight is recognized as one of the correctable risk factors for the development of many diseases and after smoking is the second leading cause of morbidity and mortality, which can be eliminated. Obesity at a young age inevitably leads to the early development of undesirable pathological changes in the cardiovascular system. Especially unfavorable is the increase in weight for persons with a familial predisposition to hypertension or type 2 diabetes.

Around the world, especially in industrialized countries, the percentage of obese people who are becoming non-infectious pandemic is rapidly increasing. According to official statistics in the United States, more than half of the population has a body mass index (BMI) exceeding the norm. In Russia, 54% of the population suffers from obesity, in the UK - 51%, in Germany - 50%. Even in China and Japan, where overweight is less common than in other countries, 15 and 16% of the BMI population exceeds the norm.

Epidemiological population studies have shown that in economically developed countries, obesity as a risk factor is recorded with a high frequency, about half of the population is overweight, and in about 20% it reaches the level

in which, in accordance with the criteria of WHO, obesity is diagnosed. At the same time, the role of obesity is very significant in the development of diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, arthrosis, many diseases of the digestive organs, malignant neoplasms, and disorders of psychosocial status.

Physical assessment of the degree of excess weight is currently determined using two main indicators: BMI and waist circumference (FROM).

BMI is calculated as the quotient of the patient’s body mass per square of height in meters.

BMI = body weight (kg): (height, m)2.

There are tables in which the already performed BMI calculations are presented, and the doctor only needs to measure the height and weight of the patient, and then find the value of the BMI at the intersection of the corresponding row and column of the table. Normal indicators of BMI for adults correspond to 18.5—24.9. The range of norms in accordance with the concept of BMI does not depend on sex and age, as well as constitutional individual characteristics. That is, any individual in 60 years should weigh about the same as he weighed in 18-20 years old, the allowable weight gain is no more than 5 kg.

Classification of the International Obesity Task Force (IOTF), underweight, overweight and obesity depending on BMI

Body mass category BMI Risk of obesity-related diseases

Insufficient body weight less than 18.5 Low

Normal body mass range 18.5-24.9 Medium by population

I degree (overweight) 25.0-29.9 Somewhat elevated

II and degree (obesity) 30.0-34.9 Moderately increased

Grade II b (severe obesity) 35.0-39.9 High

Grade III (pronounced or 40 or more. Very high morbid obesity)

Obesity and metabolism

According to this classification, obesity is verified with a BMI of 30 or more. In addition, the classification of the International Group for the Study of Obesity identifies important subgroups - pronounced and pronounced ("morbid") obesity, which begins with a BMI of 40 or more, really life-threatening to the patient and requiring urgent treatment, often surgical.

The frequency of overweight is higher among men, but women are more likely to be obese. The dynamics of weight gain is similar at a young age in both sexes. However, gender differences are observed in the older age group: in men, body weight increases from 45 to 54 years old, and then stabilizes, but in women, it can increase after 45 years and into extreme old age.

Despite the fact that BMI is the main clinical criterion for diagnosing the disease "obesity", you should know that increasing BMI is not always a true indicator of the anatomical mass of adipose tissue in the body. This indicator does not allow to differentiate overweight caused by an excess of adipose or muscle tissue. In this regard, for the diagnosis of obesity and to evaluate the effectiveness of its treatment, it has been proposed to use a number of additional laboratory, instrumental and physical methods.

The second highly informative indicator of the degree of risk due to the central (visceral) distribution of fat is the increase in RT, which is measured midway between the hypochondrium and the pelvic bone along the mid-axillary line. The value of OT is recognized as an important indicator characterizing the deposition of fat in the abdominal region. In young women, normal OT is 80 cm and no more, and for young men - no more than 94. The risk of developing complications increases significantly with OT in men more than 102 cm, and in women - more than 88 cm. It has been established that almost all people with BMI = 30 OT exceeds the norm. It should be noted that OT is not comparable to the height of a person.

Currently, the International Group for the Study of Obesity to quantify body weight recommends using a combination of two anthropometric indicators - BMI and OT.

The group of patients with obesity is diverse, it is proved that the nature of the distribution of fat is an important marker of pathological processes in the body. The predominant deposition of fat in the thighs and buttocks is more characteristic of women, and therefore has been called the “ginoid” or lower type of obesity. Excessive accumulation of fat in the trunk, and especially the abdomen (central, upper or abdominal obesity), with its predominant deposition in the abdominal cavity, is more typical for men, as a result of which it is called "android". Compared with fat in the subcutaneous tissue, visceral fat, located inside the abdominal cavity, has the following features:

• a greater number of fat cells per unit mass of tissue and increased blood flow;
• high density of adrenoreceptors, especially p3, receptors for glucocorticoids (cortisol) and androgens;
• more pronounced catecholamine-induced lipolysis, and less pronounced inhibition of lipolysis in response to insulin.

Visceral adipose tissue, therefore, has a different sensitivity to hormonal influences that regulate changes in lipid accumulation and metabolism. Visceral fat deposition directly correlates with metabolic abnormalities in the body - insulin resistance, hyperinsulinemia, impaired glucose tolerance, hypertriglyceridemia, increased fraction of low-density lipoprotein cholesterol (LDL) and a decrease in high-density lipoprotein cholesterol (HDL), while total blood cholesterol may remain relatively low. Such patients more often develop diabetes mellitus (DM), hypertension, coronary heart disease (CHD). It is with the visceral type of obesity that the mortality from these diseases increases significantly. The central distribution of fat is characteristic of type 2 diabetes (type 2 diabetes) even in the absence of overweight and, apparently, determined genetically. Excess visceral fat disrupts the excretion of insulin by the liver, increases the level of free fatty acids, disrupts the oxidation of glucose and activates gluconeogenesis. The complex of metabolic and clinical disorders accompanying the central (abdominal or visceral) type of obesity is known as metabolic syndrome, which has been intensively studied in recent years.

Medical problems caused by overweight, occur in approximately 50% of the population of European countries. The “Nurses Health Study” epidemiological study, in which 115 195 women aged from 30 to 55 were observed for 15 years, showed that with a BMI of more than 32, the relative risk of developing cardiovascular diseases increases 4.1 times compared with for which this indicator corresponds to 19.

It has been proven that after 18 years of age, an increase in body weight of 10 kg or more is accompanied by a significant increase in the frequency of mortality, including from cardiovascular diseases. Based on epidemiological data on the increase in morbidity and mortality, it can be concluded that with a BMI above 32, the relative risk of mortality increases 2.5 times as compared with persons with a BMI of less than 19. Particularly unfavorable is a high BMI at a young age. In persons under the age of 35 years with a BMI of more than 40, the mortality rate increases 12 times. With an increase in BMI, the cost of treating all diseases generally increases exponentially.

Prospective studies conducted in England confirmed that body weight is an important prognostic criterion for increased mortality in young and middle age, both among men and women. The increase in the number of overweight people is a general trend among the population of the entire globe, regardless of age. Experts are particularly alarmed by the tendency to increase in overweight among children and adolescents, which in the long term threatens with a massive increase in the incidence of diseases caused by obesity.

Obesity is dangerous because it is associated with the most common and materially costly diseases. Although the frequency of their combination is difficult to assess accurately, there is nevertheless evidence that obesity can cause 57% of cases of type 2 diabetes, 17% of cases of arterial hypertension and coronary heart disease, 14% of osteoporosis, 30% of cases of cholelithiasis, 11% of breast cancer cases glands, uterus, large intestine.

Symptoms of diseases that complicate obesity usually develop by age 40, sometimes earlier, and by age 50 a definite clinical picture of diseases requiring active medical treatment is fully formed. In humans, obesity disrupts the activity of almost all organs and systems, leading to the development of a large number of various diseases and pathological symptoms:

Cardiovascular

• Arterial hypertension.
• Coronary heart disease.
• Congestive heart failure.
• Pulmonary heart.
• Varicose veins.
• Pulmonary embolism.
• Dyslipidemia.

Bronchopulmonary

• Bronchial asthma.
• Obstructive sleep apnea.
• Hypoventilation syndrome.
• Pickwick syndrome.

Neurological

1. Brain stroke.
2. Idiopathic intracranial hypertension.

Digestive organs

• Cholelithiasis.
• Gastroesophageal reflux disease.
• Barrett's esophagus.
• Adenocarcinoma of the esophagus.
• Pancreas cancer.
• Colon cancer.
• Non-alcoholic fatty liver disease. Musculoskeletal system
• Restricted mobility.
• Degenerative arthritis.

Dermatological

• Venous stasis in the legs.
• Cellulite.
• Diaper rash.
• Pustular diseases (furuncles, carbuncles).

Endocrine

1. Diabetes mellitus type 2.
2. Insulin resistance.

Genitourinary

• Infertility.
• Violation of the menstrual cycle, amenorrhea.
• Polycystic ovary, hyperandrogenism.
• Breast cancer and uterus.
• Hypogonadism, impotence.
• Prostate cancer.
• Incontinence of urine (during stress, physical exertion).

Mental disorders

• Depression.
• Rapid fatigue, not bringing rest to sleep.
• Reduced self-criticism.
• Bulimia.

The most serious medical problems caused by obesity, threatening the patient’s life or significantly reducing the quality of life, requiring special therapy, are coronary artery disease, arterial hypertension and disorders of cerebral circulation, type 2 diabetes, malignant neoplasms.

The social significance of obesity and the costs of society due to the disability of overweight people cannot be underestimated. It is not by chance that in highly developed countries, the promotion of a healthy lifestyle has been elevated to the rank of state policy for the protection of public health, because the cost of treating diseases and complications caused by overweight reaches from 2 to 8% of the annual health budget.

It has been established that with a decrease in body weight of 10 kg from the initial one, the state and functions of many body systems are significantly improved. The elimination of excess weight is not only and not so much an improvement in the appearance of the patient. It directly contributes to improving well-being and reducing the severity of adverse health risks and diseases associated with obesity. Even with the loss of only 5% of overweight, the costs of medical care for patients are reduced, due to the improvement in the pathology associated with obesity.

Many patient complaints and clinical symptoms associated with obesity are reduced or eliminated with a loss of 5-10% of the initial weight, so in most cases, people with obesity do not need to strive to normalize body weight. However, it is important to keep in mind that positive effects with the loss of a certain number of kilograms are observed only under the condition of subsequent stable maintenance of body weight at the achieved level.

Among the first symptoms eliminated by the loss of 5-10% overweight, sweating, shortness of breath, fatigue, pain in the back and large joints characteristic of deforming osteoarthrosis, and even clinical symptoms of T2DM such as thirst and polyuria disappear. Reducing body weight significantly reduces the severity of many obesity-related risk factors, improves the clinical course of the disease.

Moreover, it is proved that with a decrease in body weight by 10%, the overall mortality decreases by 20%, the mortality due to diabetes - by 30%, the mortality from cancer diseases, often associated with obesity, by 40%.

Correction of overweight is carried out with regular patient interaction with your doctor. In cases where the correction of the eating stereotype, adherence to a low-calorie diet, the implementation of an individual program of physical activity, taking into account the physical condition and concomitant diseases for 2-3 months, does not bring an adequate result, medication is prescribed. In some cases, drugs for weight loss can be prescribed from the very beginning of therapy, for example, with a BMI over 30, or with a lower value in patients with two or more additional risk factors. Drugs can also be prescribed for maintenance therapy during the period of weight stabilization, when, after losing 5-10% of body weight, compensatory counter-regulatory processes of energy conservation are activated in the body: the rate of basal metabolism and energy costs for work decrease, and further weight loss slows down for a long time. time.

The effect of weight loss on the course of obesity related diseases

Pathology Effect of weight loss

Type 2 diabetes mellitus Improving the compensation of carbohydrate metabolism and reducing the dose of glucose-lowering drugs

Impaired glucose tolerance (IGT) Preventing IGT progression to diabetes mellitus

Arterial hypertension Lowering blood pressure and reducing doses of antihypertensive drugs

Hyperlipidemia Reduction in total cholesterol and triglycerides

Ischemic heart disease, heart failure Reduction of ischemia, increased exercise tolerance

Sleep apnea syndrome Improve ventilation, reduce hypoxia

Deforming osteoarthritis Improving mobility, reducing the need for NSAIDs

Reproductive dysfunction Restoration of the menstrual cycle and fertility

Today, for the treatment of obesity, two classes of drugs with proven clinical value are used, which, according to the mechanism of action, are divided into drugs of the central (sibutramine) and peripheral action, which reduce the flow of energy (orlistat).

Sibutramine hydrochloride is approved for clinical use in the treatment of obesity, taking into account the efficacy and safety data obtained in controlled clinical studies conducted in Europe and the USA. The drug inhibits serotonin and norepinephrine reuptake by the presynaptic membrane. The specific action of sibutramine is directed to the neuronal structures of the hypothalamus. The exchange of dopamin in the synapse it changes slightly. In peripheral tissues, serotonin levels do not change. The main effect of the drug is the rapid onset of saturation and its extension after meals. The desire for intermediate meals between the three main ones is eliminated, that is, food consumption is reduced. Frequent undesirable effects when using sibutramine are dry mouth, constipation, insomnia, dizziness and headaches are less common. The experience of using the drug showed the need to carefully control blood pressure, the drug should not be used after suffering a myocardial infarction, stroke, with congestive heart failure, in combination with serotonergic drugs or monoamine oxidase inhibitors.

Peripheral agents that reduce energy intake and mimic a low-fat diet include orlistat, a semi-synthetic selective inhibitor of gastric and pancreatic lipases that absorb fats consumed with food. The action of orlistat is associated with irreversible inhibition of the hydrolysis of food triglycerides and a decrease in the formation of free fatty acids and monoglycerides. At the same time, about a third of the triglycerides supplied with food are not absorbed and excreted through the gastrointestinal tract. The percentage of absorption of fats does not depend on their quantity, coming from food. Excretion of fat from the feces directly correlates with its amount in food. Orlistat does not affect the activity of other hydrolases in the intestine, so the absorption of carbohydrates, proteins and phospholipids is not disturbed. If orlistat is used with a low-calorie diet, it increases the deficit of energy entering the body. In clinical studies, it was found that the drug provides a more significant weight loss than just a low-calorie diet.

The absorption of orlistat is minimal, so it does not have a systemic effect and does not inhibit hepatic and tissue lipoprotein lipase. The safety of the drug is indicated by the fact that it is eliminated through the intestines, at the same time by 83% - unchanged.

To date, the world has accumulated vast experience in the use of orlistat, since more than 9 million patients have taken the drug in order to reduce excess weight. More than 30,000 obese patients received orlistat therapy in controlled clinical trials for a program to study its efficacy and safety. Thus, in a two-year multicenter study involving 688 obese patients, by the end of the first year of treatment, weight loss by 10% from baseline with orlistat was observed 2 times more often than in the comparable group receiving placebo. In the second year of treatment, despite the expansion of the diet, patients who received orlistat continued to maintain a reduced weight on average 2 times more effectively than those who stopped taking it.

Another important advantage of orlistat is the ability to predict its effectiveness based on the results of use in the first 3 months. If during this period the patient loses at least 5% of the initial body weight, then further therapy is justified. A drug for a patient can be recognized as highly effective if within a year the loss of body weight reaches 10%. With abdominal obesity, orlistat contributes to a more effective, than placebo, reduction in OT in both men and women. In a controlled study with orlistat, a decrease in abdominal adipose tissue was registered by 14% in men and 15% in women.

Orlistat helps to reduce / eliminate many risk factors associated with obesity. In particular, due to a decrease in the absorption of triglycerides and cholesterol in the intestine, the drug reduces the level of total cholesterol, LDL cholesterol and triglycerides in plasma on average 2.5 times more efficiently than just following a diet. The regularity is proved: the higher the initial hypercholesterolemia, the more significant its decline after 6 months of therapy. With prolonged use in patients with IGT, the frequency of progression of this condition to manifest T2D decreases by half. In addition, currently orlistat, in combination with antihypertensive drugs, is the drug of choice for the treatment of hypertension in obese patients.

Orlistat is well tolerated, loss of fat from the feces is accompanied at the initial stage of therapy by the appearance of symptoms from the gastrointestinal tract (diarrhea or steatorrhea), but when patients adapt to the diet with correction of the fatty component of food at 30% of energy consumed, undesirable phenomena cease to be a problem. Adherence to therapy is very high. It is extremely rare to require the additional prescription of fat-soluble vitamins to compensate for their loss through the intestines. Absorption of other drugs (warfarin, digoxin, oral contraceptives, hypoglycemic agents, dihydropyridine calcium antagonists), as well as alcohol, does not change during the treatment with orlistat. The effects of the drug on biochemical parameters, reflecting the functional state of the liver, kidneys or other body systems, have not been registered.

Concluding the presentation of orlistat, it is necessary to say that in Russia in the market in 2009 appeared orlistat, produced by the company KRKA (Slovenia), called Orsoten. Orsoten, like all the company's products, is manufactured in accordance with the strictest European standards, giving the doctor confidence in the efficacy and safety of the recommended therapy. A comparative clinical study conducted in the same year confirmed the full therapeutic equivalence of Orsoten and the original drug.

Each capsule of Orsoten contains 120 mg of orlistat. The drug is prescribed up to 3 times a day before, during or within 1 hour after a meal (if the food was not taken or did not contain fat, then the medication may be missed). Orsoten is available in three packages: 21, 42, and 84 capsules, which makes it possible to purchase the required number of capsules depending on the planned duration of therapy, and thanks to the price advantage, Orlistat-Orsoten has become more accessible to more patients.

In addition to the two classes of drugs used to treat obesity, several new drugs from the RZ-adrenoreceptor group of agonists are currently being studied as potential agents for increasing thermogenesis and energy expenditure. However, today it is premature to predict the clinical value of this class of therapeutic agents, since most of them are only at the initial stage of the study.

Although the prevalence of obesity and related diseases is increasing throughout the world, many physicians (and patients) are still afraid to prescribe (prescription) medications aimed at reducing body weight, believing that when taking them the risk outweighs the possible benefits. However, the use of, for example, orlistat (Orsoten) proved the groundlessness of such a point of view, the need for his appointment to solve a complex medical problem, which is the problem of treating obesity.