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OBEZITATEA

http://idata.over-blog.com/0/03/08/54/evolution/evo-obesity.jpg

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cresterea IMC > 30 kg/mp problema serioase de sanatate

RO 22%; locul 3 in EU, locul 1 in Est in F 1 din 10in SUA si mai rau; cheltuieli de 100 mia.

USD/an

trend ascendentla ambele sexe; si la copii

http://images.google.ro/imgres?imgurl=http://www.curierulnational.ro/foto/259_17368.jpg&imgrefurl=http://www.curierulnational.ro/%3Fpage%3Darticol%26editie%3D259%26art%3D17368&h=400&w=276&sz=15&hl=ro&start=33&tbnid=fRfEhMeT3sej5M:&tbnh=124&tbnw=86&prev=/images%3Fq%3Dobezitate%26start%3D20%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DNhttp://images.google.ro/imgres?imgurl=http://www.curierulnational.ro/foto/259_17368.jpg&imgrefurl=http://www.curierulnational.ro/%3Fpage%3Darticol%26editie%3D259%26art%3D17368&h=400&w=276&sz=15&hl=ro&start=33&tbnid=fRfEhMeT3sej5M:&tbnh=124&tbnw=86&prev=/images%3Fq%3Dobezitate%26start%3D20%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN

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Etiopatogeneza dezechilibru intre aport energetic si consum, fie prin activ. fiz.

insuficienta, fie prin alimentatie prea bogata in calorii, fie prin ambele surplus E, acumulat sub forma de TG in adipocite (forma majora deinmagazinare a E la om) masei grase si a G

Consumul energetic:- metab. bazal (70%)- E pentru termoreglare- E pentru activ. fiz.- actiunea dinamica specifica a alim.

Aportul de E:- glucide- lipide- proteineBalanta energetica dezechilibrata prin aport alim. excesiv, mai ales

prin alim. necorespunzatoare; educatie proasta idealuri precumgras si frumos, gras si bogat, indoparea copilului mic; prin sedentarism

http://images.google.ro/imgres?imgurl=http://www.richardsilverstein.com/tikun_olam/obesity.jpg&imgrefurl=http://www.richardsilverstein.com/tikun_olam/2004/03/&h=283&w=150&sz=12&hl=ro&start=10&tbnid=DRynZDu5teonKM:&tbnh=114&tbnw=60&prev=/images%3Fq%3Dobesity%26svnum%3D10%26hl%3Dro

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Factori etiologici: - genetici: multiple gene; mecanism cheie: leptina din adipocite, care

transmite hipotalamusului informatii despre cantitatea de grasimestocata si regleaza apetitul

- de mediu: MB activ. fiz. cultura (educatie) alimentatie(hipercalorica, bogata in lipide & glucide

concentrate, alcool), mai ales searamedicamente (antipsihotice, antidepresive, antiepileptice,

steroizi, antidiabetice, anticonceptionale)boli endocrine (hipotir., b. Cushing, ovar polichistic)oprirea fumatului ( apetit) factori psihici ( consolare in depresie, dupa traume

psihice)diete restrictivevarsta sex (menopauza carenta estrogenica, sarcina) profesie (bucatar, cofetar)

http://images.google.ro/imgres?imgurl=http://static.twoday.net/mahalanobis/images/obesity.jpg&imgrefurl=http://mahalanobis.twoday.net/month%3Fdate%3D200403&h=302&w=200&sz=36&hl=ro&start=60&tbnid=_LYN_tCQkBuywM:&tbnh=116&tbnw=77&prev=/images%3Fq%3Dobesity%26start%3D40%26gbv%3D2%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN

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Mas urarea (cuantificarea) obezitatii: cantarireIMC (G/talie2)18-25 = normal

25-30 = suprapondere> 30 = obezitate30-35 = obez. gr.I35-40 = o bez. gr .II> 40 = ob ez. gr.I II

raport talie/sold norm al: < 0, 8 < 0,9

obez. androida sau ginoida circumferinta talieimasurarea grasimii intraabdominale (CT, RMN,DEXA)masurarea pliului cutanat

http://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://health.indiamart.com/gifs2/obesity.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/index.html&h=231&w=200&sz=12&hl=ro&start=12&tbnid=cBrsGHGwM6zdHM:&tbnh=108&tbnw=94&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg&imgrefurl=http://www.latrobe.edu.au/podiatry/vascular/Obesity.html&h=175&w=150&sz=4&hl=ro&start=2&tbnid=FfLTvL9UHB5mBM:&tbnh=100&tbnw=86&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg&imgrefurl=http://www.latrobe.edu.au/podiatry/vascular/Obesity.html&h=175&w=150&sz=4&hl=ro&start=2&tbnid=FfLTvL9UHB5mBM:&tbnh=100&tbnw=86&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg&imgrefurl=http://www.latrobe.edu.au/podiatry/vascular/Obesity.html&h=175&w=150&sz=4&hl=ro&start=2&tbnid=FfLTvL9UHB5mBM:&tbnh=100&tbnw=86&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://images.google.ro/imgres?imgurl=http://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg&imgrefurl=http://www.latrobe.edu.au/podiatry/vascular/Obesity.html&h=175&w=150&sz=4&hl=ro&start=2&tbnid=FfLTvL9UHB5mBM:&tbnh=100&tbnw=86&prev=/images%3Fq%3Dobesity%26gbv%3D2%26svnum%3D10%26hl%3Dro%26sa%3DGhttp://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg

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Clasificare: - etiopatogenetica: primara

secundara- clinica: androida

ginoida

- dupa severitate: gr. Igr. IIgr. III

- evolutiva: dinamicastatica

- histologica: hipertrofica ( in volum a adipocitelor prin acumulare de TG)

hiperplazica ( nr. adipocite) mixta

- topografica: inalta (torace, gat, ceafa) joasa :abdominala: - de sedentarism (dupa abandonarea sportului)

- nervoasa (prin stres)- psihogena (bulimie)- aterogena (sindr. metabolic)- diabetogena

in pantaloni bufanti gluteo-femuralain cizma

capilara (pe cele 4 membre, mai ales pe fata internaa genunchilor)

mixta

http://www.latrobe.edu.au/podiatry/vascular/vascpics/obesity.jpg

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Diagnostic- anamneza: stil de viata

(alimentatie, activ. fiz.,

fumat, alcool, stres),conditii psiho-sociale &econ., AP, AHC

- ex. obiectiv: IMC, tipul deobezit., HTA, suferintecard., endocrine(hipercorticism, hipotir.,insuf. gonadica)

- paraclinic: glicemie, TTOG,lipidograma, ac. uric, GT,TSH,T4, cortizol, FSH, LH,ECG, spirograma, Rgr.osteo-artic., de sa turcica,ecografie, CT, RMNhipofiza, tir., SR, ovaremasa grasa viscerala

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Riscuri si complicatii

Obezul se sinucide lent!Mortalitatea prop. cu gr. obez.

- metabolice (DZ, rezistenta la insulina, hiperlipemie, sindr. metabolic,guta) mai ales in cea abdom. - cardio-vasc. (aritmii, IMA, IC, HTA, AVC, varice, hemoroizi) mai

ales in cea abdom.- resp. (dispnee, apnee in somn, sindr. Pickwick)- neurol. (cefalee, tulb. de vedere, dificultate de concentrare)

- osteo-artic. (sindr. trofostatic, coxartroza, gonartroza, deformari in Xsau O ale membrelor)

- digestive (constip., lit. bil., steatoza hep.,HH)- endocrine (sindr. ovarelor polichistice, insuf. gonadica, infertilitate,

hirsutism)- sexuale ( libido) - cutanate (celulita)- psihologice (dificultati de integrare soc., depresii)- oncogene (cancere genitale, de san, colorectale, prostata) mai

ales cea abdom.

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Tratament

Principii: - aportului E- pierderilor E tesutului adipos

normal: MB 60%; activ. fiz. 32%;

termoreglare 8%sedentarism: MB 75%; activ.fiz.17%; termoreglare 8%

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Mijloace de greutatii: - regim alimentar (necesar zilnic mediu 1600 -1800 kcal la si 1200-1400 kcal la

; maxim 5000 kcal alpinisti) dieta hipocalorica simpla, adaptata obiceiurilor si ritmului de viata, normala

cantitativ, calitate superioara, invatat sa-si faca singur de mancare aportului E cu 500 kcal pierdere de 0,5 kg/sapt. (scade MB)

pierdere in greutate cu 10 kg necesarul E cu 300 kcal/zi (cu cat slabeste, arenevoie de mai putina E)

regim dietetic cicluri repetate de scadere/stagnare ( cu 10% in 3 luni, apoimentinerea acestei greutati alte 3 luni si repetarea ciclurilor); pe termen scurt (2-4sapt.) 2 -2,5 kg; pe termen mijlociu (6 luni) 7 -10kg; pe termen lung (2 ani)

- activ. fiz. (consum E: mers lent < mers rapid < ciclism, inot < urcat scari)- terapie comportamentala schimbarea stilului de viata, suport psihologic - farmacoterapie orlistat (Xenical), sibutramin (Reductil, Meridia), topiramat

(Topamax)- interv. chirurg. daca IMC > 40, apar si comorbiditati; consta in shunt gastric,

lipoaspiratie

Se incepe cu modificarea stilului de viata, apoi farmacoterapie, abia apoi interv. chirurg.Indiferent de metoda terapeutica, alimentatia este esentiala!

Nu se administreaza hormoni tiroidieni, diuretice, preparate naturiste; toate degeaba sauchiar efecte secundare

Nu se practica scaderi ponderale rapide (malnutritie si risc cardiovasc.)

http://images.google.ro/imgres?imgurl=http://www.surgicalteam.com/obesity/front2.jpg&imgrefurl=http://www.surgicalteam.com/obesity/index.htm&h=150&w=225&sz=8&hl=ro&start=29&tbnid=uWUp4A8nf8HjYM:&tbnh=72&tbnw=108&prev=/images%3Fq%3Dobesity%26start%3D20%26gbv%3D2%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN

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Profilaxie- Educatia si optimizarea stilului de viata la

intreaga populatie (familie, scoala, media)- Crearea de posibilitati de a face sport

(stadioane, benzi pentru ciclisti etc.)

- Specificarea continutului caloric pealimente

- Identificarea persoanelor cu risc

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Multi obezi nu stiu ca sunt obeziChiar daca stiu, nu stiu ca trebuiesa slabeascaChiar daca stiu, nu vor Chiar daca vor, nu stiu cumChiar daca stiu cum, nu reusesc

Chiar daca reusesc, recidiveazaDe aceea, managementul obezitatii este

foarte complex

http://images.google.ro/imgres?imgurl=http://www.mercola.com/images/blog/2005/03/obesity.jpg&imgrefurl=http://www.mercola.com/2005/mar/5/obesity_costs.htm&h=191&w=184&sz=11&hl=ro&start=2&tbnid=oGOA0mR9nRTa2M:&tbnh=103&tbnw=99&prev=/images%3Fq%3Dmorbid%2Bobesity%26gbv%3D2%26ndsp%3D20%26svnum%3D10%26hl%3Dro%26sa%3DN

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DISLIPIDEMIILE

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totalitatea modificarilor calitative si cantitativeale lipidelor din sange in general, se suprapune cu termenul dehiperlipidemie ( colesterol & TG in sange)

Valori normale: colesterol seric < 190 mg%TG serice < 180 mg%HDL- colesterol > 40 mg%

LDL- colesterol < 115 mg%Prevalenta foarte mare; in RO 55%, mai aleshipercolesterolemia

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Clasificare (dupa EAS)- Hipercolesterolemii

de granita: colest. 190-250; TG < 180moderate: colest. 250-300; TG < 180severe: colest. > 300; TG < 180

- Hipertrigliceridemiimoderate: colest. < 190; TG 180-400severe: colest. < 190; TG > 400

- Hiperlipidemii mixtemoderate: colest. 190-300; TG 180-400severe: colest. > 300; TG > 400

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S-a renuntat la clasificarea luiFrederickson, completata de OMS:tip Itip IIA

tip IIBtip IIItip IV

tip V

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EtiopatogenezaClasele majore de lipoproteine:- Chilomicronii forma majora de transport a TG si

colest. exogen din intestin in sange- VLDL transporta lipide endogene, in special TG spretesuturi

- IDL transporta TG, esteri de colest. spre tesuturi; rolaterogen

- LDL forma majora de transport a esterilor de colest.spre tesuturi; rol aterogenfenotip A (cu densitate mica si vol. mare)fenotip B (cu densitate mare si vol. mic) cel

mai aterogenfenotip intermediar

- HDL transporta colest. din tesuturi in ficat; rolantiaterogen

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Lipidele din organism, atat cele exogene (alim.),cat si cele endogene, sunt transportate subforma de lipoproteine

Acest transport este reglat prin 3 cai:- alimentatia: lipidele saturate si polinesaturate

trans produc colest., TG lipidele mononesaturate si

polinesaturate cis produc colest. regim hipercaloric obez.

stimuleaza lipoliza TG regim hipocaloric colest., TG

- activ. fiz.: TG, colest. - homeostazia colest.

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Factori de risc:factori genetici agregari familiale

stil de viata nesanatos:- alim. hipercalorica, bogata in colest.,glucide rafinate,alcool > 30 g/zi

- fumat- sedentarism- stres psiho-social

sindr. metabolichiperlipemii sec.: hipotir., DZ, colestaza, SN, IRC,porfirie, sarcina, postmedicamentos (tiazide, -blocante,steroizi, estrogeni)

Acesti factori determina fie o sinteza lipoproteine, fie o acatabolismului lipoproteic, in ambele cazuri o alipoprot. serice

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DiagnosticScreening populational ar fi foarte util, dar foarte

scump; de aceea depistare la grupe de risc: - Bolnavi cu ateroscleroza: CI, arteriopatie perif.,

anevrism de AO, boala cerebro-vasculara

- Factori de risc cardio-vascular: DZ, tolerantaalterata la glucoza, obez., HTA- Persoane cu xantomatoza- Rude de gr. I cu ateroscleroza sau risc cardio-

vascular

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anamneza despre stilul de viata (alimentatie, activ. fiz.,alcool, fumat), AHC, APdozari lipidice complete: colesterol

TGHDL-colesterol

etichetarea formei clinice: primaresecundare

stabilirea clasei clinice de risc:scazut (risc cardio-vascular < 10%)moderat (RCV 10-20%)crescut (RCV > 20%)

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Complicatii- aterosclerotice, mai ales coronariene- pancreatice (PA in TG)

Boli asociate- DZ- Obezitate- HTA- sindr. metabolic

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Tratament optimizarea stilului de viata:

- dieta hipolipidica: aport caloric proveninddin lipide < 30%; reducerea alcoolului

- activ. fiz.- abandonarea fumatuluimedicatie hipolipemianta:

- derivati de ac. nicotinic (Acipimox)- fibrati (Bezafibrat, Ciprofibrat, Fenofibrat, Gemfibrozil)

in hipertrigliceridemii - rezine (Colestiramina)- statine (Atorvastatin, Fluvastatin, Lovastatin,

Pravastatin, Simvastatin) in hipercolesterolemii - ulei de peste (acizi polinesaturati 3)se pot asocia statine + colestiramina sau statine + fibrati

tratam. comorbiditatilor

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Profilaxie- primara: stil de viata sanatos

tratam. obezitatiitratam. DZdepistarea persoanelor de risc

- secundara: prevenirea aterosclerozei

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SINDROMUL METABOLIC(Sindr. X metabolic)

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sindr. descris abia din 1988, care consta in asocierea acel putin 2 dintre urmatoarele fenomene:Insulinorezistenta ! hiperinsulinismscaderea tolerantei la glucoza sau DZ tip 2hipertrigliceridemiescaderea HDL- colesterolHTAobezit. abdom.hiperuricemiesedentarismscaderea activ. fibrinolitice si tendinta la tromboza

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asociere frecventa (in SUA la peste 70mio. americani) risc cardio -vascular deosebit, efectulconditiilor incriminate nu se sumeaza, cicreste exponential

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EtiopatogenezaFactori de risc

- factor genetic- alimentatie hipercalorica, bogata in lipide

saturate si colesterol- sedentarism- imbatranirea

- subnutritia fatului (G < 2.5 kg)

Element-cheie: insulinorezistenta

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DiagnosticObezit. abdom.HTA

DZDislipidemieBoli cardio-vasc.HiperuricemieTalie > 80 cm la si > 90 cm la markerul cel

mai simplu al insulinorezistentei

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Tratament Obiectivul principal: scaderea riscului cardio-

vascular monitorizarea fiecarui factor

- Optimizarea stilului de viata scadereponderala, ameliorarea celorlalti factori de risc

- Medicatie tratam. insulinorezistentei cumetformin sau troglitazona+ adresata fiecarui factor in parte

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Profilaxie vizeaza toate elementele