Everything about obesity: Does it happen healthy and what to do with it
The discussion of body weight is always a battlefield. Some believe that weight can not affect the health, others - most importantly the adoption of themselves in any form. Even doctors turned out to be on different sides of the barricades. Can a person with a large fat mass be healthy? What exactly causes problems - fat itself or lack of activity and eating habits? We understand what evidence-based medicine says about obesity and how to combine the adoption of your body with health care.
Text: Evdokia Tsvetkova, endocrinologist
Health in any size
Acceptance can be a turning point in a person's life — Harriet Brown, a professor at Syracuse University, who, after many years of dieting, self-accusation and psychotherapy, finally came to peace with her body, speaks well of this in her book, Body of Truth. Loving and caring for the body is part of the practice of Health at Every Size (HAES), which is becoming increasingly popular among physicians. In addition to a healthy attitude to your body, HAES includes an intuitive diet and physical activity that is pleasant and which you want to do.
The main argument of the opponents of HAES is “weight that exceeds the medical norm leads to different diseases and shorter life expectancy.” But in the era of evidence-based medicine, you can only rely on reliable sources that do not depend on personal views. For example, a fairly large review of the 2011 Nutrition Journal shows that people with overweight live at least as much as people with a weight that is considered normal. The prevalence of diseases is directly related not so much to weight as to lifestyle (level of physical activity) and the percentage of adipose tissue (especially visceral fat located around the internal organs), and some diseases in larger people occur even less frequently (for example, osteoporosis).
Of course, there is a huge amount of research confirming the connection of obesity with type 2 diabetes, cardiovascular and oncological diseases, dysfunctions of the musculoskeletal system, reproductive system, liver. And then there is a difficulty with what is meant by obesity - a disease involving metabolic disorders, or just a symptom in the form of a body mass index that exceeds a certain threshold? It seems that both answers may be correct.
How obesity is diagnosed
Usually, body mass index is used for diagnosis, which is calculated by the formula BMI = body weight / height squared. A BMI of 18.5 to 24.99 kg / m is considered normal.2; from 25 kg / m2 overweight begins, and the threshold values for obesity of the first, second and third degree are body mass index equal to 30, 35 and 40 kg / m2 respectively. Of course, the classification of BMI is not universal - it is not applicable to children, pregnant women, people with very developed muscles, in the case of amputation of limbs and so on. But considering that this is a cheap (actually free) method, unlike, for example, dual-energy X-ray absorptiometry, which can be used to measure the percentage of adipose tissue, doctors around the world will continue to use it for more than a decade. Despite its imperfections, BMI helps to predict the development of diseases.
According to the IBC classification, obesity is a chronic and recurrent disease, the rate of spread of which is often compared with an epidemic. According to the WHO 2016 newsletter, more than 1.9 billion adults worldwide were overweight, and more than 600 million were diagnosed with obesity. Since 1980, this figure has more than doubled. It turns out that obesity is called a certain ratio of height and weight, and attention is focused on it, because there are statistical data on the relationship of this ratio to various diseases. Yet obesity-appropriate body mass index does not always speak of a disease, and a normal BMI is not an indicator of overall health. The development of diseases that are often attributed to the effects of obesity may be associated not with weight, but with an insufficient level of physical activity (especially aerobic), with eating habits or, for example, lack of sleep.
Why obesity occurs
Sometimes, increased body weight is one of the symptoms of a genetic or endocrine disease. But still the most frequent reason is an imbalance between the energy received and the energy spent, that is, a situation when a person gets more calories than he manages to spend. It should be understood that the accumulation of fat - a normal response to environmental instability, and it is due to genetics. All living organisms have the ability to store energy - it allows you to survive when food is temporarily unavailable.
There are the so-called theories of the economical genotype - they are based on the fact that people probably had to survive in the conditions of alternating cycles of "feast - hunger". True, they do not help to understand why today BMI in human populations varies greatly - and therefore a theory of economical epigenotype appeared. To simplify the genotype can be compared with the "iron" of the computer, and the epigenotype - with software. There is a certain set of genes, and how it will work depends on the conditions under which the organism developed from the moment of conception (and even on the conditions under which the parents lived). Now it is assumed that “economical genotype” is originally characteristic of all people, but whether it will manifest itself depends on the conditions in which the fetus developed - for example, whether it had enough nutrients.
Adipose tissue has many tasks: it helps to store energy, hormones are synthesized and water is stored in it
Studies have been conducted on how famine during World War II affected the health of unborn children. Children whose mothers were starving in the first trimester of pregnancy were born with the same body weight as others - but by the age of 19, a BMI> 30 kg / m2 among them met much more often. At an older age, metabolic (for example, type 2 diabetes mellitus) and oncological diseases were much more common in people of this group.
In addition to heredity and the conditions in which the child developed before birth, the tendency to an increase in fat mass depends on food habits (not only the calorie content of food, but also the content of fat and foods with a high glycemic index). An important role is played by sleep problems or interference with the daily rhythm of the body (for example, working at night).
Why does the body need fat
It is known that if the body fat is too much, then the risk of some diseases increases. But this does not mean that such a "harmful" tissue is not needed by the body at all, and the percentage of fat should be minimized. Adipose tissue has many tasks: it helps to store energy, hormones are synthesized in it, and water is stored. The fat keeps the organs, vessels and nerves in the right places, filling the spaces between them, and protects the internal organs from injury, damping if a person hits or falls.
Adipose tissue is of different types: brown, white and beige. White fat is the very store of energy, and the largest depots of this tissue are under the skin and between the muscles. It is believed that in a healthy person (that is, from a "normal" in terms of medicine weight) the content of this adipose tissue is in the range of 10-20%. Brown fat is responsible for mobilizing energy in the cold and protects the body from an excessive increase in reserves of white fat. This fabric is mainly located on the back between the shoulder blades. The beige fatty tissue can be found among the white ones, and in cold times it “turns” into a brown one and does its work.
In recent years, perivascular (surrounding blood vessels) fatty tissue is isolated in a separate type - it looks like brown fat, but it is still different. Today it is actively discussed what role this particular tissue plays in the development of atherosclerosis and arterial hypertension (spoiler: it looks like a big one).
What is metabolic syndrome
Adipose tissue, located in different parts of the body, is one large endocrine organ and produces many (about a hundred) hormones that affect metabolism - adipokines. The most significant and studied now is adiponectin and leptin. It is the ratio of these hormones (adiponectine-leptin ratio, ALR) that has been proposed as a marker of the "failure" in the work of adipose tissue; Based on this indicator, it is possible to predict how diseases will develop.
With such a failure, an imbalance occurs between orexigenic (forcing to eat more) and anorexigenic (appetite suppressing) hormones, the number and volume of fat cells grows, inflammatory changes begin in the adipose tissue, which become chronic and are accompanied by chronic oxygen deficiency. Next - a vicious circle: the stronger the inflammation, the more orexigenic and less anorexigenic hormones, which means more and more fat cells, less oxygen and stronger inflammation. In such a situation, when it comes to not just a high BMI, but metabolic disorders, obesity can really be considered a disease.
Metabolic syndrome, although often occurs with increased body weight, is not synonymous with obesity
Visceral (surrounding internal organs) fat is considered the most vulnerable to such disorders. It is measured by determining the waist circumference - it is believed that at 80 centimeters in women and 90 in men the risk increases, and at 88 and 102 centimeters - it is worth the alert. If the amount of visceral fat is increased, then check for the presence of the following changes: resistance to the effects of insulin, dyslipidemia (violation of the ratio of different types of cholesterol in the blood) and arterial hypertension. If there is at least one of these symptoms, then a diagnosis of metabolic syndrome is made.
Metabolic syndrome increases the risk of type 2 diabetes by five times, and the risk of coronary heart disease (including myocardial infarction) three times. It is significantly associated with the risk of stroke, non-alcoholic fatty liver disease, polycystic ovary syndrome, sleep apnea, dementia, Alzheimer's disease, and cancer. And it is important that metabolic syndrome, although often occurs with increased body weight, is not synonymous with obesity.
The metabolic syndrome still increases the risks even with a BMI of less than 30 kg / m2 - This is called central obesity with normal weight (normal-weight central obesity). But at the same time, if the BMI exceeds the medical norm, but there is no metabolic syndrome, a large weight is not a risk factor for earlier death. This phenomenon is called metabolically healthy obesity.
When to run to the doctor
(and from which doctors it is better to run)
It turns out that by themselves the weight and body mass index are still not talking about anything above the medical norm - and only on their basis should you not be alarmed. But if there are signs of metabolic syndrome (for the beginning it is worth measuring the waist volume), then it is better to go to the doctor, first of all - to the therapist or endocrinologist. Going directly to a nutritionist is not the best solution, because treatment should be preceded by a survey. If for some reason you are uncomfortable in your weight, it is better to consult with your doctor too, and not to prescribe yourself a diet yourself or on the advice of a trainer in the gym.
With the right and evidence-based approach, the endocrinologist will prescribe the necessary tests, and the treatment will take place with the participation of a psychotherapist and a nutritionist. Most likely, it will be easier to find such an approach in a good private clinic. If resources are limited, you can try to take part in a clinical study on the prevention of diseases in people with increased body mass - in Moscow this is carried out, for example, in the Endocrinology Clinic of PMGMU. I.M. Sechenov.
If you are prescribed medications and physical activity, without conducting any examinations, you are not asked to keep a food diary, give a standard printout with recommendations - then most likely you have come to an incompetent doctor. The same applies to the expectation of fast results: physiological reduction in body weight will not be more than half a kilogram-kilogram per week; it is possible to lose weight a little faster only if the initial weight exceeds 110-120 kg. As a treatment, you should not prescribe vitamins, dietary supplements, fat burners. And of course, you need to understand that the “treatment” of “nutritionists” without medical education, on the advice of coaches or thinner acquaintances, can be simply dangerous.
How are obesity treated
First of all, changes in diet and physical activity are discussed. A good professional level is not a recommendation “just eat less”, but an explanation of how to keep a food diary, followed by repeated consultations, commenting on diary entries and explaining when it is better to eat. It is necessary to accept the fact that a healthy diet for fast weight loss does not exist. Yes, body weight will decrease both on a carbohydrate-free, and on any kefir diet - but its decrease is not synonymous with health. The best option is always a balanced and varied diet, close to the Mediterranean diet, taking into account human characteristics. Calorie content should be slightly reduced so that the weight decreases gradually; The doctor gives more detailed recommendations for each patient individually.
There is no magic pill that allows you to eat anything in previous quantities so that the body weight decreases. If the body has already established itself as prone to an increase in body weight and visceral fat on this diet and activity level, then to change the trend, you need to change habits.
One of the components of treatment should always be psychological support.
Nevertheless, pills for weight loss exist - and they are used as a supplement to develop new eating habits. This, of course, not the notorious "Thai pills." There are medicinal substances that reduce appetite, affecting the synthesis of "pleasure molecules" in the brain. There are other means - they do not give a large amount of fat (this is the most caloric of what we eat) absorbed in the intestine and remove them from the body. According to 2018, six types of drugs used to reduce body weight are registered in the United States; in Russia now there are three such drugs. Naturally, only a specialist can prescribe drugs and determine the duration of their admission.
In some cases, the question of surgeries for weight loss is being addressed - and this is not about liposuction or other aesthetic interventions, but about so-called bariatric surgery. There are several techniques, all based on the removal of parts of the digestive tract - what is sometimes called "reduce the stomach." It is clear that this is an irreversible and very stressful intervention for the body, so they are resorted to in extreme cases. As a rule, this applies to people who for many years tried to reduce body weight, including under the supervision of a physician, but they did not succeed - and their state of health is such that if weight is not reduced, the risks are very high.
Why psychotherapy is an important part of treatment
Regardless of whether a large weight becomes the cause of health problems or is simply uncomfortable in it - psychological support should be one of the components of treatment. And it's not about the behavior correction in the spirit of "if you want to eat candy - drink some water," but a full-fledged work with a psychotherapist. In the course of such work you can understand a lot about yourself; The so-called abnormal eating habits (when a person sticks to stress or uses food as a reward), as a rule, originate from childhood and are caused by certain psychological traumas. For many, food (which is actually just food) is a substitute for self-love that a person did not feel in childhood and has not yet felt. That is why psychotherapy can be of great importance.
Many people believe that they can love themselves only by reaching a certain weight - and, in fact, are engaged in auto-fetching. But it does not work that way, and out of a sense of guilt and “struggle with oneself”, no one has yet begun to love themselves. On the contrary, the primary must be the resolution of internal conflict, the analysis of traumatic situations and the development of self-love. After that, if there are no metabolic problems, it may turn out that you do not need to reduce weight at all. Those who need to lose weight for medical reasons, psychotherapy is also needed - otherwise the habits are very difficult to change, and sometimes the weight returns even after stomach surgeries. Treatment should be joint work, with good cooperation between an endocrinologist, a nutritionist, a psychotherapist, a surgeon (if he participates) and the patient himself.
Photo: Composer - stock.adobe.com