Stilul de via Sedentarismul

20 / zi x 20 m = 400 m
Distana de mers / jos /
an
400 x 365 = 146.000 m
146 km = 25 h mers
1 h mers = 113-226 kcal
Energia salvat = 2800-6000 kcal

0.4-0.8 kg esut adipos / an

S. Rssner, 2002

Stilul de via
- Fumatul -

Stilul de via
- Stresul -

Obezitatea = dezechilibru energetic

Consum
energetic
Aport energetic
(caloric)

 Cel mai frecvent, obezitatea este poligenic

Adipozitatea este reglat prin procesul de
homeostazie energetic
Adipozitatea este reglat prin controlul activ al
creierului asupra aportului energetic i
consumului energetic
n acest proces de reglare particip multiple
sisteme i organe

Creierul influeneaz homeostazia energetic via

sistem nervos somatic i autonom, prin axa
hipotalamo-hipofizar

Activare neuroendocrin

Activitate parasimpatic

Activitate motorie

Activitate simpatic

Controlul adipozitii

Umoral
SNC
Mecanisme reglatoare

Aport energetic,
Consum energetic

Hormoni de adipozitate
Insulina, leptina

Balana energetic
Stocarea de calorii

Sistemul endocanabinoid
Brain

Peripheral tissues

Adipose
tissue
Hypothalamus:
^ hunger

Nucleus accumbens:
^ motivation to eat

Increased food intake

Increased fat storage

Liver
GI tract

Muscle

^ Insulin resistance

HDL-C
^ TG
Glucose uptake
Adiponectin

Bensaid M, 2003; Pagotto U, 2005; Osei-Hyiaman D, 2005; Di Marzo V, 2005; Liu YL, 2005

Obezitatea
- epidemiologie
- definiie
- clasificare,
- diagnostic
- factori de risc
- etiopatogenez
- risc cardio-metabolic
- principii de management clinic
Sindromul metabolic
- definiie
- diagnostic
- factori de risc
- etiopatogenez
- risc cardiometabolic
- principii de management clinic

RISCURILE OBEZITII

Mecanice

Metabolice

Mecanice i metabolice

- lumbago
- accidente profesionale sau
rutiere
- intertrigo
- incontinen urinar
- edem i celulit
- dehiscena plgilor
constipaie,
disconfort
abdominal (balonri)
- reflux esofagian

- insulinorezisten
- diabet zaharat tip 2, scderea
toleranei la glucoz, glicemie
bazal modificat,
- dislipidemie,
boli
cardiovasculare
aterosclerotice,
- litiaz biliar,
- hirsutism,
- cancer de sn, uter, prostat
- sterilitate,
- dismenoree
- gut

- hipertensiune arterial,
- dispnee,
- varice, hemoroizi,
- artroze,
- transpiraii,
- insuficien respiratorie
- apnee n somn,
- risc anestezic,
-disgravidie, eclampsie, natere
prematur

Riscul asociat cu distribuia abdominal a esutului adipos

La brbai

La femei

- cardiopatie ischemic

- infarct miocardic i angin

- diabet zaharat tip 2,

pectoral,

- dislipidemie,

- diabet zaharat tip 2,

- accidente vasculare cerebrale,

- accidente vasculare cerebrale

- hipertensiune arterial,

- cancer uterin,

- artroze,

- hirsutism, dismenoree,

- ulcer gastro-duodenal,

- ovar polichistic,

- apnee n somn

- litiaz biliar (renal ?)

- gut (?)
- probleme psihosociale

Circumferina taliei: se coreleaz cu obezitatea

visceral

Visceral AT

Subcutaneous AT

esut adipos visceral (cm2)

Fa

300

r=0.80

250
200
150
100
50
0
60

Spate

AT: esut adipos

80

100

120

Circumferina abdominal (cm)

Adiopzitatea intra-abdominal
risc cardiometabolic major

Markeri inflamatori

Dislipidemie
(C-reactive protein)

Acizi grai
liberi

Insulino
rezisten
Hiperinsulinemie
Disglicemie

Risc
cardiometabolic
crescut

Adipokine

Inflamaie

Kershaw EE et al, 2004; Lee YH et al, 2005;

Boden G et al, 2002

Obezitatea & Sindromul metabolic patogenez

ADIPOSOPATIE

Leptina

AGL

Fact. cretere

Angiotensinogen

Adiponectin

PG

Adipsin

Agouti

es.
Adipos
Visceral

Apo E

Resistin
Il-6 + sR
TNF-alpha + sR

TGF-beta

PAI-1

IGF-1

MCP-1

Visfatin

Factor
Steroids
tisular

Tataranni PA: Diabetes, 54(4).April 2005.917927

Intra-abdominal Adiposity Feeds Directly

into the Liver
Hepatic FFA flux
(portal hypothesis)
suppression of
lipolysis by insulin

Secretion of
metabolically active
substances (adipokines)
Intra-abdominal
adiposity
PAI-1

FFA

Insulin resistance
Dyslipidaemia
Pro-atherogenic

Adiponectin
IL-6
TNF
Net result:
Insulin resistance
Inflammation

Heilbronn L et al. Int J Obes Relat Metab Disord. 2004;28 Suppl 4:S12-21.
Coppack SW. Proc Nutr Soc. 2001;60:349-56.
Skurk T & Hauner H. Int J Obes Relat Metab Disord. 2004;28:1357-64.

High Intra-abdominal Adiposity (IAA)

Associates with Insulin Resistance
Glucose

Area

1
1,2

pmol/L

mmol/L

12

1200

1,2

1,2 1,2
1,2

1,2

800

Area

15

Insulin

1,2
1,2

1,2

400

1,2
1,2

0
0

60
120
Time (min)
Non-obese

180
Obese low IAA

0
0

60
120
Time (min)

Obese high IAA

IAA: intra-abdominal adiposity

Significantly different from 1non-obese, 2obese with low visceral AT levels
Pouliot MC et al. Diabetes. 1992;41:826-34.

180

Intra-abdominal Adiposity (Visceral

Obesity) Accentuates Dyslipidemia
Triglycerides

HDL-cholesterol

310

60

mg/dL

mg/dL

248
186
124

45

62
0

Lean

Low High
Visceral fat
(obese subjects)

Pouliot MC et al. Diabetes. 1992;41:826-34.

30

Lean

Low High
Visceral fat
(obese subjects)

Abdominal Obesity: Increases the

Risk of Developing Type 2 Diabetes
in Women
24

The Nurses Health Study

20
16

Relative
risk 12
for
T2DM 8
4
0
cm: <71
inches:

7175.9

7681
31

81.186

32

33

86.191 91.196.3
34

35

Waist circumference (cm)

Carey VJ et al. Am J Epidemiol. 1997;145:614-9.

36

37

>96.3

38 >39

Abdominal Obesity:
Increased Risk of CV Events
The HOPE Study
Waist
circ. (cm):

1.4

Men
Tertile 1
<95
Tertile 2 95103
Tertile 3 >103

1.29

1.2
Adjusted
relative
risk 1

1.35

1.27

1.17
1

Women
<87
8798
>98

1.16
1

1.14
1

0.8
CVD death

MI

All-cause deaths

Adjusted for BMI, age, smoking, sex, CVD, disease, DM, HDL-C, total-C
Dagenais GR et al. Am Heart J. 2005;149:54-60.

Metabolic Risk-Factor Clustering and

CVD Risk
The Botnia Study
<3 metabolic RFs
3+ metabolic RFs

20

*p<0.001

15
10

*
*

5
0

25

CHD

MI

Mortality rate (%)

Prevalence (%)

25

20

Isomaa B et al. Diabetes Care. 2001;24:683-689.

15
10

5
0

Stroke

*p<0.001

All-cause Cardiovascular
mortality
mortality

Stil de via
cu risc crescut:
Expuneri
multiple la
Factori de
mediu,
ambientali

Susceptibilitate
genetic

Obezitate

IR
Ateroscleroz
Sindrom metabolic
DZ 2

Ateroscleroz
Boal cardiovascular

Obezitatea & Sindromul metabolic patogenez

Adipozitate
intra-abdominal

Obezitate IR
Sindrom metabolic
cardiovascular

Visceral adipose tissue

accumulation

AGL, Insulin resistance,

inflammation, oxidative
stress, endothelial
dysfunction, PPARs
Lifestyle+
Ambiental
factors

Diabetes, Dyslipidemia,
Hypertension, Obesity,
NASH

Genetic
network

Atherogenesis/
Thrombogenesis
Oncogenesis

Cardiovascular disease
Some forms of cancer

N Hancu, 2005

Sindromul metabolic - patogenez

Geneticcauses,
causes,Overeating,
Overeating,Sedentary
Sedentary
Genetic
Abdominal obesity
Insulin resistance / Hyperinsulinemia

Muscle

Liver

Blood glucose

-cell

Ins.

Ins.

Arteries
Dyslipidemia:
TG
HDL
Small & dense
LDL
Chol/HDL ratio
apo B
PP HLP

-cell failure

T2 DM

Stiffness
Endothelial
Dysfunction

Other
Mechanisms

HBP
LVH
CHF

Blood

Pro-Thrombotic
Pro-Inflammatory
State:
PAI-1
t-PA
FVII, F XII
Fibrinogen

Atherothrombotic
Arterial disease
CVD

Alb-uria

Genetic, acquired causes

After H. Yki-Jarvinen. Textbook of diabetes, JC Pickup&G. Williams (eds),2003

Obezitatea
- epidemiologie
- definiie
- clasificare,
- diagnostic
- factori de risc
- etiopatogenez
- risc cardiometabolic
- principii de management clinic
Sindromul metabolic
- definiie
- diagnostic
- factori de risc
- etiopatogenez
- risc cardiometabolic
- principii de management clinic

Sindromul metabolic Definiie

Asociere de factori de risc cardiovascular i metabolici, cu
manifestare clinic n proporii i intensiti variate n rndul
indivizilor, dar totdeauna responsabil de un exces de
morbiditate i mortalitate cardiovascular comparativ cu fiecare
factor n parte.
Constelaie de factori de risc interrelaionai, de origine
metabolic factori de risc metabolici care promoveaz direct
dezvoltarea patologiei cardiovasculare aterosclerotice.
n plus, asociaz un risc crescut de dezvoltare a diabetului
zaharat.

Sindromul metabolic Definiie

Componentele sindromului metabolic:

Obezitate abdominal
Insulinorezisten
Dislipidemie aterogen (HDL mic, TG crescute, LDL aterogene
Disglicemie (STG, GBM, DZ tip 2)
Hipertensiune arterial
Stare protrombotic (creterea fibrinogenului, PAI-1)
Stare proinflamatorie (creterea Proteinei C-reactive, TNFalfa, interleukine)
Disfuncie endotelial
Boal hepatic non-alcoolic, steatohepatit non-alcoolic

Sindromul metabolic
Criterii de diagnostic Consensul IDF 2005
Obezitatea abdominal (condiie obligatorie)
Talie femei

80 cm; Talie brbai 94 cm

Plus minim alte 2 criterii:

Tensiune arterial 130/85 mm Hg sau
tratament hipotensor
Trigliceride 150 mg/dl
HDL colesterol

< 40 mg/dl (brbai)

< 50 mg/dl (femei)

Gicemie bazal (a jeun) 100 mg/dl

2005

Hiper TG
Hipo HDL
LDL mici i dense
Apo B crescut

Jean-Pierre Despres. Is visceral obesity

the cause of the metabolic syndrome?
Annals of Medicine. 2006; 38: 5263

Obezitatea
- epidemiologie
- definiie
- clasificare,
- diagnostic
- factori de risc
- etiopatogenez
- risc cardiometabolic
- principii de management clinic
Sindromul metabolic
- definiie
- diagnostic
- factori de risc
- etiopatogenez
- risc cardiometabolic
- principii de management clinic

34

ABORDARE TERAPEUTIC
CONTROLUL ADIPOZITII

Datorit complexitii controlului homeosataziei

energetice, strategiile terapeutice eficiente
trebuie s vizeze mai multe procese implicate n
acest control.

MANAGEMENT CLINIC (II) - BENEFICII

REDUCEREA MORBIDITII I MORTALITII GENERALE I
CARDIOVASCULARE PRIN SCADEREA PONDERALA CU 5-10% A GREUTAII
CORPORALE
Diabetul zaharat (DZ)

- reduce riscul DZ tip 2 cu 50%

- crete sperana de via n DZ tip 2
- scade mortalitatea n DZ cu 44%

HTA

- reducerea TAS si TAD cu 10 - 20 mmHg

Cardiopatia ischemic (CI) - reducerea simptomatologiei anginei pectorale cu 91%

- creterea toleranei la exerciiu cu 33%
- reduce mortalitatea prin CI cu 25%
DLP

- reducerea colesterolului cu 10%, a trigliceridelor cu 30%

- creterea col-HDL cu 8%

Cancerele

- reduce mortalitatea din cancere cu > 40%

Afeciunile osteoarticulare - ameliorarea leziunilor i a simptomatologiei dureroase

Complicaiile Ginecologice, Obstetricale i Urologice

MANAGEMENT CLINIC (I) - OBIECTIVE

Scdere ponderal 5 - 10%
Meninerea noii greuti
Prevenirea rectigului ponderal
Controlul celorlali factori de risc cardiovascular
Controlul complicaiilor / Co-morbiditii

PERSOANA CU OBEZITATE
ABORDARE INIIAL

ABORDARE CONTINU

Obiective pe termen scurt:

Obiective pe termen lung:

Un ciclu scdere - meninere

Realiste - meninere 2 ani

6 - 9 luni

Optime - noi cicluri pn la IMC < 25 kg/m2

o nou greutate

37

ABORDARE TERAPEUTIC
MANAGEMENT INTEGRAT

Evaluare clinic Evaluarea

Istoricul obezitii - riscului
Istoria familial -motivaiei de
a slbi
Examen clinic
IMC
Stabilirea de
Talie
obiective
Tensiunea arterial ponderale
Examen de urin

Modificri
comportamentale

Diet

Activitate
fizic

Realizarea
obiectivelor
ponderale

Meninerea
Greutii

Nerealizarea
obiectivelor
ponderale;
Risc crescut

Farmacoterapie

P. G. Kopelman, 2001

Management integrat:
Implicarea familiei n
optimizarea stilului de via

Chirurgie

Metode: Programele TEME

Terapie:
Optimizarea stilului de via
Farmacoterapie
Educaie terapeutic (ETP)
Monitorizare - periodic
Evaluare anual a calitii ngrijirii

39

STRATEGIILE MANAGEMENTULUI PONDERAL

OPTIMIZAREA
STILULUI DE VIATA

FARMACOTERAPIE

CHIRURGIE