Download A chief of endocrinology department, prof. Vlasenko MV

MINISTRY OF HEALTH PROTECTION OF UKRAINE
Vynnitsa national medical university named after M.I.Pyrogov
«CONFIRM»
on methodical meeting of
endocrinology department
A chief of endocrinology
department, prof. Vlasenko M.V.
_________________
“_31_”_august___ 2012 y
METHODOLOGICAL RECOМMENDATIONS
FOR INDEPENDENT WORK OF STUDENTS
BY PREPARATION FOR PRACTICAL CLASSES
Scientific discipline
Мodule № 1
substantial module №1
Topic
Course
Faculty
Internal medicine
Basis of Internal medicine
“Diagnostic, treatment and prophylactic basis of
main endocrinology diseases”
Topic №19: Obesity. Clinics, diagnostics, differential
diagnosis, treatment, prophylactics. Methabolic
syndrome.
4
Medical № 1
Vynnitsa – 2012
METHODOLOGICAL RECOМMENDATIONS
for the students of 4-th course of medical faculty for preparation to the practical
classes from endocrinology
1.Тopic №19: Obesity. Clinics, diagnostics, differential diagnosis, treatment, prophylactics.
Methabolic syndrome.
2. Relevance of topic: In 1997 WHO declared obesity as a global epidemy, which is a serious threat
to the population’s health in the world because of the development of concomitant diseases - arterial
hypertension, coronary heart disease, type 2 diabetes mellitus. Mortality risk increases much when
BMI is more than 30 kg/m2. Medium spreading of obesity in the world is about 30 %, and in high
developed countries (USA, Germany, UK) - 45-50 % of all population. According to the prognosis
for 2010 year the number of people with obesity supposed to be increasing up to 50-60 % in these
countries.
Therefore, obesity is an important medical-social problem now and a factor which
deteriorates the life quality of patients. It has considerable economic consequences. Obesity
adversely affects morbidity and mortality, primarily through cardiovascular complications. The
death rate from many diseases, from accidents, and from surgery, is significantly higher among the
obese, increasing with the magnitude of the obesity. Sudden death is also common.
3. Aim of lesson:
 To get acquainted with the spreading of Obesity in Ukraine.
Student must know:
• etiology, pathogenesis, clinical presentation and diagnostic methods of obesity, indications for
surgical treatment;
• strategies and methods of management;
• international classifcation of obesity.
Student must be able:
• to diagnose obesity accordingly to types, to calculate BMI, to provide curative and preventive
measures;
• to determine the type of fat distribution (gynoid, android) and provide differential diagnostics
between types of obesity;
• to administer the scheme of reducing diet, drug therapy, exercise complex for obese patients.
• to realize deontological principles in diagnostics and treatment practice of obesity
• to achieve habits to establish physiological contact and to create the confdential atmosphere
between doctor and obese patient.
• to form responsibility for well-timed and complete examination of obese patient and for
acknowledgement of patient about possible methods of treatment
4. References
4.1. Main literature
1. Endocrinology. Textbook/Study Guide for the Practical Classes. Ed. By Petro M. Bodnar: Vinnytsya: Nova Knyha Publishers, 2008.-496 p.
2. Basіc & Clіnіcal Endocrіnology. Seventh edіtіon. Edіted by Francіs S. Greenspan, Davіd G.
Gardner. – Mc Grew – Hіll Companіes, USA, 2004. – 976p.
3. Harrison‘s Endocrinology. Edited J.Larry Jameson. Mc Grew – Hill, USA,2006. – 563p.
4. Endocrinology. 6th edition by Mac Hadley, Jon E. Levine Benjamin Cummings.2006. –
608p.
5. Oxford Handbook of Endocrinology and Diabetes. Edited by Helen E. Turner, John A. H.
Wass. Oxford, University press,2006. – 1005p.
4.2. Additional literature
6. Endocrinology (A Logical Approach for Clinicians (Second Edition)). William Jubiz.-New
York: WC Graw-Hill Book, 1985. - P. 232-236. Pediatric Endocrinology. 5th edition. –
2006. – 536p.
Basic Level.
Students must know:
1. Anatomy and physiology of a hypothalamo – pituitary system, subcutaneous adipose tissue.
Students should be able to:
1. Ask and examine the patient.
2. Interpret data of the laboratory and instrumental methods of examination
Students’ Independent Study Program.
You should prepare for the practical class using the existing text books and lectures. Special
attention should be paid to the following:
1. Etiology and pathogenesis of obesity.
2. Clinical presentation of obesity and concomitant complications. International classifcation of
obesity.
3. Diagnostic criteria of different forms of obesity. (Alimentary, hypothalamic,Pickwickian
syndrome, Barrakcer – Simmons’s disease, Babinsky-Frelych’s disease, Dercum’s disease,
Laurence – Moon – Biedl syndrome, Morganyi – Stuart – Morel’s syndrome, postnatal
neuroendocrine syndrome )
4. Methods of treatment of obesity.Main principles of reducing diet. Medicines for treatment of
obesity.
Short content of theme
OBESITY.
Obesity is characterized by excessive accumulation of body fat.
Obesity in not a condition for which a precise definition is particularly useful. Unlike many
“real” diseases, obesity represents one arm of distribution curve of body fat or body weight, with no
sharp cut-off point. Its importance lies in the many, often serious, complications to which obese
people are subject. In these complications that warrant undertaking a treatment that is so often
unsuccessful.
Etiology.
The cause of obesity is simple – consuming more calories than are expended as energy.
However, we usually do not know why persons consume more calories than they expend.
Predisposing factors.
1. Social factors (obesity is prevalent among lower-class people than among upper-class. Other
social factors, particularly ethnic and religious are also closely linked to obesity, how these
factors lead to obesity, or its control, has not been established, but differences in life style,
dietary and exercise patterns, probably play a major role).
2. Sex (female have greater tendency to gain weight particularly at puberty and during pregnancy),
age (at middle aged people have more tendency to become obese. Anyhow, obesity is present
among all age groups).
3. Endocrine factors. (Certain diseases of endocrine glands are associated with obesity i.e.
hypothyroidism, Cushing’s disease, hypogonadism.)
4. Psychological factor.(many obese persons report that they overeat when emotionally upset, but
many nonobese persons also overeat in such conditions. Two deviant eating patterns based on
stress and emotional disturbance, however, may contribute to the obesity of a few patients.
Bulemia is the sudden, compulsive ingestion of very large amounts of food in a very short time,
usually followed by agitation, self-condemnation, and often by self-induced vomiting. The
night-eating syndrome consists of morning anorexia, evening hyperphagia, and insomnia.
Attempts at weight reduction in these 2 conditions are usually unsuccessful and may cause the
patient unnecessary distress.)
5. Genetic factors (It is widely recognized that obesity runs in families: 80 % of the offspring of 2
obese parents are obese, compared with 40 % of the children of 1 obese parent and only 10 % of
the offsprings of 2 nonobese parents.).
6. Physical activity. (Decreased physical activity in affluent societies is often sited as a major
factor in the rise obesity.)
7. Development factors.(The increased adipose tissue mass in obesity can result from either an
increase in size of fat cells (hypertrophic obesity), from an increase in the number of fat cells
(hyperplastic obesity), or from an increase in both (hypertrophic-hyperplastic obesity). Most
persons whose obesity began in adult life suffer from hypertrophic obesity. They lose weight
solely by the decrease in the size of their fat cells; the number of fat cells does not change.
Persons whose obesity began in childhood are more likely to suffer from hyperplastic obesity,
usually of the combined hypertrophic-hyperplastic type. They may have up to 5 times as many
fat cells as either persons of normal weight or those suffering from pure hypertrophic obesity.
As a result, they may be able to reach a normal body weight only by marked depletion of the
lipid content of each fat cell.)
8. Brain damage. (Brain damage, particularly to the hypothalamus, can lead to the obesity.)
Classification by Egorov.
1. Alimentary.
2. Endocrine.
3. Cerebral.
Classification due to stages of obesity.
A. According to Brock’s index (N: weight = height – 100).
I.
Weight excess < 30 %.
II.
Weight excess 30 – 50 %.
III.
Weight excess 50 – 100 %.
IV.
Weight excess > 100 %.
B. According to Kettle’s index (N: weight, kg – height, m2).
I.
27,5 – 29,9
II.
30,0 – 34,9
III.
35,0 – 39,9
IV.
> 40,0
Classifcation of overweight in adults by BMI (WHO, 1997)
Class
Underweight
Normal
Overweight
Preobesity
Obesity: class I
class II class
III
-
BMI, kg/m2
<18,5
18,5–24,9
>25 25–
29,9 30–
34,9 35–
39,9
>40
Associated disease risk
Low
Medium
Increased High Very high
Extremely high
Classification due to deposition of fat tissue.
upper type (abdominal);
lower type (gluteofemoralis).
Classifcation of Obesity (Dedov I.I., Melnichenko G.A., Fadeev V.V., 2000)
Primary obesity
I. Alimentary constitutive obesity
1. Android (upper type, abdominal, visceral):
a) with components of metabolic syndrome;
b) with developed symptoms of metabolic syndrome.
2. Gynoid (lower type, gluteal thigh).
3. With marked disorder of nutritional behavior:
a) night eating syndrome;
b) seasonal affective alternations;
c) with hyperphagic reaction to stress.
4. With Pickwick’s syndrome.
5. With sleep apnea syndrome.
6. Combined.
Secondary (symptomatic) obesity
I. With determined genetic defect.
II. Cerebral
1. Tumor, trauma of brain.
2. Systemic lesions of brain, infectious diseases.
3. Hormone-inactive tumors of hypophysis, “empty” ephippium syndrome.
4. In mental diseases.
III. Endocrine
1. Hypothalamic-pituitary (hypothalamic).
2. Hypothyroid.
3. Hypoovarial.
4. Hypercorticoid.
Diseases and syndromes, accompanied with obesity
Metabolic diseases
and syndromes
Type 2 diabetes mellitus, impaired glucose tolerance, hyperinsulinemia,
dyslipidemia (increased level of triglycerides and low density lipoprotein
cholesterol, decreasing level of high-density lipoprotein cholesterol),
cholecystolithiasis, hyperuricemia, steatohepatitis.
Cardio-vascular
diseases and
syndromes
Neoplasm
Arterial hypertension, coronary heart disease, left ventricle hypertrophy,
cardiac failure, venous insuffciency
Increased risk for development of neoplasm, hormone-dependent and
hormone-independent tumors
Hyperfbrinogenemia
Apnea (the stop of breathing) while sleeping, Pickwickian syndrome
Impaired blood
clotting
Respiratory
system
diseases
Musculoskeletal
Arthrosis and other degenerative diseases of joints
system disorders
Genital system
Dysmenorrhea, fertility failure, loss of libido
disorders
Clinical manifestations.
Obese people come to the doctor not only complain about their fitness but also with complications
(cardiovascular, pulmonary, orthopedic and others).
Clinical particularities of hypothalamic obesity.
1. Fast gain weight (20 – 30 kg during 1 – 2 years).
2. More frequent dysplastic localization of the fat.
3. The presence of the striae.
4. Symptoms associated with increased intracranial pressure and neurologic picture (somnolence,
raised appetite and others).
5. Signs of hypothalamic dysfunction (palpitation, hyperhydrosis, hypertension).
Differential diagnosis
have to be made between different types of obesity.
Alimentary obesity.
1. Genetic (family) factor.
2. Eating habits (ingestion of large amounts of food).
3. Slow progressing.
Pickwickian syndrome. It can occur in the massively obese persons. Pressure on the thorax from the
encompassing sheath of the fatty tissue combined with pressure on the diaphragm from below by
large intra-abdominal accumulations may lead to reducing of the respiratory capacity,
hypoventilation, retention of CO2 leading to decreased effects of CO2 as respiratory stimulant and
resultant hypoxia and somnolence.
Hypothalamic-pituitary disorders.
Barrakcer – Simmons’s disease (progressing lipodystrophia).
1. More frequent is in young women.
2. Atrophy of the subcutaneous adipose tissue in the region of face neck, thorax; increased
quantity of adipose tissue in the lower part of body, thighs, legs (“riding-breeches” type).
3. Duration of the disease, as a rule, without any changes in nervous and endocrine system and
patients have only cosmetic defect.
Dercum’s disease (generalized painful lipomatosis).
1. More frequent is in women in menopause.
2. There is localized, painful nodes (knots) in the subcutaneous adipose tissue. These nodes are
painful, itch, the skin over nodes is red.
3. Patient can have normal weight or be obese.
4. Person has nervous changes (CNS asthenia, neuroses) and endocrine disturbances (decreasing of
function of sexual glands).
Babinsky-Frelych’s disease (adipose-genital dystrophy).
1. More frequent is observed in boys.
2. Characterized by obesity (dysplastic type) and hypogenitalism (development of primary and
secondary sexual signs is stopped: small sizes of scrotum, penis, may be criptorchism).
3. There is often lack in growth.
Endocrine pathology.
Laurence – Moon – Biedl syndrome.
1. Obesity, hypogenitalism like in patients with Babinsky-Frelych’s disease.
2. Decreased mental activity or debility.
3. Pigmental retinitis.
4. Bones or inner organs abnormalities (polydactylia, syndactylia and others)
Morganyi – Stuart – Morel’s syndrome.
1. More frequent in young women or in climacteric female.
2. Adipose tissue localized in the region of chin, abdomen (like apron) mammary glands
(mastoptosis), skin is flabby, striae are absent.
3. Hirsutism is present (beard, moustache).
4. Hypertension.
5. Diabetes mellitus.
6. Increased thickness of lamina interna of frontal bone.
Postnatal neuroendocrine syndrome (PNES).
1. Increasing of the weight during 3 – 12 months after abortion or labor (Kettle’s index usually is
more than 30).
2. Subcutaneous adipose tissue is localized like in patients with Cushing’s syndrome.
3. Striae are present.
4. There is moderate hirsutism, tendency to hypertension and hyperglycemia.
Differential diagnosis of alimentary constitutive and hypothalamic-pituitary obesity
Complains
1
Pain in cardiac area
Palpitation
Breathlessness
General weakness
Thirst
Sexual disorders
Pain in right subcostal area
Pain in abdomen
Mouth dryness
Pain in joints
Headache
Vertigo
Irritability
Memory impairment
Oedema at legs
Striae
Forms of obesity
Alimentary constitutive
2
+
+
+
+
+/+
+
+
+
+/+
+/+
-
Hypothalamic-pituitary
3
+/+
+
+
+/+/+
+
+
+
+
+
+
Comment: “+” – the sign is present; “-” – the sign is absent; “+/-” – the sign may be.
Treatment.
The prognosis for obesity is poor, particularly for obese children, and the course tends to
progress throughout the life. Obesity is a chronic condition resistant to treatment and prone to
relapse. Most obese persons will not participate in outpatient treatment, and those who do will not
lose a significant amount of weight. Most of those who do lose weight will regain it. These results
are poor, not because of failure to implement any therapy of known effectiveness, but because no
simple or generally effective therapy exists. The numerous people who try to reduce without
medical assistance, on diets and advice from magazines, may have more success.
The basis of weight reduction in all treatment regimens is to establish a caloric deficit by reducing
intake below output.
Diet.
The simplest way to reduce caloric intake is with a low-calorie diet. Optimal long-term
effects are achieved with a balanced diet containing readily available foods. For most people, the
best reducing diet consists of their usual foods in amounts limited with the aid of standard tables of
food values. Such a diet gives the best chance of long-term maintenance of the weight loss,
although it is the most difficult diet to follow during weight reduction. Consequently, many people
turn to novel or even bizarre diets, of which there are many. The effectiveness of these diets, if any,
results, in large part, from monotony - nearly everyone will tire of almost any food if that is all they
get to eat. Consequently, when they stop the diet and return to their usual fare, the incentives to
overeat are increased. Fasting has had considerable vogue as a treatment for obesity, but it is now
rarely used. Most patients promptly regain most of the weight they lose. Since fasting is not without
complications, it should be carried out in a hospital.
Several recommendations. Patient has to:
1) eat 4 – 5 times a day, only in a direct time, not to eat between basic meal receptions;
2)
3)
4)
5)
eat only one portion;
limit a free liquid to 1,0 – 1,2 l/day;
not to eat with the aim of decreasing depression, not to eat “for a company”;
the total daily energy intake should be between 1600 – 800 Kcal.
Physical activity.
It is frequently recommended in weight reduction regimens and its usefulness has probably been
underestimated even by its proponents. Since caloric expenditure in most forms of physical activity
is directly proportional to body weight, with the same amount of activity obese persons expend
more calories than do those of normal weight.
Physical activity has to be: 1) regular; 2) bring only positive emotions; 3) it is better to work in a
group of the patients.
Medications.
Many preparations (amphetamines, fenfluramine, others) are used as anorectic drugs. Their
efficacy and side effects seem comparable and their potential to abuse limited. However, to an even
greater degree than after other conservative treatment, weight is regained after drug treatment and
the use of appetite suppressants is currently out of favor.
We have to use medications in patients with endocrine and cerebral pathology: antiinflammatory drugs (to treat encephalitis, arachnoiditis), bromcreptin, peritol (to treat hypothalamic
and pituitary disorders) and others.
Physiotherapy. Massage, automassage, circulating shower-massage are very effective in the
treatment of the patients.
Surgery. Radical surgical treatment may offer some hope to persons with morbid obesity (100
% overweight) in whom all others treatments have failed.
Tests and Assignments for Self-assessment.
Multiple Choice.
Choose the correct answer/statement:
1. Which of these signs can’t be present in patient with pituitary insufficiency?
a. Hypotension.
b. Hyperpigmentation.
c. Weight loss.
d. Hypogonadism.
e. Hypothyroidism.
2. The anterior pituitary does not produce such hormone as:
a. Growth hormone.
b. Thyrotropin.
c. Oxytocin
d. Prolactin.
e. Gonadotropins.
3. A patient I., 16 years old, female, complains of increased body mass, headache, irritability, quick
fatigue. A considerable weight gain has occurred when she was 14. Now body mass is 87 kg,
height is 156 cm, regular body composition. Adipose cellular disposal is equable. There are pink
stria on the hips, abdomen and breasts.
What is the provisional diagnosis?
a. Pubertal-juvenile dispituitarism
b. Alimentary constitutive obesity
c. Cushing disease
d. Neurocirculatory distonia
e. Hypoovarial obesity
4. A 36-years-old patient complains of moderate weight enlargement, breathlessness at physical
exertion. He has no disease in anamnesis. His body mass is 108 kg, height is 160 cm. Body
composition is normal, adipose cellular disposal is equable. What disease has the patient?
a.
b.
c.
d.
e.
Alimentary obesity
Adipose-genital dystrophy
Cushing disease
Hypothalamic obesity
Hypoovarial obesity
5. A 28-years-old patient complains of general weakness, which increases to the evening, dyspnea,
frequent headache, thirst. She is ill for 4 years and infuenza is supposed to be the cause. Her height
is 168 cm, body mass is 79 kg. Adipose disposal is dysplastic, prevalent on trunk, upper body. The
face is round, red. The skin is dry. There are deep-red stria on the skin of the abdomen and hips.
Pulse is 92 st/min, blood pressure is 150/90 mmHg.
What is the provisional diagnosis?
a. Cushing disease
b. Cushing syndrome
c. Alimentary obesity
d. Pubertal-juvenile dispituitarism
e. Hypothalamic obesity
6. A patient D., 17 years old, complains of overweight, increased appetite, headache, weakness,
fatigue. She had frequent quinsy before. A growth of weight has begun from the age of 12 years,
especially it progressed at last year. The patient doesn’t limit herself in carbohydrates and doesn’t
follow any diet. Her mother is obese. Patient’s height is 161 cm, body mass is 88 kg. Adipose
cellular disposal is equable. Pulse is 86 st/min, blood pressure 135/85 mmHg.
What is the provisional diagnosis?
a. Alimentary obesity
b. Adipose-genital dystrophy
c. Pubertal-juvenile dispituitarism
d. Hypothalamic obesity
e. Cushing disease
7. A patient M., 16 years old, has overweight. He was born in asphyxia at premature delivery with
body mass 2600 g, length 46 cm. His weight gain has begun at the age of 10. Now his height is 169
cm, body mass is 85 kg. Female stature, gynecomastia are present. Secondary sexual charachters are
bad developed - hair growth at the face is absent, pubic hair is lean. The penis is 3,5 cm length.
What is the provisional diagnosis?
a. Adipose-genital dystrophy;
b. Pubertal-juvenile dispituitarism;
c. Alimentary obesity;
d. Hypothalamic obesity;
e. Cusing‘s disease
Answer: 1 – b. 2 – c. 3 – a. 4 – a. 5 – a. 6 – a. 7 – a.
Real-life situations to be solved:
As a part of a general check-up obesity and hypogonadism was found in a 16-year-old male.
The patient has no complaints. What is your diagnosis?
Answer: Babinsky-Frelych’s disease (adipose-genital dystrophy).
A 34-year-old man S. complains of headache, increased sweating, periodical palpitation,
elevation of blood pressure, severe weight gain (30 kg in 2 years), sexual failure. There are no
relatives with overweight in his family. The patient considers himself to be ill for 2 years. He
connects his disease with having infuenza.
Physical examination. The height is 165 cm, body mass is 130 kg, adipose cellular disposal is
equable. There are numerous pink thin stria on the hips and abdomen, the skin is highly wet. The left
heart border is displaced to 2 cm laterally. Cardiac sounds are dull, there is an accent of the second
heart sound above the aorta, blood pressure is 190/100 mmHg on the left arm and 160/90mmHg –
on the right arm.
Lungs are without pathology. Abdomen is enlarged because of adipose tissue, painless. Liver is
near the border rib’s arc. Secondary sexual characters are retained. Thyroid gland is not enlarged.
What is the clinical diagnosis?
Answer: hypothalamic obesity, class III.
A 30-years-old woman Z. complains of permanent headache, hard weakness, enlargement of
body mass, menstrual disorders, hypertrichosis. She is ill for 2 years, but didn’t consult a doctor. At
physical examination height is 160 cm, body mass 90 kg, adipose cellular disposal is not equable,
prevalent at face, neck, chest, abdomen. The skin is dry, pale, has vide red stria on the chest,
abdomen, hips, hypertrichosis. Blood pressure is 180/100 mmHg. Fasting glucose blood level - 7
mmol/L; urinary 17-OHCS, 17-HCS levels are increased. Glucosuria is absent. At the X-ray of the
skull osteoporosis of the Turkish saddle wall is revealed.What is the clinical diagnosis?
Answer: Cushing disease, obesity, class II.
Students Practical Activities.
Work 1 : Students’ group is divided into 2 sub-groups, that work near the patients’ bed: ask the
patients on organs and systems, take anamnesis of the disease , anamnesis of life, make objective
exam. With the teacher’s presence. In the class-room they discuss the patients, learn data of
laboratory and instrumental exam. of these patients.
1.To group the symptoms into the syndromes.
2.To find out the leading syndrome and make differential diagnosis.
3.To formulate the diagnosis.
4.To make a plan of treatment.
Methodological recommendation prepared assistant, c.m.s. Chernobrova O.I.
It is discussed and confirm on endocrinology department meeting
" 31 " august 2012 y. Protocol № 1.