Obesity is a risk factor for cardiovascular diseases. Risk factors for obesity - Economic status. Treatment methods for overweight and obesity: fasting days

06.04.2016

The rise in obesity has become an epidemic among both adults and children (1,2). An adult is considered overweight if his body mass index (BMI) is between 25 and 29.9 kg/m2, and obese if his BMI is more than 30 kg/m2. If your body weight is two or more times greater than normal weight, then they talk about morbid obesity.

Updated 12/18/2018 12:12

Obesity has now become a serious problem in the United States. During the 1980s and 1990s, the prevalence of obesity increased by 50% and continues to increase (3). While 40 years ago, only 25% of American adults were overweight or obese, today this figure has risen to almost 70% (3-5). In addition, the proportion of the population with morbid obesity is growing faster than the proportion of Americans who are overweight or moderately obese (1,2,3,5). According to recent data, smoking, alcoholism and poverty increase the risk of gaining excess weight. If current trends continue, obesity in the United States will soon overtake smoking as the leading cause of preventable death (4–6). Moreover, if we fail to stop the obesity epidemic soon, the increase in human life expectancy will stop, and the process may be reversed (7,8).

Obesity is a significant factor determining a person's likelihood of death. Thus, it has been proven that both general obesity and abdominal obesity (mainly in the abdomen and upper body) are associated with an increased risk of premature death (9). However, doctors talk about the “paradox of obesity”: despite the fact that it is a risk factor for hypertension, heart failure and coronary disease heart disease, research indicates that if they carry extra pounds, people with these diseases often have a better prognosis than those with normal weight.

Physiology of obesity

Adipocytes (fat cells) function as an endocrine organ and play a significant role in the development of obesity and its consequences (1,10). Adipocytes produce leptin, the “satiety hormone.” When it enters the hypothalamus (a part of the brain), appetite suppression occurs (10,11).

In obesity, leptin levels increase, which affects food intake and energy metabolism, and a state of leptin resistance develops when the body stops correctly assessing its amount. Even with increased levels of the satiety hormone, the brain believes that the body is hungry and produces ghrelin, a “hunger hormone” that stimulates appetite and makes a person look for food.

C-reactive protein (CRP), a key protein in the acute phase of inflammation, the level of which increases in obesity, also plays a role in the development of leptin resistance (12). It binds to leptin, leading to hyperleptinemia (a condition in which leptin levels are chronically elevated) and promoting the development of leptin resistance.

The effect of obesity on the cardiovascular system

The heart is an organ primarily composed of specialized cardiac striated muscle tissue (myocardium). The two atria and two ventricles of the heart are organized into two circles of blood circulation: the small (pulmonary), through which the blood is enriched with oxygen, and the large, through which the blood carries oxygen throughout the body.
They talk about two main phases of the heart: systole (contraction) and diastole (relaxation). In the systole phase, two stages can be distinguished:

1) first, the atria contract and the blood from them enters the ventricles;

2) then the ventricles contract, and the blood from them enters: from the left ventricle - to the organs of the body, from the right - to the lungs.

In the diastole phase, the heart muscle relaxes and the atria are filled with blood: the left atrium with oxygen-rich blood from the lungs, the right atrium with oxygen-poor blood from organs and tissues.

Obesity affects the amount of blood that flows through the heart. A larger volume of blood puts more pressure on the walls of the vessels of the circulatory system, that is, the body is forced to adapt to greater loads. Let's look at how this happens.

With obesity, the total blood volume increases and, accordingly, cardiac output - the amount of blood pushed out by the heart per unit of time. Basically, the increase in cardiac output occurs due to an increase in the stroke (systolic) volume of the heart - the amount of blood ejected by the heart in one contraction (systole). There is also usually a slight increase in heart rate due to activation of the sympathetic nervous system (13). Typically, in obese patients, cardiac output increases as weight increases, and the level of peripheral vascular resistance remains reduced at any blood pressure (14,15), that is, the tone of the vascular walls decreases in inverse proportion to obesity. It is believed that this is an adaptive mechanism that allows, to a certain extent, to maintain normal pressure and resistance of the vascular walls in the body. However, it cannot completely compensate for the negative effects of obesity. With increasing stretching of the heart muscle, the force of heart contractions increases, that is, the load on the blood vessels increases. Therefore, obese patients are more likely to be hypertensive than lean people, and weight gain is generally associated with an increase in blood pressure (13,15).

As volumes and pressures increase as blood fills the chambers of the heart, the left ventricular chamber often enlarges in overweight and obese people (13,14,16). Moreover, the risk of left ventricular hypertrophy (enlargement) increases regardless of age and blood pressure. The likelihood of changes in the structure of the heart increases: concentric remodeling of the myocardium and left ventricle (17). Remodeling is understood as a whole complex of changes occurring in the heart: thickening of the walls and muscle fibers themselves, an increase in the number of components of the cardiac striated muscles, etc. In addition to left ventricular hypertrophy, obesity is a common cause of left atrial dilatation, which is associated with increased circulating blood volume and changes in left atrium filling volume during diastole (relaxation) (14,18). All of these changes increase the risk of developing heart failure. Left atrial enlargement also increases the risk of developing atrial fibrillation and related complications (19).

Clinical consequences of obesity

Hypertension is a disease in which there is a constant or regular increase in blood pressure. Typically, hypertension results in thickening of the walls of the ventricle of the heart without dilatation of the chamber itself - this process is referred to as concentric remodeling if the mass of the left ventricle does not increase. If it grows, then we are talking about concentric hypertrophy of the left ventricle. With obesity, there is usually an expansion of the chamber of the left ventricle without a noticeable increase in the thickness of its walls - eccentric hypertrophy of the left ventricle (muscle fibers increase in length and width) (4.17).

At the same time, hypertensive patients who are obese paradoxically have a better chance of survival. All-cause mortality in people with hypertension and overweight and obesity is 30% lower than in people of normal weight (20), i.e. there is an obesity paradox. Similar results were found in other studies of hypertension, which showed that increased mortality was consistently observed at extremes of BMI at both ends of the scale—both those that were too high and those that were too low (21,22,23). One explanation is an adaptation of the blood pressure maintenance mechanism, the renin-angiotensin-aldosterone system (RAAS), a hormonal system that regulates blood pressure and blood volume in the body (24). The lower the RASS activity, the lower the blood pressure.

Heart failure is a syndrome in which acute or chronic dysfunction of the heart develops, which leads to a deterioration in the blood supply to the rest of the body. However, many studies claim that such patients have better prognoses than people with heart failure, but with normal weight.
The Framingham Heart Study found that for every 1 kg/m2 increase in BMI, the risk of heart failure increased by 5% in men and 7% in women (25). This stepwise increase in risk was observed for people of all BMIs. In another study of morbidly obese patients, about a third had clinical symptoms disease, and the likelihood of its development increased with increasing duration this state(26). Finally, compared with individuals whose BMI was not increased, overweight and obese patients had a reduction in mortality from cardiovascular diseases(by 19% and 40%, respectively) and from all causes (by 16% and 33%, respectively) (27). And according to another study, for every 5 units increase in BMI, the risk of death decreases by 10% (28).

Researchers believe that excess body weight may be protective (27–30). Progressive heart failure is a catabolic state (state of breakdown), and patients with heart failure and obesity have higher metabolic reserve (31–33). It has also been shown that adipose tissue produces soluble tumor necrosis factor alpha (TNF-α) receptors and may play a protective role in obese patients with acute or chronic heart failure by binding to TNF-α and neutralizing their negative effects. biological effects(34). In addition, circulating lipoproteins (cholesterol), which are elevated in obese patients, bind and detoxify lipopolysaccharides, which play a role in stimulating the production of inflammatory cytokines, thereby protecting the patient (31,35).

Coronary heart disease (CHD)- a disease in which the blood supply to the heart muscle is disrupted due to damage to the coronary arteries. Obesity plays a negative role in the formation of such risk factors for the development of coronary artery disease as hypertension, dyslipidemia and diabetes mellitus (DM) (4,24,36,37). Excessive obesity is strongly associated with primary non-ST-segment elevation myocardial infarction (MI), a type of infarction that often occurs in young adults (38).

Atrial fibrillation- a life-threatening condition in which the electrical activity of the atria is 350-700 impulses per minute, which prevents them from contracting in a coordinated manner. Obesity increases the risk of the disease by 50%, paralleling increases in BMI (39).

Stroke- This is a violation of cerebral circulation. They talk about two types of stroke: hemorrhagic, when an artery ruptures due to excessive blood flow to the brain; and ischemic, when some areas of the brain, on the contrary, suffer from disturbances in the flow of blood due to interruptions in the functioning of the heart or atherosclerotic plaques clogging blood vessels. It has been proven that increasing BMI by one unit increases the risk ischemic stroke by 4% and hemorrhagic - by 6% (1.40). The increased risk of stroke correlates with the increasing incidence of hypertension and the prothrombotic/proinflammatory state that develops as excess fat tissue accumulates, which also increases the likelihood of atrial fibrillation.

Sudden cardiac death– practically healthy obese patients receive this post-mortem diagnosis 40 times more often than people with normal weight (13). Doctors associate this fact with the increased sensitivity of the heart to electrical impulses in obesity, which can cause frequent and extensive ventricular arrhythmias.

Sleep apnea- a sleep disorder in which a sleeping person stops breathing several times during the night. The body needs a certain amount of oxygen, which comes through the walls of the alveoli in the lungs. Obesity develops a condition of alveolar hypoventilation (41), in which insufficient oxygen is supplied due to the fact that obese people are unable to breathe." full breasts" Sleep apnea contributes to the development of hypertension, and also activates inflammatory processes and increases the level of C-reactive protein(SRB). Such patients have an increased risk of hypertension, arrhythmias, pulmonary hypertension (15–20% of cases), heart failure, myocardial infarction, stroke, and overall mortality (42).

Vein disease– another side effect of obesity, which develops against the background of a combination of increasing intravascular volume and an overloaded lymphatic system. In addition, a decrease in physical activity has a negative effect. As a result, obesity often develops venous insufficiency and edema (43), which leads to venous thromboembolism and pulmonary embolism, especially in women (44,45).

The Importance of Weight Loss

The obesity paradox has become the basis for the theory that targeted weight loss is not only not beneficial, but may even be harmful for patients with cardiovascular disease (46,47–49). However, assessing mortality not only by BMI, but also by percentage of body fat and lean muscle mass, showed that mortality was reduced among people who lost weight by reducing fat rather than muscle (48,50).

You should also consider possible side effects of losing weight. Fasting, super low calorie diets, liquid protein diets and obesity surgery are associated with an increased risk of life-threatening arrhythmias (1). A similar situation is observed with various weight loss drugs, which have limited effectiveness or are quite toxic (51-53).

However, lifestyle changes, including the introduction of exercise and gradual weight loss while restricting calories, have been shown to reduce the risk of developing diabetes by 60%, which is significantly more effective in preventing diabetes than treatment with metformin (54,55). Introduction to medical practice of cardiac rehabilitation with physical exercise reduced the prevalence of metabolic syndrome by 37% (56). And losing weight in patients with coronary artery disease improves CRP, lipid levels, and blood glucose (57,58). In hypertension, a weight loss of as little as 8 kg reduces left ventricular wall thickness (59). Even in morbid obesity, gastroplasty (suturing the stomach) leads to improvements in all mortality indicators (26), including for cancer patients, patients with diabetes and cardiovascular diseases (60).

conclusions

The vast majority of studies confirm the influence of obesity on the development and progression of cardiovascular diseases. Despite the existence of the obesity paradox, in which people with excess weight and cardiovascular disease have a better prognosis than thin patients with the same diagnosis, research suggests that weight loss is effective in preventing and treating cardiovascular disease. According to scientists, more research is needed, because if the current obesity epidemic continues, we may soon witness the sad end of the saga of increasing life expectancy.

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Based on materials from Lavie C.J., Milani R.V., Ventura H. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss // J Am Coll Cardiol. 2009 May 26;53(21):1925-32. doi: 10.1016/j.jacc.2008.12.068.

1

1 State Budgetary Educational Institution of Higher Professional Education “Moscow State Medical and Dental University named after. A.I. Evdokimov" of the Ministry of Health of the Russian Federation

2 Federal State Budgetary Institution "Central Research Institute of Organization and Informatization of Health Care" of the Ministry of Health of the Russian Federation

In the modern world, the percentage of obese people is increasing year by year. The main reasons for the increase in the number of people with impaired body weight are poor nutrition and decreased physical activity. Obesity is currently an undeniable risk factor for the development of many chronic non-communicable diseases. The most common of them are diseases of the cardiovascular system, such as arterial hypertension (AH) and coronary heart disease (CHD). Cardiovascular diseases cause the majority of deaths worldwide. They kill 17.5 million people every year. They are followed by cancer (8.2 million), respiratory diseases(4 million) and diabetes (1.5 million). A number of researchers note the connection between professional activity and the development of body weight disorders. Persons in dangerous professions, such as firefighters and rescuers, deserve special attention. Totality unfavorable factors professional working conditions for such people require special control and monitoring their health status. Many firefighters are diagnosed with hypertension, hyperlipidemia and obesity. Loss of body weight in such individuals can lead not only to the development of chronic non-infectious diseases, but also to professional unsuitability. However, existing methods for assessing health status do not allow us to determine the relationship between anthropometric indicators of the body and the risk of developing chronic non-communicable diseases among people in hazardous professions.

chronic non-communicable diseases

dangerous professions

risk factors

obesity

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Low physical activity and unbalanced nutrition lead to the development of overweight and subsequently obesity. Weight loss is a huge global problem. Its frequency is so high that it has become a non-infectious epidemic. According to the World Health Organization (WHO), the number of people suffering from excess body weight is approaching 2 billion. According to UN statistics, Russia is among the twenty most “complete” countries in the world. Every fourth Russian is overweight.

The origins of obesity lie in childhood and adolescence when basic food preferences, habits, lifestyle are formed and metabolic processes in the body are being established. The prevalence of obesity in the child population is growing catastrophically both in Russia and abroad, and varies from 4.5 to 38%.

The most common and probable reasons Obesity in children is usually overeating and undereating motor activity. This is often due to poor diet and eating habits that adults instill in them. Nutritionists say that teenage obesity often occurs in families where one or both parents have excess weight. If there is one overweight parent, the risk of developing the disease in children is 30%, and if both mother and father suffer from this, then the risk is already more than 80%. Childhood obesity is a factor associated with a higher likelihood of obesity, premature death and disability in adulthood.

Both in childhood and in adulthood, excess body weight is not only a personal problem for a person, significantly reducing his quality of life. Obesity is now an undeniable risk factor and predictor of many chronic diseases. This marks an increase in the medical, economic and social significance of the problem of obesity. Thus, about 70% of patients with arterial hypertension and 90% of patients with type 2 diabetes mellitus are overweight or obese.

Among chronic non-infectious diseases, a special place is occupied by type 2 diabetes mellitus (DM2), atherosclerosis, and coronary heart disease (CHD). In the United States, according to the National Institutes of Health, ischemic heart disease is the leading cause of death. This picture is typical for all developed countries.

Arterial hypertension (AH) is a major pandemic that determines the structure of cardiovascular morbidity and mortality. The prevalence of hypertension in the world among the adult population ranges from 450 to 900 million (30-40%), and in Russia - more than 40 million people (39% of men and 41% of women). Hypertension is often combined with obesity, especially its abdominal type (AO).

The problem of hypertension in combination with obesity is in the spotlight modern medicine due to the increased risk of developing cardiovascular complications and premature mortality compared with the general population. In obese patients, hypertension occurs up to 6 times more often than in individuals with normal body weight, and the presence of obesity at a young age is a risk factor for its subsequent development. The combination of obesity and hypertension increases the risk of coronary artery disease by 2-3 times, and cerebral stroke by 7 times.

In people with excess body weight, the level of systolic and diastolic blood pressure during the day is higher than in people with normal body weight, and the structure of the daily profile is dominated by an insufficient decrease in blood pressure at night. Even with the use of antihypertensive therapy in such people, these indicators are higher normal values, especially in obese individuals.

The main reason for the increase in the number of people with impaired body weight is the development of civilization. Progress has led to a reduction in the need for manual labor and reduced the need for active movement. According to WHO, every third adult in the world is not active enough. This is due to both a person’s lifestyle and his professional activities. A number of researchers note the connection between professional activity and the development of body weight disorders.

Persons in hazardous professions deserve special attention, because, on the one hand, they are constantly exposed to stress, and on the other, they have an irregular work schedule and night shifts. Decision-making and the activities of rescuers themselves require an accurate analysis of the situation, as much as possible effective action in a limited time and under extreme conditions, which places special demands on professional selection and psychological state, which determines professional performance.

The combination of unfavorable factors in the professional working conditions of such people requires special control and monitoring of their health. Many firefighters are diagnosed and undertreated for hypertension, hyperlipidemia, and obesity, as well as eating habits and extreme physical activity.

According to the National Fire Protection Association (USA), 65-70% of firefighter illnesses are cardiovascular diseases, which may be due to the high intensity of their work.

In the foreign literature there are few studies of certain categories of people in dangerous professions, such as firefighters and rescuers. According to some foreign researchers, firefighters and police officers are one of the prevailing groups in the development of obesity. For example, in North America, 80% of firefighters are overweight or obese. Due to high rates of obesity and cardiovascular events, the leading cause of on-duty deaths among firefighters is cardiovascular disease.

In Russia, depending on their work experience, up to 80% of rescuers have various pathologies internal organs. This indicator reaches its maximum values ​​with work experience of up to 3 years and more than 6 years as a professional rescuer. This is due to a violation of adaptation mechanisms during these periods. The predominant diseases are diseases of the digestive, circulatory, respiratory, endocrine and musculoskeletal systems.

During the clinical examination of professional rescuers of the Ministry of Emergency Situations of Russia from the North-West region, a connection was revealed between the morbidity and functional state of rescuers with age and length of service in their specialty. However, there are no data on the analysis of the prevalence of overweight and obesity among this group of people.

IN Russian literature There are data on assessing the violation of the relationship between mental, psychophysiological and physiological functions of the body among themselves among persons in hazardous professions. It allows you to determine the nature and level of changes in professional health and select methods for its correction aimed at normalizing intersystem interactions. However, these methods do not allow us to assess the relationship between anthropometric indicators of the body and the risk of developing chronic non-communicable diseases among people in hazardous professions.

Conclusion

The development of cardiovascular diseases - hypertension, coronary artery disease, myocardial infarction and cerebral stroke, as well as heart failure, in turn, leads to early disability and premature death. Meanwhile, a comparative study of the prevalence of body weight disorders in people in hazardous professions depending on the type of professional activity and a detailed description of the nature of changes in the health status of this professional group is practically absent in the available literature.

However, it should be remembered that impaired body weight in people in hazardous professions can lead not only to the occurrence of chronic non-infectious diseases, but also to professional unsuitability, which is disadvantageous for the country’s economy, because may lead to the loss of highly qualified personnel.

A loss skilled workers directly affects the quality and efficiency of the work performed, which in emergency situations can lead to untimely provision of assistance, and, consequently, to unnecessary casualties among the population.

The work was carried out within the framework of the grant of the President of the Russian Federation MK-5330.2015.7

Reviewers:

Lakshin A.M., Doctor of Medical Sciences, Professor of the Department of General Hygiene of the State Budgetary Educational Institution of Higher Professional Education "Moscow State Medical and Dental University named after A.I. Evdokimov", Moscow;

Yarygin N.V., Doctor of Medical Sciences, Associate Professor of the Department of Disaster Medicine and Life Safety of the State Budgetary Educational Institution of Higher Professional Education "Moscow State Medical and Dental University named after A.I. Evdokimov" of the Ministry of Health of the Russian Federation.

Bibliographic link

Arkhangelskaya A.N., Burdyukova E.V., Ivkina M.V., Lastovetsky A.G., Kudentsova S.N., Stulina D.D., Gurevich K.G. OBESITY AS A RISK FACTOR FOR THE DEVELOPMENT OF CHRONIC NON-COMMUNICABLE DISEASES IN PERSONS OF HAZARDOUS PROFESSIONS // Modern problems of science and education. – 2015. – No. 5.;
URL: http://site/ru/article/view?id=22107 (date of access: 04/06/2019).

We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

For quotation: Lupanov V.P. Obesity as a risk factor for the development of cardiovascular accidents // RMJ. 2003. No. 6. P. 331

Institute of Clinical Cardiology named after A.L. Myasnikov RKNPK Ministry of Health of the Russian Federation, Moscow

ABOUT obesity is a chronic polyetiological disease associated with the influence of a number of genetic and neurological factors, changes in the functions of the endocrine system, the patient’s lifestyle and eating behavior, and not only with an imbalance in energy balance. Distinguish nutritional-constitutional form obesity, which is the most common, and "endocrine" obesity caused by some primary endocrine disease - hypothyroidism, dysfunction of the ovaries, adrenal glands and other reasons. Obesity can be defined as excess accumulation of fat in the body, which poses a health risk. It occurs when the energy intake into the body from food exceeds energy expenditure (consisting of basal metabolism or metabolism at rest and during physical activity). Overweight simply means that a person's body weight is greater than what is considered normal for their height. The importance of obesity as a risk factor for cardiovascular disease (CVD) has recently increased significantly as the prevalence of obesity in the global population has increased. In Western European countries, more than half of the adult population aged 35-65 years are either overweight (body mass index /BMI/ from 25 to 29.9 kg/m2) or obese (BMI more than 30 kg/m2); In the United States, one third of the total population is overweight (20% or more than ideal weight); In Russia, about 30% of people of working age are obese, and 25% are overweight. Table 1 shows the classification of obesity by BMI and risk concomitant diseases.

Obesity is a risk factor for the development of cardiovascular diseases (CVD), diabetes mellitus, and the presence of obesity in patients with coronary artery disease contributes to its progression and increased mortality. The relationship between BMI and relative risk of mortality is shown in Figure 1.

Rice. 1. The relationship of body mass index with the relative risk of mortality (WHO Report, 1998).

The increased risk associated with obesity is largely due to high frequency coronary and cerebral disorders in obese people. High performance mortality and incidence of cardiac complications are mainly a consequence of vascular damage, because obesity is important factor, predisposing: to the development of dyslipidemia (up to 30% of obese individuals have hyperlipidemia), type 2 diabetes mellitus (up to 80% of patients with type 2 diabetes are overweight or obese), arterial hypertension (approximately half of obese individuals simultaneously have arterial hypertension) And sudden death. Moreover, the independent effect of obesity on cardiovascular system may be explained by its influence: on the function and structure of the myocardium, increased cardiac output, the development of eccentric left ventricular hypertrophy (LVH), dystrophic disorders, the appearance of congestive heart failure. LVH is more common in obese people than in lean people, regardless of the presence of arterial hypertension, which confirms the independent role of obesity in the origin of LVH, which in turn is an independent factor in the development of congestive heart failure, acute myocardial infarction, sudden death and other cardiovascular events . In patients with coronary artery disease, a combination of lesions caused by impaired fat metabolism with lesions of cardiosclerosis after suffered a heart attack myocardium significantly reduces the functionality of the heart.

Obesity is associated with a number of dyslipidemias that predispose to the development of CAD, including hypercholesterolemia, hypertriglyceridemia, decreased high-density lipoprotein (HDL) cholesterol, increased levels of apoprotein B and small, dense low-density lipoprotein (LDL) particles. In obesity, there is also a decrease in the activity of various tissue and plasma lipoprotein lipases, and the level of fibrinogen increases. Some authors find a connection between obesity and the level of lipoprotein a (small) and C-reactive protein. Obesity is accompanied by impaired insulin action at the level of peripheral tissues - insulin resistance , which is one of the reasons for the formation of arterial hypertension (due to increased sodium reabsorption). In addition, the development of hypertension in obesity is associated with an increase in the load on the heart and an increase in blood volume, hypercortisolemia, and increased activity of the renin-angiotensin system. Obesity is characterized by hypertrophy of fat cells, and with severe obesity, the number of fat cells in the tissues of fat depots increases. The adipose tissue itself performs endocrine function, secreting substances that reduce tissue sensitivity to insulin. The role of leptin (a peptide hormone that mediates information between the hypothalamus and adipose tissue and takes part in the regulation of the hunger and satiety center) in the pathogenesis of obesity has not yet been fully studied.

A clear connection between obesity and the development of cardiovascular complications has been established based on data obtained in Framingham Study . In a 26-year follow-up of 5209 men and women without CVD at enrollment, obesity was shown to be an independent risk factor for cardiovascular events, especially in women. Multiple logistic analysis showed that relative body weight (actual weight/ideal weight) at the beginning of the study played a prognostic role in the development of coronary heart disease (angina, unstable angina, myocardial infarction, sudden death), cardiac mortality, and heart failure in men. The effect of obesity on prognosis was independent of age, systolic blood pressure, cholesterol, daily cigarette smoking, degree of LVH, and the presence of impaired glucose tolerance. In women, the value of relative body weight had a statistically significant relationship with the development of myocardial infarction, cerebral stroke, heart failure, as well as with the level of cardiovascular mortality. Obesity has had a long-term prognostic value for CVD, especially in patients under 50 years of age. Further weight gain with age increases the risk of CVD in both men and women, regardless of initial body weight or the presence of other risk factors associated with weight gain (Fig. 2 and Fig. 3).

Rice. 2. The results of the Framingham study (26-year follow-up) showed that the incidence of cardiovascular diseases in general, coronary heart disease, and myocardial infarction increased depending on excess body weight (as a percentage of ideal) in men and women.

Rice. 3. The results of the Framingham study (26-year follow-up) showed that the incidence of sudden death increased depending on excess body weight (as a percentage of ideal weight) in men and women.

Although obesity is an independent risk factor for the development of CVD, there is a close relationship between obesity and dyslipidemia, arterial hypertension, impaired glucose tolerance, and LVH. In the Framingham Study, only 8% of men and 18% of women who were overweight (30% of ideal weight) did not have these classic CVD risk factors.

A study of the relationship between obesity (BMI) and mortality in 115,195 women aged 30 to 55 years, without CVD at enrollment, was conducted over 16 years in " Health Research nurses (The Nurses Health Study)". The primary endpoint of this study was all deaths. Secondary end points were: death from ischemic heart disease, incident CVD and cancer. A trend towards higher mortality from coronary artery disease and other CVDs was revealed among women with average body weight and slight excess weight. The lowest mortality rate was observed among women who weighed at least 15% less than the average body weight of a woman of the same age in the United States. The relative risk between BMI and mortality followed a J-shaped curve. Women who never smoked and had a BMI greater than 32 kg/m2 had a relative risk of death from CVD of 5.8.

A prospective study was conducted in the United States to examine the relationship between body mass index and mortality in American adults. The study examined the influence of age, gender, smoking and previous diseases on the relationship between BMI and mortality. It included 4,576,785 men and 588,369 women. The main criterion for “effectiveness” was deaths caused by any reason. At the same time, the relationship between BMI and deaths due to CVD, cancer and other causes was studied. Over 14 years of observation, 201,622 deaths were registered. In 4 subgroups, separated depending on adherence to smoking and the presence of a current or past disease, the relationship between BMI and the risk of overall mortality was studied. Relative risk was used to assess the association between BMI and mortality. It has been shown that The relationship between BMI and mortality risk was significantly influenced by smoking and the presence of concomitant diseases . For those who have never smoked healthy individuals the nadir of the mortality-BMI curve ranged from 23.5 to 24.9 for men and 22.0 to 23.4 for women. Compared with those individuals whose BMI was between 23.5 and 24.9, white men and women with the highest BMI values ​​had a relative risk of mortality of 2.58 and 2.00, respectively. High BMI was a strong predictor of CVD mortality, especially in men (relative risk 2.9; confidence interval 2.37 to 3.56). An increased risk of mortality was found in obese men and women of all major groups. The results concluded that the risk of mortality from all causes, including cardiovascular disease and cancer, increased across the entire range of moderate to severe obesity in men and women of all age groups. Thus, the results of this study confirm the previously established relationship between mortality risk and severe obesity, as well as the increased risk of mortality with moderate excess body weight.

For the risk of developing CVD, not only the degree of obesity, but also the nature of the distribution of subcutaneous fat is of great importance. The relationship between obesity and CVD is often observed in the so-called. central or visceral obesity (which is most pronounced in the abdomen and chest) than general obesity (which affects the lower half of the body). Visceral adipose tissue is characterized by pronounced lipolytic activity and metabolic disorders. The clinical diagnosis of central obesity is made based on changes in waist circumference and hip circumference. A waist circumference of more than 100 cm at the age of 40 years and more than 90 cm at the age of 40-60 years (both men and women) is an indicator of visceral obesity. If the ratio of waist circumference to hip circumference in men exceeds 0.95, and in women 0.85, then we can talk about pathological fat deposition in the abdominal area. Determination of disorders of accumulation and distribution of subcutaneous and intra-abdominal adipose tissue (mass or volume of visceral fat) in last years most effectively carried out using computed tomography and magnetic resonance imaging, but the high cost of these methods limits their use in widespread practice.

The combination of visceral (abdominal) obesity, arterial hypertension, hyperinsulinemia, impaired glucose tolerance or type 2 diabetes mellitus, dyslipidemia (HDL level less than 1.0 mmol/l, TG more than 2.2 mmol/l), hyperuricemia, microalbuminemia, hemostasis disorders is Name metabolic syndrome and is accompanied by an increased risk of developing coronary artery disease . It has been proven that the more significant severity of this syndrome in men is associated with a greater prevalence of atherosclerotic lesions in the coronary bed, an increase in the frequency of detection of occlusions and hemodynamically significant stenoses.

The main goal of treating obesity is to reduce the risk of developing obesity-related diseases and increase the patient's life expectancy. Currently, the accepted method is gradual (0.5-1.0 kg per week) weight loss over 4-6 months and maintaining the result for a long time. A longitudinal prospective study of never-smoking white US women 40–64 years old examined the association of body weight and mortality. After a 12-year follow-up of 43,457 patients, it was shown that reducing body weight by only 5-10% (from 0.5 to 9.0 kg) and then long-term maintenance of body weight reduces mortality and morbidity, improves health status and treatment prognosis concomitant diseases (overall mortality decreased by 20%, mortality from CVD by 9%).

Rapid weight loss, especially in patients with CVD, can lead to a number of serious complications and the development of arrhythmias and sudden death (insufficient dietary protein intake, myocardial atrophy can lead to prolongation of the QT interval on the ECG and the development of severe arrhythmias). Sudden changes in body weight significantly increase the risk deaths Therefore, in the process of losing weight, regular electrocardiographic monitoring and blood pressure measurements are necessary. When treating obesity in patients with chronic ischemic heart disease, it is necessary to: keep in mind the danger of both medication and non-pharmacological means for quick weight loss; exercise caution when making recommendations to limit both protein intake and essential electrolytes; recommend increasing physical activity only if the patient’s condition is stable and a thorough cardiac examination (physical stress tests, blood pressure measurement, Holter ECG monitoring); avoid forced weight loss in unstable condition, frequent attacks of angina pectoris, with low and moderate exercise, the presence of frequent painless episodes of myocardial ischemia or unstable angina, or a history of myocardial infarction during the previous 6 months; consider rapid weight loss contraindicated in the presence of concomitant diabetes mellitus or signs of heart failure; exercise caution when prescribing new ones pharmacological drugs, taking into account possible high risk for patients, their side effects on the cardiovascular system.

Traditional non-drug methods of treating obesity, based on diet therapy (calorie restriction) and increased physical activity, do not provide sustainable weight loss over a long period of time. Only if they are ineffective can drug therapy be considered. Drugs for the treatment of obesity are indicated for patients with a BMI of more than 30 kg/m2, as well as patients with a BMI of more than 27 and abdominal obesity, or with other risk factors (diabetes, hypertension, dyslipidemia) or with concomitant diseases, in the absence of a positive effect of lifestyle changes within 6 months. Drug therapy prescribed in combination with a hypocaloric diet and increased physical activity.

One of the treatment options for obesity is very low calorie diet . It allows you to quickly achieve weight loss, which in patients with moderate and severe obesity is accompanied by a decrease in the complications of excess weight. However, it is rarely possible to maintain body weight at such a reduced level, and in patients with CVD diseases this can lead to complications. Diet therapy should be carried out lifelong and continuously. The following drugs are currently used to treat obesity.

Phentermine - A sympathomimetic, it suppresses appetite by stimulating the release of norepinephrine and dopamine from nerve endings in the saturation center of the hypothalamus. In addition, the drug suppresses gastric secretion and increases energy expenditure. The usual dose of phentermine is 8 mg 3 times a day 30 minutes before meals, or 15-37.5 mg once. The most common side effects of phentermine include nervousness, dry mouth, constipation, and hypertension. In this regard, the use of phentermine is not recommended for patients with arterial hypertension and concomitant cardiovascular pathology, arrhythmias, anxiety conditions.

One approach to treating obesity is to take medications that suppress the absorption of nutrients, primarily fats. Fats are the main nutritional factor responsible for excess weight, so they should be reduced first by correcting body weight.

Orlistat is an inhibitor of gastrointestinal lipases. The drug is practically not absorbed when taken orally and reduces the absorption of fats from the intestines by 30% or more. A European randomized placebo-controlled study of 743 obese patients (with a BMI of 28-43 kg/m2) showed that the combination of a moderately hypocaloric diet with orlistat (360 mg/day) for 2 years contributed to sustained weight loss, reduced the risk of developing concomitant diseases.

In another study, 605 obese patients with a BMI of 28–43 kg/m2 were given either placebo or orlistat at varying doses (90, 180, 360, or 720 mg/day) during a 6-month trial. It was found that the optimal dose of the drug is 360 mg/day (or 120 mg 3 times a day with each main meal), and increasing the dose of the drug does not lead to an increase in its therapeutic effect.

We assessed the effect of the drug orlistat and diet therapy in patients with coronary artery disease with stable angina, hyperlipidemia and increased body weight. An open comparative randomized study examined the effectiveness of orlistat and diet therapy in 30 patients with chronic stable angina of functional class I-II, aged 45 to 65 years ( average age 55±6 years), the diagnosis of which was verified (the presence of angina attacks, a positive test on a bicycle ergometer with ischemic depression of the ST segment of 1 mm or more, the presence of stenosing coronary atherosclerosis according to coronary angiography). In all patients upon inclusion in the study: BMI exceeded 25 kg/m2 and averaged 33.5 kg/m2; hyperlipidemia was determined (LDL cholesterol level exceeded 4.14 mmol/l, HDL cholesterol was less than 0.9 mmol/l, or triglyceride level was more than 2.2 mmol/l, but not higher than 4.5 mmol/l). The patients followed a lipid-lowering diet and took it for 6 months. orlistat at a dose of 360 mg/day. If the patient was receiving antianginal drugs upon inclusion in the study, their use was not changed during the entire period of taking orlistat. In both groups (orlistat + diet and diet only) there was significant decrease in BMI, however, in the main group taking orlistat, it decreased by 9.9%, and in the control group by only 4.2% . Stabilization of body weight over 6 months was important. treatment and the fact that the weight loss process itself occurred slowly and gradually. Orlistat was an effective treatment for obesity in patients with coronary artery disease: at the end of 1 month of taking the drug, the decrease in body weight was 4.2%, 3 months. - 6.6% and 6 months. - 9.4%. The drug at a dose of 360 mg/day was well tolerated by patients for 6 months. and did not produce serious side effects. Biochemical blood parameters did not change significantly during treatment with orlistat. The drug did not reduce the effectiveness of antianginal therapy in patients with ischemic heart disease and increased tolerance to physical activity according to repeated bicycle ergometry at the end of 6 months. treatment. Positive dynamics of lipid metabolism indicators were also noted: total cholesterol by 6 months. treatment decreased by 10.9%, LDL cholesterol by 12.2% (p<0,05). Уровень холестерина ЛПВП и триглицеридов достоверно не изменялся. Следует отметить отсутствие достоверного влияния орлистата на другие биохимические показатели крови (глюкозу, билирубин, трансаминазы). При соблюдении диеты и потреблении жира не более 30% от суточной калорийности наблюдавшиеся побочные эффекты при приеме орлистата по стороны желудочно-кишечного тракта (жирный стул, учащение дефекации и др.) обычно были минимальными. Было отмечено, что в группе больных, получавших препарат, уровни общего холестерина и ХС ЛПНП в плазме снижаются больше, чем этого можно было бы ожидать только от уменьшения массы тела как таковой. Вероятно, это самостоятельное гипохолестеринемическое действие препарата отражает тот факт, что он уменьшает массу тела именно за счет снижения поступления энергии от жира в организм .

Sibutramine hydrochloride is a sympathomimetic drug that blocks the uptake of both norepinephrine and serotonin by receptors. The drug affects the regulation of the hunger/satiety center, allows you to reduce food consumption (due to rapid satiety) and increases thermogenesis (increased energy expenditure), and in combination with a hypocaloric diet and increased physical activity leads to a significant decrease in body weight. It should be noted that the drug increases blood pressure by 1-3 mmHg. and increases heart rate by an average of 3-7 beats/min, so sibutramine should not be taken for ischemic heart disease, myocardial infarction and stroke. The initial dose of sibutramine is 10 mg once in the morning, after 4 weeks it can be increased to 15 mg once a day. Side effects include: increased blood pressure, tachycardia, dry mouth, anorexia, insomnia, constipation. An increase in blood pressure can be compensated by both a decrease in body weight and the administration of beta-blockers.

Orlistat and sibutramine are the drugs of choice in obese patients and can be used long-term (at least 1 year).

Conclusion

The World Health Organization (WHO) has recognized obesity as a new non-infectious “epidemic of the 21st century”. According to the latest WHO estimates, More than a billion people on the planet are overweight . In recent years, there has been a constant increase in the number of overweight people, especially among the working population, so the problem of obesity is one of the pressing problems of medicine. Excess body weight is currently considered an independent risk factor, as it often leads to an increased risk of CVD. Moreover, obesity is not inferior in importance to such risk factors as increased blood pressure or smoking. Obesity is closely related to other risk factors and affects the survival of patients with coronary artery disease; it contributes to early disability and a decrease in both overall life expectancy and quality of life due to the development of concomitant diseases. Stabilization and further correction of body weight increases the survival rate of patients with coronary artery disease. Epidemiological studies have shown that the combination of several risk factors for IHD in one patient greatly increases the total risk of IHD and its fatal complications in the coming years. The impact of obesity on the development of CVD is complex, because With excess body weight, not only the incidence of coronary artery disease, but also cardiac, venous insufficiency and other diseases increases.

Traditional non-drug methods of treating obesity, based on diet therapy and physical exercise, as a rule, do not provide weight loss for a long time, so many patients have to be prescribed medications. Drug treatment should be used as part of a comprehensive program to reduce and maintain body weight, including diet, physical activity, and lifestyle changes. Currently, various approaches to the drug treatment of obesity are used: impact on the centers of hunger and satiety (blockade of reuptake of norepinephrine and serotonin), blocking the absorption of dietary fat (suppression of intestinal lipase activity), stimulation of thermogenesis. Some drugs for the treatment of obesity are contraindicated in patients with coronary artery disease and arterial hypertension. When treating obesity, it is important that the process of weight loss occurs slowly, gradually (weight loss by approximately 5-10% of the initial weight over 6-12 months) - then, simultaneously with weight loss in patients with CVD, the health status will improve. The development of adequate methods for the prevention and treatment of obesity with an impact on other risk factors will significantly improve the prognosis of patients with coronary artery disease with a high risk of complications.

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Obesity is a risk factor

Are you overweight?

First of all, you need to decide whether you are normal weight or overweight. To do this you need to calculate your Body mass index , abbreviated BMI.

It's very easy to do it yourself:

1. Measure and write down your weight in kilograms

2. Measure and write down your height in meters

3. Divide your body weight in kilograms by your height in meters squared.

Thus,

BMI=weight(kg) / [height(m)] 2

For example,

Your weight is 102 kg,

Height -1.68 m (168 cm),

hence,

Your BMI = 102: (1.68 x 1.68) = 36

Waist circumference If calculating body mass index seems complicated to you, then you can use a simpler indicator - Waist Circumference (WC). It is measured under the lower edge of the ribs above the navel. Women with a WC less than 88 cm and men with a WC less than 102 cm have nothing to worry about. Higher rates are a serious reason to think about your health.

In accordance with the obtained BMI, you can assess the degree of risk of developing concomitant diseases (diabetes mellitus, atherosclerosis, arterial hypertension and a number of other equally serious diseases) using the following table:

Classification	BMI	Health Risk	What to do
Underweight	Less than 18.5	Absent
Norm	18.5 - 24.9	Absent
Excess body weight	25.0 - 29.9	Elevated	weight loss
Obesity	30.0 - 34.9	High	weight loss
	35.0 - 39.9	Very tall
Sharply expressed obesity	More than 40	Extremely high	Necessary immediate reduction body weight

Please note: BMI values ​​> 30 indicate obesity, which poses a serious health threat. In this case, you should immediately consult a doctor to develop an individual weight loss program.

Obesity-related diseases and risk factors

Many obese individuals have dysfunction of insulin and carbohydrate metabolism, as well as cholesterol and triglyceride metabolism. All of these concomitant conditions are risk factors for cardiovascular diseases, and their severity increases with increasing BMI (see table).

Relative risk of diseases often associated with obesity

Sharply increased (relative risk > 3)	Moderately elevated (relative risk 2-3)	Slightly elevated (relative risk 1-2)
Diabetes mellitus type 2	Cardiac ischemia	Cancer (breast in postmenopausal women, endometrium, colon)
Gallbladder diseases	Arterial hypertension	Hormonal disorders of reproductive function
Hyperlipidemia	Osteoarthritis (knee joints)	Polycystic ovary syndrome
Insulin resistance	Hyperuricemia/gout	Infertility
Dyspnea		Low back pain caused by obesity
Sleep apnea syndrome		Increased anesthetic risk
		Fetal pathology caused by maternal obesity

For example, in obese individuals, the relative risk of type 2 diabetes is three times that of the general population. Likewise, the risk of coronary heart disease doubles or triples in obese individuals.

Obesity is often accompanied by the development of:

? type 2 diabetes mellitus

? impaired glucose tolerance

? elevated insulin and cholesterol levels

? arterial hypertension

Obesity is an independent risk factor for cardiovascular diseases. Body weight is a better predictor of coronary heart disease than blood pressure, smoking, or high blood sugar. Moreover, obesity increases the risk of other forms of pathology, including some types of cancer, diseases digestive system, respiratory organs and joints.

Obesity significantly impairs quality of life. Many obese patients suffer from pain, limited mobility, low self-esteem, depression, emotional distress and other psychological problems due to prejudice, discrimination and exclusion in society.

The main property of a living organism is constant self-renewal, which is much more intense during work than at rest. Active work increases the vitality of the body and slows down aging. “Muscular joy” was what I. Pavlov called the feeling of elation and vigor that he experienced as a result of work. Here is what he notes about this: “All my life I have loved and love mental and physical work, and, perhaps, even more than the second. And I especially felt satisfied when I made some good guess into the last one, that is, I connected my head with my hands.”

Aging is characterized by a gradual weakening of many vital functions, a decrease in metabolic rate, and a decrease in the activity of biological catalysts - enzymes. True, sometimes signs of obvious aging are detected at 40 or even 30 years old, and sometimes at 60 or even 70 years old a person is young and full of energy. Thus, old age is a concept that should be associated not only with calendar age, but also with the physiological state of the body.

There are about 250 theories of aging. Some scientists view old age as a result of a decrease in the adaptive capabilities of the body, others - as a consequence of a decrease in the activity of the endocrine glands, others see the main cause in chronic intoxication, and others - in the processes of replacement of vital tissues with elements of connective tissue.

Some researchers believe that aging occurs mainly due to the gradual weakening of metabolic processes. However, this is not the only reason for the onset premature old age. Imbalance also plays a significant role. individual species exchange. The most common sign of premature aging is energy imbalance with accompanying obesity, decrepitness of body muscles and heart muscle, decreased mobility, and shortness of breath.

As we can see, it is no coincidence that obesity is given a prominent place among other factors. Many people mistakenly believe that not too much body fat in middle and old age is an indicator of health. Actually this is not true. The fact is that a disorder of fat metabolism is usually accompanied by an imbalance of mineral (salt), cholesterol and energy metabolism.

Naturally, all types of metabolism are closely related to the nature of nutrition. The conclusion involuntarily suggests itself that in rational, targeted nutrition we can see the opportunity to put into action powerful levers that help actively combat the process of aging and decrepitude.

As you age, you should gradually limit your caloric intake. In order to prevent a sharp break in the dynamic stereotype, the World Health Organization recommends reducing the caloric content of the diet with age over the decades as follows:

It is also important to take into account the anti-sclerotic orientation of the diet: reducing the total calorie content of food, reducing animal fats in its composition by increasing vegetable oils, ensuring a sufficient content of vitamins in the diet, consuming foods that are easily digested by digestive enzymes.

An elderly person should be especially demanding of himself in maintaining a diet. It is known that over the years the functional capabilities of the body decrease. Therefore, it becomes important correct technique food, adherence to the principle of “what” and “how much”. Indulging in large amounts of food is extremely harmful. No wonder people say: “A glutton digs his own grave with his teeth.” Eating food at large intervals has no less detrimental effect on the body’s functioning. You must adhere to the rule: less and more often. An elderly person should avoid fatty foods, strong broths, and fried foods.

We advise older people to reduce diet amount of carbohydrates per day (up to 300-320 g for men, up to 280-290 g for women). It should be no more than 50% of daily calories. This recommendation is based on the fact that carbohydrates have the ability to easily turn into fats in the body.

It should be remembered that with age, the regulation of carbohydrate metabolism changes, the ability of the liver to metabolize glucose decreases, and the activity of insulin circulating in the blood decreases, which disrupts the absorption of carbohydrates and can lead to the development of diabetes.

It is worth warning older people against excessive consumption of sugar, sweets, and all kinds of sweets. We recommend more often using foods containing fiber and pectin substances: carrots, cabbage, beets, prunes, wholemeal bread. Fruits that are rich in carbohydrates and have a positive effect on metabolic processes in the body are very useful. In cases where eating fruits in old age is associated with unpleasant subjective sensations (stool retention, increased gas formation), you should change the method of preparing them - take them boiled and baked. In winter and spring (when food lacks vitamins), it is necessary to take multivitamins, strictly adhering to the doctor’s recommendations.

As for foods containing protein, you need to remember the optimal daily protein intake. For older people, it is 1.4 g per 1 kg of body weight (for people over 70 years old, it is advisable to reduce the amount of protein to 1 g per 1 kg of body weight).

The need for proteins is best met through animal products. Particular attention should be paid to the balance of amino acids in food. To do this, we recommend combining products that provide good absorption protein (for example, dairy and meat), with cereals, as well as “less valuable” proteins (bread, porridge) - with “more valuable” ones (meat, milk, cheese, cottage cheese). The assignment of proteins to one group or another is determined by the nature of their amino acid composition.

Of course, the daily diet should be tailored to your lifestyle, individual characteristics body. For example, older people who have switched to less intensive work due to age are recommended to reduce the total amount of protein contained in food, primarily by reducing animal protein, which is very much found in meat. Animal protein should be no more than 40% of the total amount of protein in the diet.

Elderly people should strictly limit their fat intake, since data obtained in numerous scientific studies indicate a significant participation of fatty substances in the pathogenesis of atherosclerosis. Optimal daily requirement fat in old age is 0.8-1 g per 1 kg of weight. Their share in the total daily calorie intake should not exceed 25%. Particularly important are fats of vegetable origin (sunflower and cottonseed oil), which have a stimulating effect on oxidative processes in the body.

With premature aging, redox processes slow down, which leads to dysfunction of individual organs and systems, the intensity of which can be increased with the help of vitamins. They seem to be specially designed for older people, as they accelerate physiological processes in the body. It should be borne in mind that vitamins should be supplied to the body moderately and comprehensively. Of particular importance are those that have the ability to strengthen blood vessels and thereby prevent the development of atherosclerosis.

Under the influence of, for example, vitamin C, the permeability of the vascular wall decreases, its elasticity and strength increase. Vessels become less brittle. In addition, vitamin C regulates cholesterol metabolism, helping to stabilize the physiological balance between the production of cholesterol and its utilization in tissues. However, you should not oversaturate your body with this vitamin. The norm is 70-80 mg per day.

In addition to natural ascorbic acid (vitamin C), food products contain substances that enhance its biological effect. These are the so-called P-active substances that support normal condition the smallest vessels- capillaries, increase their strength and reduce permeability.

This can explain the greater activity of natural sources of vitamin C - fruits, vegetables, berries, which also contain vitamin P. There is especially a lot of vitamin P in black currants, blueberries, lingonberries, and chokeberries.

Elderly people need vitamin preparations such as choline (found in cabbage, fish, legumes), as well as inositol (a B vitamin), which have a beneficial effect on the nervous system and are involved in regulating the motor function of the stomach and intestines. . Inositol is found in oranges, melons, and green peas.

Vitamins, improving metabolic processes in the body, also have an anti-sclerotic effect. However, it should be remembered that with age they are less absorbed in the intestines. Therefore, it is advisable for older people to take ready-made multivitamin complexes (decamevit, undevit, panhexavit and others). The results of studies conducted at the Institute of Gerontology of the Russian Academy of Medical Sciences indicate that systematic (3-4 courses per year) intake multivitamin complexes gives a stimulating effect, has a positive effect on the function of the heart, blood vessels, nervous system, and significantly improves mental state.