lvrachЛечащий ВрачLechaschi Vrach1560-51752687-118110.51793/OS.2021.24.7.011lvrach-786Research ArticleАКТУАЛЬНАЯ ТЕМАTOPICAL THEMEОбоснование необходимости создания новой классификации ожиренияJustification of the need to create a new classification of obesityМиклишанскаяС. В.MiklishanskayaS. V.

кандидат медицинских наук

Москва

Moscow

kvant83@list.ruЗолозоваЕ. А.ZolozovaE. A.

кандидат медицинских наук

Москва

Moscow

ОрловскийА. А.OrlovskyA. A.

Москва

Moscow

ШлевковаГ. В.ShlevkovaG. V.

кандидат медицинских наук

Москва

Moscow

МазурН. А.MazurN. A.

доктор медицинских наук, профессор

Москва

Moscow

ФГБОУ ДПО РМАНПО Минздрава РоссииРоссияRussian Medical Academy of Continuous Professional EducationRussian FederationФГБУ НМИЦ кардиологии Минздрава РоссииРоссияNational Medical Research Center of CardiologyRussian Federation202103092021075862Copyright © Миклишанская С.В., Золозова Е.А., Орловский А.А., Шлевкова Г.В., Мазур Н.А., 20212021Миклишанская С.В., Золозова Е.А., Орловский А.А., Шлевкова Г.В., Мазур Н.А.Miklishanskaya S.V., Zolozova E.A., Orlovsky A.A., Shlevkova G.V., Mazur N.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.lvrach.ru/jour/article/view/786

Результаты многочисленных исследований, проведенных в последние десятилетия, показали, что наибольшее значение в определении риска развития заболеваний и смерти на индивидуальном уровне имеет накопление висцеральной жировой ткани, сопряженное с развитием метаболических нарушений и местным влиянием при ее накоплении во внутренних органах. Биоимпедансный анализ служит простым и доступным в широкой клинической практике способом определения избыточного содержания висцеральной жировой ткани, позволяя тем самым выявлять пациентов с ожирением и высоким риском развития сердечно-сосудистых осложнений даже в рамках первой встречи с врачом. Результаты определения висцеральной жировой ткани с помощью биоимпедансного анализа сопоставимы с данными, полученными при КТ и МРТ. По нашим наблюдениям, проведенным на 154 больных с различными сердечно-сосудистыми заболеваниями, содержание висцеральной жировой ткани, составляющее 14% и более по данным биоимпедансного анализа, сочеталось с нарушениями, характерными для метаболического синдрома. При этом нарастание индекса массы тела от 1-й до 3-й степени никак не отражало степень тяжести метаболических нарушений. Достоверных отличий по содержанию висцеральной жировой ткани и уровням содержания в крови триглицеридов, глюкозы и липопротеинов высокой плотности у больных с разными степенями ожирения также выявлено не было. На сегодняшний день очевидно, что ожирение, определяемое с помощью индекса массы тела, является очень гетерогенным и его отрицательная роль в развитии заболеваний выявляется только при наблюдении за очень большими группами населения. Данные исследований о значении висцеральной жировой ткани и ее связи с факторами риска развития сердечно-сосудистых заболеваний свидетельствуют о необходимости создания новой классификации ожирения. Проект для ее обсуждения приводится в нашей статье.

The results of numerous studies conducted over the past decades have shown that the greatest importance in determining the risk of disease and death at the individual level is the accumulation of visceral adipose tissue, associated with the development of metabolic disorders and local influence when it accumulates in the internal organs. Bioimpedance analysis is a simple and widely available clinical method for determining the excess content of visceral adipose tissue, thereby allowing you to identify patients with obesity and a high risk of developing cardiovascular complications, even in the first meeting with a doctor. The results of the determination of visceral adipose tissue by bioimpedance analysis are comparable with the data obtained by CT and MRI. According to our observations conducted on 154 patients with various cardiovascular diseases, the content of visceral adipose tissue , which is 14% or more according to bioimpedance analysis, was combined with disorders characteristic of the metabolic syndrome. At the same time, the increase in BMI from the 1st to the 3rd degree did not reflect the severity of metabolic disorders. There were no significant differences in the content of visceral adipose tissue and blood levels of triglycerides, glucose, and HDL-C in patients with different degrees of obesity. To date, it is obvious that obesity, determined by BMI, is very heterogeneous and its negative role in the development of diseases is revealed only when observing very large groups of the population. Research data on the importance of visceral adipose tissue and its association with risk factors for cardiovascular disease suggest the need for a new classification of obesity. We present a draft for discussing the new classification of obesity in our article.

висцеральная жировая тканьбиоимпедансный анализклассификация ожиренияметаболические нарушенияиндекс массы телаvisceral adipose tissuebioimpedance analysisclassification of obesitymetabolic disordersbody mass indexReferencesOmura-Ohata Y., Son C., Makino H., Koezuka R., Tochiya M., Tamanaha T., et al. Efficacy of visceral fat estimation by dual bioelectrical impedance analysis in detecting cardiovascular risk factors in patients with type 2 diabetes // Cardiovasc Diabetol. 2019; 18: 137. DOI: 10.1186/s12933-019-0941-y.Omura-Ohata Y., Son C., Makino H., Koezuka R., Tochiya M., Tamanaha T., et al. Efficacy of visceral fat estimation by dual bioelectrical impedance analysis in detecting cardiovascular risk factors in patients with type 2 diabetes // Cardiovasc Diabetol. 2019; 18: 137. DOI: 10.1186/s12933-019-0941-y.Mulasi U., Kuchnia A. J., Cole A. J., Earthman C. P. Bioimpedance at the Bedside: Current Applications, Limitations, and Opportunities // Nutrition in Clinical Practice. 2015; 30 (2): 180-193. DOI: 10.1177/0884533614568155.Mulasi U., Kuchnia A. J., Cole A. J., Earthman C. P. Bioimpedance at the Bedside: Current Applications, Limitations, and Opportunities // Nutrition in Clinical Practice. 2015; 30 (2): 180-193. DOI: 10.1177/0884533614568155.Окороков П. П., Васюкова О. В., Воронцов А. В. Методы оценки количества и распределения жировой ткани в организме и их клиническое значение // Проблемы эндокринологии. 2014; 3: 53-58. DOI: 10.14341/probl201460353-58.Okorokov P. L., Vasyukova O. V., Vorontsov A. V. Metody otsenki kolichestva I raspredeleniya zhirovoi tkani v organizme i ikh klinicheskoe znachenie [The methods for the characteristic of adipose tissue in the organism and their clinical significance] // Problemy endokrinologii. 2014; 60 (3): 53-58. DOI: 10.14341/probl201460353-58.Yamakage H., Ito R., Tochiya M., Muranaka K., Tanaka M., Matsuo Y. et al. The utility of dual bioelectrical impedance analysis in detecting intra-abdominal fat area in obese patients during weight reduction therapy in comparison with waist circumference and abdominal CT // Endocrine Journal. 2014; 61 (8): 807-819. DOI: 10.1507/endocrj.EJ14-0092.Yamakage H., Ito R., Tochiya M., Muranaka K., Tanaka M., Matsuo Y. et al. The utility of dual bioelectrical impedance analysis in detecting intra-abdominal fat area in obese patients during weight reduction therapy in comparison with waist circumference and abdominal CT // Endocrine Journal. 2014; 61 (8): 807-819. DOI: 10.1507/endocrj.EJ14-0092.Berker D., Koparal S., Işik S., Paşaoğlu L., Aydin Y., Erol K., Delibaşi T., Güler S. Compatibility of different methods for the measurement of visceral fat in different body mass index strata // Diagn Interv Radiol. 2010; 16: 99-105. DOI: 10.4261/1305-3825.DIR.2749-09.1.Berker D., Koparal S., Işik S., Paşaoğlu L., Aydin Y., Erol K., Delibaşi T., Güler S. Compatibility of different methods for the measurement of visceral fat in different body mass index strata // Diagn Interv Radiol. 2010; 16: 99-105. DOI: 10.4261/1305-3825.DIR.2749-09.1.Park K. S., Lee D. H., Lee J., Kim Y. J., Jung K. Y., Kim K. M., et al. Comparison Between Two Methods of Bioelectrical Impedance Analyses for Accuracy in Measuring Abdominal Visceral Fat Area // J Diabetes Complications. 2016; 30 (2): 343-9. DOI: 10.1016/j.jdiacomp.2015.10.014. DOI: 10.1016/j.jdiacomp.2015.10.014.Park K. S., Lee D. H., Lee J., Kim Y. J., Jung K. Y., Kim K. M., et al. Comparison Between Two Methods of Bioelectrical Impedance Analyses for Accuracy in Measuring Abdominal Visceral Fat Area // J Diabetes Complications. 2016; 30 (2): 343-9. DOI: 10.1016/j.jdiacomp.2015.10.014. DOI: 10.1016/j.jdiacomp.2015.10.014.Ryo M., Maeda K., Onda T., Katashima M., Okumiya A., Nishida M., Yamaguchi T., Funahashi T., Matsuzawa Y., Nakamura T., Shimomura I. A new simple method for the measurement of visceral fat accumulation by bioelectrical impedance // Diabetes Care. 2005; 28: 451-453. DOI: 10.2337/diacare.28.2.451.Ryo M., Maeda K., Onda T., Katashima M., Okumiya A., Nishida M., Yamaguchi T., Funahashi T., Matsuzawa Y., Nakamura T., Shimomura I. A new simple method for the measurement of visceral fat accumulation by bioelectrical impedance // Diabetes Care. 2005; 28: 451-453. DOI: 10.2337/diacare.28.2.451.Lee D. H., Park K. S., Ahn S., Ku Eu. J., Jung K. Y., Yoon Ji, Kim Y. J. et al. Comparison of Abdominal Visceral Adipose Tissue Area Measured by Computed Tomography with That Estimated by Bioelectrical Impedance Analysis Method in Korean Subjects // Nutrients. 2015; 7: 10513-10524. DOI: 10.3390/nu7125548.Lee D. H., Park K. S., Ahn S., Ku Eu. J., Jung K. Y., Yoon Ji, Kim Y. J. et al. Comparison of Abdominal Visceral Adipose Tissue Area Measured by Computed Tomography with That Estimated by Bioelectrical Impedance Analysis Method in Korean Subjects // Nutrients. 2015; 7: 10513-10524. DOI: 10.3390/nu7125548.Browning L. M., Mugridge O., Chatfield M. D., Dixon A. K., Aitken S. W., Joubert I., Prentice A. M., Jebb S. A. Validity of a new abdominal bioelectrical impedance device to measure abdominal and visceral fat: comparison with MRI // Obesity. 2010; 18: 2385-2391. DOI: 10.1038/oby.2010.71.Browning L. M., Mugridge O., Chatfield M. D., Dixon A. K., Aitken S. W., Joubert I., Prentice A. M., Jebb S. A. Validity of a new abdominal bioelectrical impedance device to measure abdominal and visceral fat: comparison with MRI // Obesity. 2010; 18: 2385-2391. DOI: 10.1038/oby.2010.71.Tu A. W., Humphries K. H., Scott A. L. Longitudinal changes in visceral and subcutaneous adipose tissue and metabolic syndrome: Results from the Multicultural Community Health Assessment Trial (M-CHAT) / Diabetes Metab Syndr. 2017; 11 Suppl 2: S957-S961. DOI: 10.1016/j.dsx.2017.07.022.Tu A. W., Humphries K. H., Scott A. L. Longitudinal changes in visceral and subcutaneous adipose tissue and metabolic syndrome: Results from the Multicultural Community Health Assessment Trial (M-CHAT) / Diabetes Metab Syndr. 2017; 11 Suppl 2: S957-S961. DOI: 10.1016/j.dsx.2017.07.022.Neeland I. J., Colby R., Ayers C. R., Rohatgi A. K., Turer A. T., Berry J. D., Das S. R., Vega G. L., Khera A., McGuire D. K., Grundy S. M., Lemos J. A. Associations of Visceral and Abdominal Subcutaneous Adipose Tissue with Markers of Cardiac and Metabolic Risk in Obese Adults // Obesity. 2013; 21: E439-E447. DOI: 10.1038/oby.20135.Neeland I. J., Colby R., Ayers C. R., Rohatgi A. K., Turer A. T., Berry J. D., Das S. R., Vega G. L., Khera A., McGuire D. K., Grundy S. M., Lemos J. A. Associations of Visceral and Abdominal Subcutaneous Adipose Tissue with Markers of Cardiac and Metabolic Risk in Obese Adults // Obesity. 2013; 21: E439-E447. DOI: 10.1038/oby.20135.Sato F., Maeda N., Yamada T., Namazui H., Fukuda S., Natsukawa T., et al. Association of Epicardial, Visceral, and Subcutaneous Fat With Cardiometabolic Diseases // Circ J. 2018; 82: 502-508. DOI: 10.1253/circj.CJ-17-0820.Sato F., Maeda N., Yamada T., Namazui H., Fukuda S., Natsukawa T., et al. Association of Epicardial, Visceral, and Subcutaneous Fat With Cardiometabolic Diseases // Circ J. 2018; 82: 502-508. DOI: 10.1253/circj.CJ-17-0820.Yumi M., Toru N., Shuichiro Y., Yoshihiko T., Tetsuji Y., Tetsuya M., Mitsuhiko N. Visceral Fat area Cutoff for the Detection of Multiple Risk Factors of Metabolic syndrome in Japanese: the Hitachi Health study // Obesity. 2012; 20: 1744-1749. DOI: 10.1038/oby.2011.285.Yumi M., Toru N., Shuichiro Y., Yoshihiko T., Tetsuji Y., Tetsuya M., Mitsuhiko N. Visceral Fat area Cutoff for the Detection of Multiple Risk Factors of Metabolic syndrome in Japanese: the Hitachi Health study // Obesity. 2012; 20: 1744-1749. DOI: 10.1038/oby.2011.285.Ozhan H., Alemdar R., Caglar O., Ordu S., Kaya A., Albayrak S., Turker Y., Bulur S. MELEN Investigators Performance of bioelectrical impedance analysis in the diagnosis of metabolic syndrome // J Investig Med. 2012; 60 (3): 587-591. DOI: 10.2310/JIM.0b013e318244e2d9.Ozhan H., Alemdar R., Caglar O., Ordu S., Kaya A., Albayrak S., Turker Y., Bulur S. MELEN Investigators Performance of bioelectrical impedance analysis in the diagnosis of metabolic syndrome // J Investig Med. 2012; 60 (3): 587-591. DOI: 10.2310/JIM.0b013e318244e2d9.Rodríguez A. S., Soidán J. G., Gómez J. A., Rodríguez R. L., Álamo Alonso A. D., Pérez Fernández M. R. Metabolic syndrome and visceral fat in women with cardiovascular risk factor // Nutr Hosp. 2017; 34 (4): 863-868. DOI: 10.20960/nh.1085.Rodríguez A. S., Soidán J. G., Gómez J. A., Rodríguez R. L., Álamo Alonso A. D., Pérez Fernández M. R. Metabolic syndrome and visceral fat in women with cardiovascular risk factor // Nutr Hosp. 2017; 34 (4): 863-868. DOI: 10.20960/nh.1085.Unno M., Furusyo N., Mukae H., Koga T., Eiraku K., Hayashi J. The utility of visceral fat level by bioelectrical impedance analysis in the screening of metabolic syndrome – the results of the Kyushu and Okinawa Population Study (KOPS) // J Atheroscler Thromb. 2012; 19 (5): 462-70. DOI:10.5551/jat.11528.Unno M., Furusyo N., Mukae H., Koga T., Eiraku K., Hayashi J. The utility of visceral fat level by bioelectrical impedance analysis in the screening of metabolic syndrome – the results of the Kyushu and Okinawa Population Study (KOPS) // J Atheroscler Thromb. 2012; 19 (5): 462-70. DOI:10.5551/jat.11528.Шляхто Е. В., Недогода С. В., Конради А. О., Баранова Е. И., Фомин В. В., Верткин А. Л., Чумакова Г. А. Концепция новых национальных клинических рекомендаций по ожирению // Российский кардиологический журнал. 2016; 4 (132): 7-13. DOI: 10.15829/1560-4071-2016-4-7-13.Shlyakhto E. V., Nedogoda S. V., Konradi А. О., Baranova E. I., Fomin V. V., Vertkin А. L., Chumakova G. А. Kontseptsiya novykh natsionalnykh klinicheskikh rekomendatsii po ozhireniyu [The concept of novel national clinical guidelines on obesity] // Rossiiskii kardiologicheskii zhurnal. 2016; 4 (132): 7-13. DOI: 10.15829/1560-4071-2016-4-7-13.Romero-Corral A., Somers V. K., Sierra-Johnson J. et al. Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality // Eur Heart J. 2010; 31: 737-746. DOI: 10.1093/eurheartj/ehp487.Romero-Corral A., Somers V. K., Sierra-Johnson J. et al. Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality // Eur Heart J. 2010; 31: 737-746. DOI: 10.1093/eurheartj/ehp487.Jung C. H., Lee W. J., Song K. Metabolically healthy obesity: a friend or foe? // Korean J Intern Med. 2017; 32: 611-621. DOI: 10.3904/kjim.2016.259.Jung C. H., Lee W. J., Song K. Metabolically healthy obesity: a friend or foe? // Korean J Intern Med. 2017; 32: 611-621. DOI: 10.3904/kjim.2016.259.Dhana K., Koolhaas C. M., van Rossum E., Ikram M. A., Hofman A., Kavousi M. et al. Metabolically Healthy Obesity and the Risk of Cardiovascular Disease in the Elderly Population // PLoS ONE. 2016; 11 (4): e0154273. DOI: 10.1371/journal.pone.0154273.Dhana K., Koolhaas C. M., van Rossum E., Ikram M. A., Hofman A., Kavousi M. et al. Metabolically Healthy Obesity and the Risk of Cardiovascular Disease in the Elderly Population // PLoS ONE. 2016; 11 (4): e0154273. DOI: 10.1371/journal.pone.0154273.Alberti K. G., Eckel R. H., Grundy S. M., Zimmet P. Z., Cleeman J. I., Donato K. A. et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity // Circulation. 2009; 120: 1640-1645. DOI: 10.1161/CIRCULATIONAHA.109.192644.Alberti K. G., Eckel R. H., Grundy S. M., Zimmet P. Z., Cleeman J. I., Donato K. A. et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity // Circulation. 2009; 120: 1640-1645. DOI: 10.1161/CIRCULATIONAHA.109.192644.Fruh S. M. Obesity: Risk factors, complications, and strategies for sustainable long-term weight management // J Am Assoc Nurse Pract. 2017; 29 (S1): S3-S14. DOI: 10.1002/2327-6924.12510.Fruh S. M. Obesity: Risk factors, complications, and strategies for sustainable long-term weight management // J Am Assoc Nurse Pract. 2017; 29 (S1): S3-S14. DOI: 10.1002/2327-6924.12510.Musunuru K. Atherogenic dyslipidemia: Cardiovascular risk and dietary intervention // Lipids. 2010; 45 (10): 907-914. DOI: 10.1007/s11745-010-3408-1.Musunuru K. Atherogenic dyslipidemia: Cardiovascular risk and dietary intervention // Lipids. 2010; 45 (10): 907-914. DOI: 10.1007/s11745-010-3408-1.Neeland I. J., Ross R., Després J. P. et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement // Lancet Diabetes Endocrinol. 2019; 7: 715-725. DOI: 10.1016/S2213-8587(19)30084-1.Neeland I. J., Ross R., Després J. P. et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement // Lancet Diabetes Endocrinol. 2019; 7: 715-725. DOI: 10.1016/S2213-8587(19)30084-1.Scaglione R., Di Chiara T., Cariello T. et al. Visceral obesity and metabolic syndrome: two faces of the same medal? // Intern Emerg Med. 2010; 5: 111. DOI: 10.1007/s11739-009-0332-6.Scaglione R., Di Chiara T., Cariello T. et al. Visceral obesity and metabolic syndrome: two faces of the same medal? // Intern Emerg Med. 2010; 5: 111. DOI: 10.1007/s11739-009-0332-6.Tchernof A., Després J.-P. Pathophysiology of Human Visceral Obesity: An Update // Physiol Rev. 2013; 93: 359-404. DOI: 10.1152/physrev.00033.2011.Tchernof A., Després J.-P. Pathophysiology of Human Visceral Obesity: An Update // Physiol Rev. 2013; 93: 359-404. DOI: 10.1152/physrev.00033.2011.Piché М., Tchernof А., Després J. Obesity Phenotypes, Diabetes, and Cardiovascular Diseases // Circulation Research. 2020; 126: 1477-1500. DOI: 10.1161/CIRCRESAHA.120.316101.Piché М., Tchernof А., Després J. Obesity Phenotypes, Diabetes, and Cardiovascular Diseases // Circulation Research. 2020; 126: 1477-1500. DOI: 10.1161/CIRCRESAHA.120.316101.

The authors declare that there are no conflicts of interest present.