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17INTEGRATED CLINICAL AND METABOLIC EVALUATION OF THE CONDITION OF CHILDREN WITH OBESITY
AND ARTERIAL HYPERTENSION 1 2 Garifulina L.M.\ Kholmuradova Z.E.2
1Garifulina Lilya Maratovna - Associate Professor, Head of Department; 2Kholmuradova Zilola Ergashevna - Assistant, DEPARTMENT OF PEDIATRICS, FACULTY OF MEDICINE, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: 50 children with obesity and AH were comprehensively examined. It was revealed that in this category of children there is a high, accelerated pace of sexual development, a decrease in the quality of life and a high frequency of pathology from the cardiovascular system in the form of functional disorders and increased blood pressure. Biochemical studies have shown that from one-third of children with abdominal obesity was observed pathology of carbohydrate and lipid metabolism, which was accompanied by an increase in the level of uric acid in the blood.
Keywords: obesity, abdominal obesity, arterial hypertension, metabolic syndrome, insulin resistance, children.
Relevance of the problem: The growing prevalence of obesity in children and adolescents, the high incidence of disorders of carbohydrate and lipid metabolism, and arterial hypertension against the background of obesity indicate the relevance of the study of the problem of metabolic syndrome (MS) in this age group [4, 10]. To date, a number of studies of MS in adolescents and single studies in children have been carried out, however, many pathogenetic aspects of the formation of this symptom of the complex remain poorly understood. Recently, the controversial IDF criteria transferred to childhood [4, 3, 6, 9, 11] do not allow reliable verification of the metabolic syndrome, since in pediatric practice there is no unambiguous definition of abdominal obesity, a leading component of MS and a proven independent predictor of the formation of metabolic and cardiovascular complications in adults. One of MS components is hypertension (AH), wherein the children with this comorbidity have a high frequency and metabolic complications in adulthood, due to these children and adolescents are optimal contingent to study the opening forming disease is a complication of obesity and hypertension [3, 6, 7, 8, 12].
The aim of the research: identification of clinical and metabolic characteristics in children with obesity and hypertension, with the definition of the components of metabolic syndrome.
Material and methods: 55 children with exogenously constitutional obesity and arterial hypertension were examined. The criterion for selection of patients was the definition of BMI and waist volume in children and adolescents diagnosed with excess weight and / or obesity which is above the 97 percentile for age and gender (WHO 2006). The study included 25 girls (45%) and 30 (55%) boys, the average age of which was 14,35 ± 0,21 years (10 to 18 years).
The study was carried out by general clinical standard examination. Body weight was estimated using percentile tables of the ratio of linear growth to body weight or body mass index (Quetelet index ) for a specific age and gender (WHO, 1998). About the maximum volume of the waist (OT) and hips (OB), the ratio of which is an indicator of abdominal obesity. For RT / OB values > 0,85 in girls and> 0,9 in boys, it was regarded as abdominal obesity ( IDF, 1997).
Children with exogenously-constitutional obesity were divided by the presence of abdominal (visceral) obesity and the presence of hypertension. In group I there were 17 people (16,83%) with a uniform type of obesity, with OT 80,11 ± 1,36, OT / OB 0,87 ± 0,01
cm. The II group included 38 children with AO, while OT was 99,82 ± 1,3 cm; OT / V 0,92 ± 0,009. 20 of them had normal blood pressure (group IIA) and 18 children had a confirmed diagnosis of hypertension ( group II B ). Differences in the OT / OB ratio in groups I and II were significant ( P <0,05). Moreover, the BMI value exceeded the 97 percentile and averaged 31,27 ± 0,51 kg / m 2 with a scatter of indicators from 23,5 to 47,2 kg / m 2 BMI in group I of patients reached 28,85 ± 0,52 kg / m 2 ; in group II, it was significantly higher than 35,37 ± 0,63 kg / m 2 ( P <0,01).
The comparison group consisted of 20 children without obesity, aged 14,31 ± 0,63 years, with OT 64 ± 1,51 cm, OT / OB 0,81 ± 0,02 cm, with a difference in the OT / OB ratio was reliable with group I ( P <0,01) and II (P <0,001). There were 9 girls and 11 boys. All children were assigned to group I health. The average BMI in the comparison group was 19,44 ± 0,47 kg / m 2 with a range of values from 18,2 to 20,4 kg / m 2 The difference in BMI value with the observation group is significant ( P <0,001).
The serum glucose concentration was determined by the glucose oxidase method. Cholesterol (cholesterol), high-density blood cholesterol (HDL) was determined using the enzymatic method. The cholesterol of low density lipoproteins (LDL) and very low density (VLDL) was determined by the Friedwald formula. Blood and urine MKs were determined spectrophotometrically according to Morimont et London (1982). The level of immunoreactive insulin (IRI) was determined by enzyme-linked immunosorbent assay (ELISA) with the calculation of the indices of HOMA R IR according to the formulas
Research results and discussion. When analyzing the clinical characteristics of obese children, I would first like to dwell on the timing of the manifestation of obesity in children of the compared groups. So, for the first time, signs of overweight, and then the rapid onset of obesity in children with a uniform type of obesity were observed at the age of 12-14 years, i.e. with the onset of puberty, the average duration of manifestation of obesity in this group was 12,2 ± 0,8 years. In children with AO and AO and AH, earlier periods of disease manifestation were observed, for example, in the 2A group it was 9,5 ± 0,6 years and in the 2B group 8,9 ± 0,5 years, which was significantly earlier compared to a group with a uniform type of obesity ( P <0,01).
When sexually comparing the manifestation and the largest number of obese children, it was found that in boys the largest number of obese children was 15-16 years old (36,6%), while the onset of the disease was on average 8,3 ± 0,5 years, while in girls the largest number of obese children was 13-14 years old (36,6%) with a debut of the disease at the age of 7,4 ± 0,3 years.
When determining the BMI value, it was revealed that it exceeded the value of 97 percentile and averaged 31,27 ± 0,51 kg / m 2 with a scatter of indicators from 23,5 to 47,2 kg / m 2 BMI in group I of patients reached 28,85 ± 0,52 kg / m 2 ; in group II, it was significantly higher than 35,37 ± 0,63 kg / m 2 ( P <0,01). A significant increase in RT was observed with an increase in the degree of obesity. A weak positive correlation of BMI and RT was observed in group I patients ( r = 0,456), while an increase in BMI was not accompanied by an increase in the RT / OB ratio ( r = 341). The same patterns were determined in group II: the OT significantly increased with an increase in BMI ( r = 0,640 in 2A and r = 0,708 ; P <0,01 and P <0,01), with respect to the OT / OB coefficient, no such relationship was noted ( r = 0,124 and r = 0,199). Thus, in children the nature of the distribution of fat is more accurately assessed using OT than the OT / OB ratio, which is consistent with the opinion of a number of authors [5].
When assessing blood pressure in the compared groups, it was found that in the group with a uniform type of obesity, an excess of the level of SBP and DBP above the border units, respectively, of the percentile table of blood pressure, respectively, by gender and age, the recommended GFCF was observed in 4 (23,5%) children. In this case, an increase in blood pressure was observed only at the first dose, in connection with this, we regarded this condition as hypertension of the white coat. In sick children with AO, "white coat"
hypertension was noted in a higher percentage - in 11 (28,9%), while 18 children (47,3%) were diagnosed with 1st degree AH, from which a group with AO was formed and hypertension. It should be noted that in this group of children, the values of SBP and DBP were higher than 97 percentile for the corresponding age and gender.
In children of the main groups, a significant positive correlation was found for BMI with levels of SBP ( r = +0,602), DBP ( r = +0,589) in the group with a uniform type of obesity, in group 2A, SBP ( r = +0,618), and DBP ( r = +0,602) and in group 2B the GARDEN ( r = +0,701), DBP ( r = +0,658).
When assessing physical development, tallness was detected in 17 (47,0%) children with a uniform type of obesity and in 19 (50%) children with AO, while the distribution of tallness in groups showed its presence in 12 (60%) children of group 2A and in 7 (38,8%) children with AO and AH.
Changes in the skin in the form of striations from pale pink to burgundy, located in typical places - on the anterior abdominal wall, shoulders, and hips were detected in 29,4% of children with a uniform type of obesity, black acanthosis in 11,7% of children in this group. In children with AO, striae and black acanthosis were also observed, while their frequency was almost the same in both observation groups (35% and 15% in the 2A group; 33,3% and 16,6% in the 2B group).
Assessment of sexual development in adolescents according to the classification of J. Tanner (1969) showed that most of the examined sick boys and girls in both groups had IV and V stages of sexual development. Almost no patients with stage I sexual development in the observation groups
According to the questionnaire on assessing the quality of life of obese children, we found that the most common complaint in obese children was a recurring headache that appeared against the background of emotional stress, mainly in the afternoon and evening hours (70,5%; 80% and 88,8% respectively in groups 1, 2A and 2B). Moreover, among children in the control group only 20% of children complained of irregular headaches. One third of obese children experienced tingling episodes in the region of the heart, occurring both at rest and during exercise (29,4%; 35% and 44,4%, respectively, in groups 1, 2A and 2B). In the control group, 10,0% of children indicated pain in the region of the heart associated with emotional or physical stress.
When conducting an ECG in children of the main group with obesity in 21,8% (15 children) of cases, functional disturbances in the form of sinus tach and - or bradycardia were recorded, in 7,2% (4 children) an atrial rhythm was detected, which, when the patient moves to a vertical position replaced by an accelerated sinus. Conduction disturbances in the form of incomplete blockade of the legs of the bundle of His were noted (10,9% - 6 children). Moreover, in the control group, max and - and bradyarrhythmias were observed in 5% (1 child), and incomplete blockade of the legs of the bundle of His was also diagnosed in 1 child. There is a clear tendency towards the steady growth and spread of obesity and metabolic syndrome (MS). The prevalence of MS among children and adolescents when applying various diagnostic criteria ranges from 0,4 to 25% [4]. In this regard, one of the objectives of our work was to identify the components of MS in children with obesity.
Thus, according to the analysis of carbohydrate metabolism indicators, it was revealed that the average glycemia levels (fasting and postprandial glucose ) and IRI in the main groups did not deviate from the established norm, however, an excess of the HOMA - R index ( p <0,05) indicated the presence of insulin resistance (IR). At this concentration fasting glucose, postprandial plasma glucose and IRI ( p <0,05) were significantly Your e similar values of the control group grew and as the progression of obesity (Table 1 ).
1 Control group Main group
1 group 2A group 2B group
2 Postprondeal glycemia; mmol / l on an empty stomach 3,25 ± 0,41 4,02 ± 0,68 4,92 ± 0,52 5,08 ± 0,41
In 2 hours 6,07 ± 0,52 6,62 ± 0,61 7,02 ± 0,55 7,94 ± 0,51
3 Blood insulin level, ^MU / ml 7,89 ± 0,80 9,36 ± 0,80 10,91± 0,80 10,97 ± 0,98
4 NOMA- R Index 2,57 ± 0,83 2,89 ± 0,83 3,68 ± 0,78 4,39 ± 2,11 *
Note: * p <0.05 with respect to control.
When analyzing the frequency of occurrence of violations of carbohydrate metabolism, it was found that an increase in fasting glucose was detected in 17,6%, 20% and 27,7% of children in group 1, 2A and 2B, respectively, while in 5,8%, 15%, 22,2% of children (in groups 1, 2A and 2B, respectively) showed an increase in postprandial glycemia, an increase in IRI was observed in 23,5%, 25% and 27,7% of cases (in groups 1, 2A and 2B, respectively). In the control group, carbohydrate metabolism disorders were not detected, however, 2 children (10%) had a slight increase in the HOMA - R index due to the concentrations of fasting glycemia and IRI close to the border, but not exceeding the norm.
Obesity in the abdomen (abdominal, central or apple-shaped type) is a leading sign of MS [1,2]. It is this type of obesity that is usually associated with high triglycerides (TG). Similar changes were noted in our sample of patients. As a result of the assessment of the lipid profile, it was found that lipid metabolism disorders occurred in one third of patients among children of the main group with obesity.
In the analysis of the level of triglycerides it was found that 29,4%, 30% and 38,8% of patients had trigletsiridemiya. On average, the level of TG was 1,56 ± 0,25, 1,92 ± 0,16 and 2,3 ± 0,23 mmol / L (in groups 1A, 2A and 2B, respectively). For dyslipidemia in MS characterized by an increase in total cholesterol, and decrease HSLPNP HSLPVP. This type of dyslipidemia has recently been given great importance in connection with an increased risk of cardiovascular complications. The risk of developing coronary heart disease is 2-4 times higher and the risk of acute myocardial infarction is 6-10 times higher than the general population in adulthood [1,2]. Dyslipidemia is accompanied by an increase in the concentration of atherogenic lipoproteins with a large molecular weight, which leads to an increase in plasma viscosity, an increase in OPSS and maintains a high level of blood pressure.
Thus, an increase in the level of total cholesterol above normal or its borderline values was observed in 35,2%, 35% and 44,4% of cases (in groups 1, 2A and 2B, respectively), while the level of total cholesterol was significantly increased in groups with abdominal obesity compared with the control of 4,56 ± 0,58; 5,01 ± 0,33 and 5,76 ± 0,52 mmol / L (in group 1, 2A and 2B, respectively). HDL studies showed a decrease in its level in patients with obesity in 17,6% of 25% and 22,2% of cases (in groups 1, 2A and 2B, respectively), its average values averaged 1,22 ± 0,12; 1,13 ± 0,09 and 1,03 ± 0,07 mmol / L. When studying the fractions of LDL cholesterol, it was found that the level was 3,04 ± 0,23; 3,66 ± 0,18 and 4,14 ± 0,39 mmol / L, while an increase in this indicator was observed in 29,4%, 35% and 44,4% of cases (in groups 1, 2A and 2B, respectively).
In recent years, one of the important components in the pathogenesis of MS, including in children, is an increase in the level of blood uric acid (MK) [4,6]. Thus, the analysis of the concentration of MK in children of the main group showed that it did not exceed the norm,
but was significantly higher than in the control group and had a direct proportional relationship with the degree of obesity ( r = 0,592, p <0,001) and blood pressure ( r = 0,446; and r = 0,369; p <0,001). In children with uniform obesity, an increase in MK was observed to 0,324 ± 0,011 mmol / l; compared with the control group 0,180 ± 0,013 mmol / l ( P <0,01). However, in 3 children (17,64%) with a uniform type of obesity, GU was detected (0,366 ± 0,01 mmol / L). GU in the group of children with AO reached % cases and amounted to 0,415 ± 0,021 mmol / L (average 0,369 ± 0,012 mmol / L). In children with AH and AO, the level of uric acid also turned out to be high ( 0,398 ± 0,130 ), and in 55,5% of cases this was the state of GU (0,413 ± 0,03 mmol / L ).
Conclusions: In this way at one quarter of the children with AD and one third of children with AS and AG observed abnormality of carbohydrate metabolism, as well as in one-third of children of all observed groups was determined by the change in lipid parameters, this was accompanied by elevated levels of MK blood, which had a direct correlation with BMI and blood pressure. At the same time, children with AO and AH showed tallness, accelerated pace of sexual development, decreased quality of life, and a high frequency of pathology from the cardiovascular system of functional disorders and increased blood pressure.
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ДИАГНОСТИЧЕСКАЯ ЦЕННОСТЬ НАТРИЙУРЕТИЧЕСКОГО ПЕПТИДА ПРИ ВЫЯВЛЕНИИ ПАЦИЕНТОВ С БЕССИМПТОМНОЙ СИСТОЛИЧЕСКОЙ ИЛИ ДИАСТОЛИЧЕСКОЙ ДИСФУНКЦИЕЙ
1 2 3
Ярмухамедова С.Х. , Бекмурадова М.С. , Назаров Ф.Ю.
1Ярмухамедова Саодат Хабибовна - доцент, заведующая кафедрой;
2Бекмурадова Махсуда Салхиддиновна - ассистент;
3Назаров Феруз Юсупович - ассистент, кафедра пропедевтики внутренних болезней, лечебный факультет, Самаркандский государственный медицинский институт, г. Самарканд, Республика Узбекистан
Аннотация: систолическая и диастолическая сердечная недостаточность (СН) являются распространенными и дорогостоящими заболеваниями во всем мире. СН является одной из основных причин заболеваемости и смертности, а также прогрессирующим заболеванием, часто возникающим в результате клинически невидимых форм желудочковой дисфункции. Изучение проблемы сердечной недостаточности на ранних этапах ее развития вызывает особый интерес кардиологов. Появились данные о возможности ранней диагностики систолической и/или диастолической хронической сердечной недостаточности (ХСН) любой этиологии и прогнозирования возникновения неблагоприятных исходов сердечной недостаточности с помощью натрийуретического пептида.
Ключевые слова: систолическая сердечная недостаточность, диастолическая сердечная недостаточность, эхокардиография, натрийуртический пептид.
Актуальность. Систолическая и диастолическая сердечная недостаточность (СН) являются распространенными и дорогостоящими заболеваниями во всем мире [3, 8]. СН является одной из основных причин заболеваемости и смертности, а также прогрессирующим заболеванием, часто возникающим в результате клинически невидимых форм желудочковой дисфункции [1, 4]. Изучение проблемы сердечной недостаточности на ранних этапах ее развития вызывает особый интерес кардиологов. Появились данные о возможности ранней диагностики систолической и/или диастолической хронической сердечной недостаточности (ХСН) любой этиологии и прогнозирования возникновения неблагоприятных исходов сердечной недостаточности с помощью натрийуретического пептида [2]. Обнаружено, что систолическая дисфункция связана с повышенным риском развития симптоматической систолической сердечной недостаточности. Около 50% людей с систолической дисфункцией левого желудочка остаются не диагностированными и не получающими лечения, хотя ранняя терапия может улучшить исход [1, 6]. Считается, что диастолическая дисфункция является предшественником диастолической сердечной недостаточности, но влияние ранней терапии на риск развития симптоматической сердечной недостаточности менее четко определено. Лечение
