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Aikuisten lihavuus

Käypä hoito
22.1.2007
Suomalaisen Lääkäriseuran Duodecimin ja Suomen Lihavuustutkijat ry:n asettama työryhmä

Suosituksen tulostettava versio (pdf) «»1

Käypä hoito -tiivistelmä suomeksi «Aikuisten lihavuus»1

Potilasversio «Lihavuus aikuisilla»2

Keskeinen sanoma

  • Tämä suositus käsittelee lihavuuden hoitoa.
  • Lihavuus aiheuttaa runsaasti sairauksia, joita voidaan tehokkaasti ehkäistä ja hoitaa laihduttamalla.
  • Terveydenhuollossa lihavuuden aktiiviseen hoitoon valitaan erityisesti potilaat, joilla on
    • tyypin 2 diabetes (aikuistyypin diabetes) tai heikentynyt glukoosinsieto
    • kohonnut verenpaine
    • metabolinen oireyhtymä
    • uniapnea
    • sepelvaltimotauti
    • polviartroosi
    • astma.
  • Tavoitteena on lihavuuteen liittyvien sairauksien hoito ja ehkäisy, mihin riittää painon pysyvä pieneneminen 5–10 %:lla.
    • Tavallisin hoitomuoto on lihavuuden "perushoito", jolla tarkoitetaan usealla tapaamiskerralla toteutettua ohjausta elintapojen muutoksiin. Toteutetaan yleensä ryhmässä.
    • Muita lihavuuden hoitomenetelmiä ovat erittäin niukkaenergiainen ruokavalio (perushoidon yhteydessä), lääkehoito ja leikkaushoito.
    • Osa potilaista hyötynee perushoitoa lyhyemmästä lyhyestä interventiosta.

Tavoitteet ja kohderyhmät

  • Tämän suosituksen tavoitteena on lihavuuden hoidon tehostaminen koko terveydenhuollossa.
  • Hoitosuositus on tarkoitettu pääasiassa perusterveydenhuoltoon sekä vaikean ja sairaalloisen lihavuuden osalta myös erikoissairaanhoitoon.

Lihavuuden määritelmä ja luokitus

Taulukko 1. Lihavuuden luokitus painoindeksin (BMI) perusteella
PainoindeksiPainoluokka
18.5–24.9Normaali paino
>25Liikapaino (ylipaino)
25.0–29.9Lievä lihavuus
30.0–34.9Merkittävä lihavuus
35.0–39.9Vaikea lihavuus
40 tai yliSairaalloinen lihavuus

Lihavuuden yleisyys

Taulukko 2. Aikuisten lihavuuden yleisyys (%) eri painoindeksiluokissa Suomessa eri-ikäisillä henkilöillä (Kansanterveyslaitoksen Terveys 2000 -tutkimus) «Aromaa A, Koskinen S. Terveys ja toimintakyky Suomessa. Terveys 2000 -tutkimuksen perustulokset. Kansanterveyslaitoksen julkiaisuja B3/2002. Laskettu aineiston tietojen perusteella, henkilökohtainen t»10
MiehetNaiset
*Ilmoitetut painot, pituudet ja ympärysmitat, muissa ikäluokissa mitattu
M=miehet, N=naiset
18–29 v*30–64 v =>65 v18–29 v*30–64 v=>65 v
Painoindeksi
=>25 kg/m231.366.964.221.354.067.1
=> 306.820.519.56.221.5.28.5
=> 350.85.52.52.36.27.3
=> 400.10.80.80.52.01.7
Vyötärönympärys
M > 100, N > 90 cm6.837.237.26.235.749.0

Lihavuuteen liittyvät sairaudet ja kuolemanvaara

Laihduttamisen vaikutus sairauksien kulkuun

Psykososiaaliset tekijät ja elämänlaatu

Laihduttamisen mahdollisia haittavaikutuksia

Sappikivitauti

Painonvaihtelu (weight cycling)

Osteoporoosi

Syömishäiriöt

Hoidon tavoitteet ja yleisperiaatteet

  • Terveydenhuollossa lihavuuden hoidon tarkoituksena on ehkäistä ja hoitaa sairauksia.
  • Tavoite saavutetaan painon riittävällä vähentämisellä ja mahdollisimman pysyvällä tuloksella sekä myönteisillä elämäntapojen muutoksilla.
  • Lihavuuden hoidon tavoitteena on 5–10 %:n suuruinen pysyvä painon pieneneminen.
  • Jos potilaalla on useita lihavuuteen liittyviä sairauksia tai vaaratekijöitä, laihtuminen korjaa näitä kaikkia.
  • Sairauksien lisäksi laihtuminen parantaa elämänlaatua.
  • Huomattavaa laihtumista tärkeämpi tavoite on sairauksien lievittyminen tai ehkäisy.
  • Etenkin vaikeassa ja sairaalloisessa lihavuudessa normaalipainon (painoindeksi alle 25 kg/m2) saavuttaminen on yleensä epärealistinen tavoite eikä ole välttämätön sairauksien hoidon tai elämänlaadun parantamisen kannalta.
  • Lihavilla henkilöillä on taipumus lihoa vuosien mittaan edelleen, joten varsinkin lievästi lihavilla painon nousun ja vyötärönympäryksen suurenemisen pysäyttäminen on jo merkitsevä tulos.

Potilaiden valinta

  • Lihavuus on niin yleistä, että läheskään kaikkia liikapainoisia ei voida hoitaa terveydenhuollossa.
  • Hoitoon valitaan sellaisia henkilöitä, joille laihduttaminen ja painonhallinta ovat terveyden kannalta erityisesti hyödyksi.
  • Valintaperusteita lihavuuden hoitoon
    • Lihavuuden aste
      • mitä suurempi liikapaino sitä suurempi sairauksien vaara ja enemmän muita haittoja
    • Rasvakudoksen kertyminen vatsaonteloon
      • vyötärölihavuuteen liittyy suurempi sairastumisvaara
    • Lihavuuteen liittyvät sairaudet
      • tyypin 2 diabetes tai sen vaara (mm. heikentynyt glukoosinsieto), kohonnut verenpaine, metabolinen oireyhtymä, uniapnea; muista sairauksista esimerkiksi sepelvaltimotauti, astma ja alaraajojen nivelrikko
    • Diagnoosihetki
      • otollinen lähtökohta lihavuuden hoidolle on silloin, kun todetaan laihduttamisella paraneva sairaus (etenkin tyypin 2 diabetes)
    • Ikä
      • mitä nuorempi potilas, sitä tärkeämpää on lihavuuden hoito
      • yli 65-vuotiaiden lihavuuden hoidosta ei ole riittävästi tutkimuksia; heillä lihavuuden hoito on aiheellista vain, jos liikapaino uhkaa vakavasti toimintakykyä.

Laihduttaminen ja painonhallinta

Taulukko 3. Lihavuuden hoitomenetelmän valintaperiaatteet aikuisilla (++ ensisijainen, + mahdollinen hoitomuoto)
Painoindeksi ja lisätekijätPerushoito (ryhmä)ENED1) ja perushoito (ryhmä)Lääkehoito + ohjausLeikkaushoito + ohjaus
  1. ENED = erittäin niukkaenergiainen dieetti
  2. Tyypin 2 diabetes tai heikentynyt glukoosinsieto, kohonnut verenpaine, metabolinen oireyhtymä, uniapnea tai muut lihavuussairaudet
  3. Painoindeksi vähintään 28
25–29.9
lisäksi vyötärölihavuus tai sairauksia2)++ +3)
30–34.9+++ +
lisäksi vyötärölihavuus tai sairauksia2)++++
35–39.9++++
lisäksi sairauksia2)+++++
40 tai yli+++++
Taulukko 4. Lihavuuden perushoito: elämäntapaohjauksen osatekijät ja periaatteet.
Ohjauksen sisältöKeskeiset tavoitteet
Ruoan energiamäärän vähentäminen
  1. Tärkeintä on vähentää runsaasti rasvaa sisältävien ruokien käyttöä ja suosia vesi- ja kuitupitoisia ruokia. Terveyden kannalta on suositeltavinta vähentää kovan (tyydyttyneen) rasvan määrää.
  2. Jos potilas haluaa noudattaa tietyn energiamäärän sisältävää ruokavaliota (esim. 5.0–7.5 MJ/vrk eli 1 200–1 500 kcal/vrk), sen tulee olla koostumukseltaan monipuolinen.
  3. Yksipuolisia muotidieettejä ei suositella «Yksipuolisia muotidieettejä ei suositella»2.
Fyysisen aktiivisuuden lisääminen
  1. Fyysisen aktiivisuuden vaikutus painoon on vähäisempi laihduttamisen aikana mutta tärkeä painonhallinnassa.
  2. Päähuomio kiinnitetään päivittäisen fyysisen aktiivisuuden lisäämiseen (hyöty-, arkiliikunta).
  3. Lisäksi rohkaistaan omavalintaisen vapaa-ajan liikunnan harrastamiseen.
Ajatukset ja asenteet (kognitiiviset seikat)
  1. Keskitytään muuttamaan sellaisia ajatuksia ja mielikuvia, jotka ovat muutosten esteenä.
  2. Erityisesti käsitellään epärealistisia tavoitteita sekä "sortumiseen" ja "repsahduksiin" liittyviä ajatuksia ja tunteita.
Syömisen hallinta
  1. Parempaan syömisen hallintaan pyritään antamalla ohjausta ruoan hankinnassa tai syömiseen liittyvissä konkreettisissa tottumuksissa.
  2. Tärkeimmät muutosten kohteet: säännöllinen ateriarytmi, harkitut ruokaostokset ja syömisen houkutusten vähentäminen, syömiseen keskittyminen.

Lyhyt interventio

Perushoito

Ruokavalio

Erittäin niukkaenergiainen ruokavalio (ENE-ruokavalio)

Fyysinen aktiivisuus

Käyttäytymismuutosten ohjaaminen

Lihavuuden perushoidon vaikutus painoon

Lääkehoito

  • Suomessa lihavuuden lääkehoitoon on käytössä orlistaatti.
  • Lääkehoito sopii vain potilaille, joilla on motivaatiota laihduttaa ja muuttaa elintapojaan.
  • Lääkitys ei yleensä ole ensisijainen hoitomenetelmä, mutta sitä voidaan käyttää silloin, kun painoindeksi on vähintään 30 (tai vähintään 28, kun potilaalla on lihavuuteen liittyviä sairauksia).
  • Lääkkeitä voidaan käyttää paitsi laihduttamiseen myös painonhallinnan tukena muuten kuin lääkkeillä toteutetun laihduttamisen jälkeen.
  • Lääkehoidon yhteydessä tulee antaa riittävästi ohjausta elintapojen muuttamiseksi.
  • Silloin kun lääkehoito on tuloksellista, sitä kannattaa jatkaa riittävän pitkään laihtumistuloksen ylläpitämiseksi.
  • Useimmissa lääkehoitotutkimuksissa sekä lume- että tutkimuslääkeryhmät ovat saaneet pysyviin elintapamuutoksiin, erityisesti ruokailutottumuksiin, tähtäävää ohjausta.

Orlistaatti

Sibutramiini

Rimonabantti

Leikkaushoito

Lihavuuden hoidon järjestäminen ja työnjako terveydenhuollossa

Suomalaisen Lääkäriseuran Duodecimin ja Suomen Lihavuustutkijat ry:n asettama työryhmä

Aikuisten lihavuus -suosituksen historiatiedot «Aikuisten lihavuus, Käypä hoito -suosituksen historiatiedot»8

Puheenjohtaja:

Pertti Mustajoki, LKT, professori, sisätautien ja endokrinologian erikoislääkäri, ylilääkäri; HYKS, Peijaksen sairaala, Vantaa

Jäsenet:

Jarmo Kaukua, LT, sisätautien erikoislääkäri, kliininen opettaja; Helsingin yliopisto ja HYKS, Helsinki

Lea Annanmäki, LL, yleislääketieteen erikoislääkäri, sairaanhoidon johtaja; Martinlaakson sosiaali- ja terveyskeskus, Vantaa

Mikael Fogelholm, ETT, dosentti, johtaja; UKK-instituutti, Tampere

Paula Hakala, FT, dosentti, johtava tutkija, laillistettu ravitsemusterapeutti; Kansaneläkelaitoksen tutkimusosasto, Turku

Sirkka Keinänen-Kiukaanniemi, LKT, yleislääketieteen erikoislääkäri, professori; Oulun yliopisto, kansanterveystieteen ja yleislääketieteen laitos, Oulu

Katriina Kukkonen-Harjula, LKT, dosentti, liikuntalääketieteen erikoislääkäri, vanhempi tutkija; UKK-instituutti, Tampere (Käypä hoito -toimittaja)

Tuula Pekkarinen, LT, sisätautien erikoislääkäri, osastonlääkäri; HYKS, Peijaksen sairaala, Vantaa

Aila Rissanen, LKT, sisätautien erikoislääkäri, professori; HUS:n psykiatrian klinikka, lihavuustutkimusyksikkö, Helsinki

Sidonnaisuudet

Lea Annanmäki: Osallistunut ulkomaisiin kongresseihin eri lääkealan yritysten rahoituksella (Lundbeck, Novartis, Recip Ab).

Mikael Fogelholm: Ei sidonnaisuuksia.

Paula Hakala: Ei sidonnaisuuksia.

Jarmo Kaukua: Luentoja lääkealan yritysten tukemissa/järjestämissä koulutustilaisuuksissa (Abbott, Roche, Sanofi-Aventis). Osallistunut ulkomaisiin kongresseihin lääkealan yritysten kustantamana (Abbott, Sanofi-Aventis).

Sirkka Keinänen-Kiukaanniemi: Kutsuttuna luennoitsijana lääkealan yritysten järjestämissä / tukemissa koulutustilaisuuksissa (Novartis, Novo Nordisk, Pfizer, Sanofi-Aventis). Osallistunut ulkomaisiin kongresseihin lääkealan yritysten kustantamana. Tutkijana useissa kliinisissä lääketutkimuksissa.

Katriina Kukkonen-Harjula: Ks. www.kaypahoito.fi

Pertti Mustajoki: Konsultaatiota lääketehtaalle (AstraZeneca) motivoivasta haastattelusta vuoden 2005 lopulla ja 2006 alussa.

Tuula Pekkarinen: Osallistunut ulkomaisiin kongresseihin eri lääkealan yritysten rahoituksella (Lilly, Novartis, Novo Nordisk, Pfizer, Sanofi-Aventis)

Aila Rissanen: Kutsuttuna luennoitsijana ja tieteellisten neuvottelukuntien jäsenenä useiden lääkealan yritysten toimeksiannosta. Koordinoinut useita kliinisiä lääketutkimuksia ja osallistunut tutkijana lääketutkimuksiin.

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

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