simsuqnis marTva pirvelad jandacvaSi
simsuqnis marTva pirvelad jandacvaSi
simsuqnis marTva pirvelad jandacvaSi
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miRebulia “klinikuri praqtikis erovnuli<br />
rekomendaciebis (gaidlainebi) da<br />
daavadebaTa marTvis saxelmwifo<br />
standartebis (protokolebi) SemuSavebis,<br />
Sefasebisa da danergvis erovnuli sabWos"<br />
2009 wlis 30 dekembris #2 sxdomis<br />
gadawyvetilebis Sesabamisad<br />
<strong>simsuqnis</strong> <strong>marTva</strong> <strong>pirvelad</strong><br />
<strong>jandacvaSi</strong><br />
danarTi 1<br />
klinikuri praqtikis erovnuli rekomendacia<br />
(gaidlaini)<br />
damtkicebulia saqarTvelos Sromis,<br />
janmrTelobisa da socialuri dacvis<br />
ministris 2010 wlis 30 seqtembris<br />
# 315/o brZanebiT<br />
1
<strong>simsuqnis</strong> <strong>marTva</strong> <strong>pirvelad</strong> <strong>jandacvaSi</strong><br />
samizne populacia - klinikuri rekomendacia exeba mozardebisa da<br />
mozrdili pacientebis <strong>simsuqnis</strong> prevencias, diagnostikasa da<br />
mkurnalobas da moicavs cxovrebis wesis modificirebas, medikamentur<br />
mkurnalobas da qirurgiul Carevas. gaidlaini ar ganixilavs<br />
pediatriul populacias, magram TandarTuli aqvs sxeulis masis<br />
gamosaTvleli centiluri rukebi bavSvTa asakisTvis (danarTi 1).<br />
gamoyenebuli Semoklebebi<br />
smi – sxeulis masis indeqsi<br />
FDA<br />
– sakvebi produqtebisa da medikamentebis<br />
kontrolis sammarTvelo (Food and Drug<br />
Administration)<br />
1. daavadebis ganmarteba, sinonimebi, klasifikacia da<br />
terminologia<br />
simsuqne warmoadgens qronikul, multifaqtoruli genezis daavadebas,<br />
romelsac kompleqsuri fsiqologiuri, garemo pirobebis, socialuri,<br />
kulturuli, genetikuri, metaboluri da cxovrebis wesiT gamowveuli<br />
mizezebi da Sedegebi gaaCnia. simsuqne _ organizmSi cximis Warbad<br />
Calagebas gulisxmobs, ramac SesaZloa uaryofiTad imoqmedos adamianis<br />
janmrTelobaze.<br />
<strong>simsuqnis</strong>a da Warbi wonis ganviTarebas safuZvlad udevs qronikuli<br />
disbalansi organizmis mier miRebul da daxarjul energias Soris.<br />
energiis cvla da cximis dagrovebis intensivoba biologiur (genetikuri<br />
da hormonuli), socialur, qceviT da garemo faqtorebs Soris rTuli<br />
urTierTqmedebiT ganisazRvreba. iTvleba, rom ukanaskneli 30 wlis<br />
manZilze <strong>simsuqnis</strong> gavrcelebis swrafi mateba kulturuli da garemo<br />
faqtorebis zemoqmedebis Sedegia.<br />
Warbi masis, <strong>simsuqnis</strong> xarisxis dadgena xdeba sxeulis masis indeqsis<br />
safuZvelze (ix. Tavi `diagnozi).<br />
cxrilSi #1 mocemulia sxeulis masisa da <strong>simsuqnis</strong> klasifikacia<br />
sxeulis masis indeqsis mixedviT.<br />
2
2. epidemiologia<br />
sxeulis masisa da <strong>simsuqnis</strong> klasifikacia<br />
sxeulis masis da <strong>simsuqnis</strong> Sefaseba smi (kg/m 2 )<br />
sxeulis masis deficiti < 18,5<br />
normaluri wona 18,5-24,9<br />
Warbi wona 25,0-29,9<br />
simsuqne (I xarisxis) 30,0-34,9<br />
simsuqne (II xarisxis) 35,0-39,9<br />
morbiduli simsuqne (III xarisxis) > 40<br />
cxrili #1<br />
rogorc ganviTarebul ise ganviTarebad qveynebSi <strong>simsuqnis</strong>a da Warbi<br />
wonis epidemiologiuri gavrcelebis monacemebi sagangaSo tempiT imatebs.<br />
garemo pirobebisa da cxovrebis wesis cvlilebebi, romlebic<br />
ganpirobebulia ekonomikis ganviTarebiT, modernizaciiT da<br />
urbanizaciiT, xels uwyoben <strong>simsuqnis</strong> momatebas. <strong>simsuqnis</strong>a da Warbi<br />
wonis maCveneblebi mzardi xasiaTisaa bavSvebsa da mozrdilebSi, da am<br />
problemis Sedegad ganviTarebuli garTulebebis Sedegebi<br />
janmrTelobisTvis SeiZleba aisaxos uaxloes momavalSi.<br />
janmos monacemebiT, planetis mosaxleobis daaxloebiT 30%-s sxeulis<br />
wonis siWarbe aReniSneba. <strong>simsuqnis</strong> gavrceleba epidemiologiuri<br />
kvlevebiT sxvadaxva qveynebSi, sxvadasxva kontinentze, sxvadasxva<br />
rasebSi, mowmobs <strong>simsuqnis</strong> sakmaod farTo variabelobas, Warbi smi-is<br />
mqone pirTa umetesoba gvxvdeba zrdasrul qalebs Soris, gansakuTrebiT<br />
maRalia aSS-is Savkanian mosaxleobasa da avstraliis aborigenebSi (35-<br />
45%). smi-is sakmaod maRali maCvenebelia aSS-is TeTrkanian mosaxleobas<br />
Soris, aseve dasavleT germaniaSi. maRalia is saqarTveloSic. sxeulis<br />
masis indeqsis normis zemoT matebas Tan sdevs saerTo sikvdilobis<br />
mateba, rac ZiriTadad kardiovaskularuli sikvdilobis zrdis xarjze<br />
xdeba. (III). simsuqne aseve asocirebulia sarZeve jirkvlis, saSvilosnos,<br />
sakvercxisa da kolinjis kibos, naRvlis buStisa da saxsrebis<br />
daavadebebis momatebul riskTan. (III). Warbi wona da simsuqne, xSirad<br />
socialuri problemebis mizezi xdeba da mniSvnelovnad aqveiTebs<br />
cxovrebis xarisxs. (IV). evropis qveynebSi simsuqnesTan dakavSirebuli<br />
jandacvis danaxarjebi 7%-s Seadgens, rac kiboze daxarjul Tanxebs<br />
utoldeba (Branka, 2007).<br />
simsuqne erovnul epidemiad iqca aSS-Si, sadac samkurnalo<br />
dawesebulebebSi arahospitalizirebuli mozrdilebis 32% msuqania,<br />
3
xolo 66,3% an Warbi wonisaa an msuqania. yvelaze uaxlesi monacemebis<br />
mixedviT 12-19 wlebis asakSi myofi mozardebis 17% Warbi wonisaa da<br />
kidev 16% imyofeba Warbi wonis riskis qveS (Odgen, 2006). Eevropis<br />
qveynebSi <strong>simsuqnis</strong> gavrcelebis maCvenebeli mamakacebSi 10- 25%-s, xolo<br />
qalebSi 10-30%-s Seadgens (Branka 2007; James WP, 2008). ukanaskneli aTi<br />
wlis manZilze simsuqniT avadoba msoflioSi 10-40%-iT gaizarda.<br />
saqarTveloSi 2005 wels aRiricxa <strong>simsuqnis</strong> 2539 avadobis maCvenebeli<br />
100000 mosaxleze, maT Soris, 920 axali SemTxveva.<br />
saqarTveloSi simsuqniT daavadebulTa 69%-s aReniSneboda visceraluri<br />
simsuqne, maT Soris 55% mamakacia, xolo 45% qali.<br />
TbilisSi 2007 wels janmos xelSewyobiT aragadamdebi daavadebebis riskfaqtorebis<br />
gavrcelebis Sefasebis mizniT Catarebuli kvlevis<br />
monacemebiT, gamokvleuli 2500 piridan mxolod 34%-s hqonda normaluri<br />
wona (smi 18,5-24,9). Warbi wona aRmoaCnda 34,9%-s (smi 25-29,9). simsuqne<br />
aRiniSna respondentebis TiTqmis 1/3-Si (29,4%), ufro xSirad qalebSi.<br />
respodentTa mxolod 1,7% iyo gamxdari (smi< 18,5) da 2,6%-s (mamakacTa<br />
1,4% da qalTa 3,7%) aReniSna III xarisxis simsuqne. welis<br />
garSemowerilobis saSualo maCvenebeli qalebSi (90,2sm) aRemateboda<br />
optimalur maCvenebels, maSin, roca mamakacebSi iyo mowodebuli normis<br />
farglebSi (99,3sm.) welis garSemoweriloba mamakacTa 38,8% da qalTa<br />
54,4%-Si aRemateboda optimalur maCveneblebs. TeZos/welis<br />
garSemowerilobis maCvenebeli mamkacebSi ar aRemateba standartul<br />
maCvenebels (0,94), magram qalebSi igi optimalur maCvenebelze maRalia<br />
(0.83) (aragadamdeb daavadebaTa risk-faqtorebis kvleva saqarTveloSi<br />
2006-2007ww.).<br />
<strong>simsuqnis</strong> da masTan dakavSirebuli daavadebebis ekonomikuri zegavlena<br />
aSS-s ekonomikaze gansacvifrebelia da daaxloebiT 118 miliardi<br />
dolariT fasdeboda 1990-iani wlebis bolos, anu erovnul biujetSi<br />
jandacvaze gamiznuli biujetis daaxloebiT 12%-s Seadgenda, Tanaxmad<br />
2000 wels “Worldwatch Institute”-is mier moyvanili monacemebisa.<br />
aSS-s monacemebiT simsuqnesTan asocirebulia weliwadSi 110000 letalur<br />
SemTxvevaze meti (Flegal, 2005 [C]).<br />
4
Warb wonasa da simsuqnesTan asocirebuli daavadebebi<br />
wonis momatebasTan da simsuqnesTan erTad, mamakacebsa da qalebSi,<br />
matulobs sxvadasxva daavadebebi (ix. cxrili #2, #3) 1 .<br />
Ddaavadeba<br />
zogierTi daavadebebis avadoba mamakacebSi<br />
sxulis masis indeqsis mixedviT (smi, BMI)<br />
18,5-dan 24,9mde<br />
sxeulis masis indeqsi<br />
25-dan 29,9mde<br />
30-dan 34,9mde<br />
cxrili #2<br />
gavrcelebis koeficienti (%) (prevalensi)<br />
40-ze<br />
meti<br />
tipi 2 diabeti 2.03 4.93 10.10 10.65<br />
gulis iSemiuri<br />
daavadebebi<br />
8.84 9.60 16.01 13.97<br />
maRali arteriuli wneva 23.47 34.16 48.95 64.53<br />
osteoarTritebi 2.59 4.55 4.66 10.04<br />
daavadeba<br />
zogierTi daavadebebis avadoba qalebSi<br />
sxulis masis indeqsis mixedviT (smi, BMI)<br />
18,5-dan 24,9mde<br />
sxeulis masis indeqsi<br />
25-dan 29,9mde<br />
30-dan 34,9mde<br />
cxrili #3<br />
gavrcelebis koeficienti (%) (prevalensi)<br />
40-ze<br />
meti<br />
tipi 2 diabeti 2.38 7.12 7.24 19.89<br />
Ggulis iSemiuri<br />
daavadebebi<br />
6.87 11.13 12.56 19.22<br />
maRali arteriuli wneva 23.26 38.77 47.95 63.16<br />
osteoarTritebi 5.22 8.51 9.94 17.19<br />
wyaro: janmrTelobis da kvebis Semowmebis erovnuli mimoxilva (NHANES) III,<br />
1988-1994.<br />
1 zogierTi gamokvleva iZleva mniSvnelovan eTnikur variabelobas (Hedley, 2004 [C]; Ogden,<br />
2002 [C]).<br />
5
3. etiopaTogenezi<br />
Warbi wonis da <strong>simsuqnis</strong> ZiriTadi mizezi energetikuli disbalansia. am<br />
disbalans ganapirobebs an sakvebiT miRebuli kaloriebis siWarbe, an<br />
fizikuri aqtiurobiT daxarjuli energiis Semcireba, an orive faqtori<br />
erTad. Tu energetikuli balansi ar dairRva adamiani ar moimatebs<br />
wonaSi, miuxedavad imisa, Tu rogoria misi genetikuri da sxva monacemebi.<br />
is konkretuli mizezi, romelic energetikul disbalans gansazRvravs<br />
sadReisod sabolood dadgenili ar aris. gamokvlevaTa farTo speqtri<br />
moicavs hormonalur da metabolur kvlevebs da hipoTezebs qceviTi,<br />
fsiqologiuri, socialuri da garemo faqtorebis rolis Sesaxeb, Tumca<br />
jerjerobiT es procesi Sors aris saboloo gadawyvetilebisagan.<br />
<strong>simsuqnis</strong> risk-faqtorebs Soris aRsaniSnavia maRalkaloriuli dieta,<br />
sakvebis ulufis raodenobis gazrda, fizikuri aqtiurobis Semcireba da<br />
mjdomare cxovrebis wesi (IV, V). swored es qceviTi da garemo faqtorebi<br />
iwveven sabolood adipozuri qsovilis struqturis cvlilebasa<br />
(hipertrofia, hiperplazia, anTeba) da cximovani ujredebis sekreciis<br />
gaZlierebas, rac Tavis mxriv, safuZvlad udevs simsuqniT gamowveul<br />
metabolur da cximis masis zrdiT ganpirobebul paTologiebs.<br />
<strong>simsuqnis</strong> Camoyalibebas adreul bavSvobaSi Tan axlavs cximovani<br />
qsovilis hiperplaziis formireba, romelic xasiaTdeba adipocitebis<br />
raodenobrivi matebiT, mozrdilebSi ki cximovani ujredebis ricxvi,<br />
ZiriTadad, mudmivia da sxeulis masis matebasTan erTad xdeba<br />
adipocitebis zomebis Sesabamisi gadideba (hipertrofia).<br />
Zalze mniSvnelovania T.A. Manolio-sa da Tanaavtorebis gamokvlevebi,<br />
romlebic miuTiTeben dabadebisas bavSvebSi mcire masisa da wonis<br />
matebis dabali tempis SesaZlo prognozul mniSvnelobaze. igi SeiZleba<br />
gansazRvravdes am bavSvebSi visceraluri <strong>simsuqnis</strong> Camoyalibebis maRal<br />
albaTobas zrdasrul asakSi.<br />
4. diagnozi da Sefaseba<br />
<strong>simsuqnis</strong> diagnozi moicavs Warbi wonis da <strong>simsuqnis</strong> faqtis dadgenas<br />
sxeulis masis indeqsis da/an muclis garSemowerilobis safuZvelze da<br />
Tanmxlebi daavadebebisa da <strong>simsuqnis</strong> xelSemwyobi faqtorebis<br />
identifikacias.<br />
sxeulis masis indeqsis gamoTvla<br />
<strong>simsuqnis</strong> dadgena da xarisxis Sefaseba xdeba sxeulis masis indeqsis<br />
safuZvelze, rac wonis simaRlis kvadratTan SefardebiT gamoiangariSeba<br />
(kg/sm 2 ) (III).<br />
6
sxeulis masis indeqsis gamoTvla<br />
wona<br />
simaRle kvadratSi<br />
= kg/m 2<br />
sxeulis masis 30-ze meti indeqsi <strong>simsuqnis</strong> maCvenebelia da gulsisxlZarRvTa<br />
daavadebebis gazrdil riskze miuTiTebs.<br />
simsuqnesTan dakavSirebuli riskis Sefaseba rekomendirebulia, aseve,<br />
welis garSemowerilobis safuZvelze. welis garSemoweriloba 102sm-ze<br />
meti mamakacebSi da 88sm-ze meti qalebSi diabetisa da<br />
kardiovaskularuli avadobis gazrdil riskze miuTiTebs (IV).<br />
gamoTvaleT sxeulis masis indeqsi rogorc minimum yovelwliurad<br />
skriningisTvis da imdenjer, ramdenic saWiroa mkurnalobisas.<br />
daaxarisxeT is sxeulis masis indeqsis kategoriebis mixedviT. gaanaTleT<br />
pacientebi sxeulis masis indeqsis da masTan dakavSirebuli riskebis<br />
Sesaxeb (McTigue, 2003 [D]).<br />
sxeulis masis indeqsis Sefaseba<br />
sxeulis masis indeqsis mniSvnelobis mixedviT xdeba sxeulis masis<br />
klasificireba Semdegi kategoriebis mixedviT: sxeulis masis deficiti,<br />
normaluri masa, Warbi masa, simsuqne I xarisxis, simsuqne II xarisxis da<br />
simsuqne III xarisxis anu ukiduresi simsuqne (ix. cxrili #4).<br />
mozrdilTa sxeulis masis indeqsis kategoriebi<br />
sxeulis masis indeqsi kategoria<br />
18,5-ze naklebi sxeulis masis deficiti<br />
18,5-24,9 normaluri wona<br />
25-29,9 Warbi wona<br />
30-34,9 simsuqne _ I xarisxi<br />
35-39,9 simsuqne _ II xarisxi<br />
40 an meti morbiduli simsuqne _ III<br />
xarisxi<br />
cxrili #4<br />
7
sxeulis masis Sefaseba mozardebSi<br />
sxeulis masis indeqsi bavSvebsa da mozardebSi gamoiTvleba centilebSi,<br />
sanam bavSvi simaRleSi izrdeba. es centilebi gansazRvrulia<br />
“janmrTelobis da kvebis Sefasebis erovnuli gamokvlevis kvlevis’<br />
(NHANES) monacemebis mixedviT. Warbi wona ganisazRvreba rogorc 85%ze<br />
meti sxeulis masis indeqsi, simsuqne ganisazRvreba, rogorc 95%-ze<br />
meti sxeulis masis indeqsi, xolo <strong>simsuqnis</strong> ukiduresi forma<br />
ganisazRvreba, rogorc 99%-ze meti sxeulis masis indeqsi gamomdinare<br />
asakidan. (ix. danarTi 1 `sxeulis masis maCveneblebis da asakis Sefardeba<br />
centilebSi~.)<br />
sxeulis masis indeqsis gaangariSeba xdeba zrdis procesSi myofi pacientebisTvis,<br />
imitom rom is uzrunvelyofs saorientacio maCvenebels<br />
momavali SedarebisaTvis. marTalia, erTwliani periodisaTvis sxeulis<br />
masis indeqsis cvlilebis raime standartebi ar arsebobs, magram swrafi<br />
mateba an kleba warmoadgens klinikurad sayuradRebo niSans. gansxvaveba<br />
50 da 75 centilebs Soris igivea, rac sxeulis masis indeqsis<br />
daaxloebiT oridan sami erTeuliT sxvaoba mozardi gogonebisaTvis.<br />
mozard biWebs ki daaxloebiT sxeulis masis indeqsis ori erTeuli<br />
centiliT sxvaoba axasiaTebs. sam erTeulze meti sxeulis masis indeqsis<br />
wliuri mateba gadaWarbebul matebas gulisxmobs (Barlow, 1998 [D]).<br />
sxeulis masis indeqsis aranormalurad an swrafad cvlilebis<br />
klinikuri mniSvneloba Semdegi momentebis gaTvaliswinebiT fasdeba:<br />
sxeulis masis indeqsi ar aRwers <strong>simsuqnis</strong> formas. is gamoyvanili<br />
sidide gaxlavT, romelic karg korelaciaSia sxeulis mTlian<br />
cximTan da aris meoradi garTulebebis, magaliTad hipertenziis da<br />
dislipidemiis markeri (Barlow, 1998 [D]);<br />
Zalian maRali sxeulis masis indeqsi ar miuTiTebs sxeulSi cximis<br />
ganawilebaze. centraluri an visceraluri (Sida organoebis) cximi<br />
daavadebisa da sikvdilis ufro did risks warmoadgens;<br />
welis garSemoweriloba warmoadgens kidev erT damatebiT monacems<br />
visceraluri <strong>simsuqnis</strong>a da klinikuri riskis SefasebisaTvis;<br />
metabolizmis Sefaseba mniSvnelovania riskis qveS myofi<br />
pacientebisTvis, gansakuTrebiT Tu saxezea gulis daavadebis<br />
ojaxuri anamnezi an Saqriani diabeti tipi 2;<br />
mozardebis simsuqnesTan dakavSirebuli klinikuri daavadebebi<br />
naCvenebia me-5 cxrilSi:<br />
8
cxrili #5<br />
mozardebis simsuqnesTan dakavSirebuli klinikuri daavadebebi*<br />
istoria fizikuri daavadeba<br />
Seferxeba<br />
ganviTarebaSi<br />
dismorfuli<br />
Taviseburebebi<br />
zrdaSi CamorCena Ddabali tanadoba<br />
RamiT sunTqvis<br />
gaZneleba<br />
varjiSis<br />
gaZneleba<br />
“akantozis<br />
nigrikans”<br />
(imigranti)<br />
barZayis/muxlis<br />
tkivili<br />
amenorea<br />
Tavis tkivilebi<br />
muclis tkivilebi<br />
gadidebuli nuSurebi<br />
genetikuri moSliloba, magaliTad<br />
prader-uilis sindromi, lourens<br />
mun-bidlis sindromi<br />
hipoTireoidizmi, kuSingi, zrdis<br />
hormonebis deficiti<br />
Zilis apnoe, hipoventilaciuri<br />
sindromi<br />
mstvenavi sunTqva asTma<br />
akantokeratodermia<br />
barZayis areSi<br />
moZraobis SezRudva<br />
hirsutizmi (WarbTmianoba)akantokeratodermia,<br />
insulini-<br />
sadmi rezistentoba<br />
Tvalis optikuri<br />
diskis cvlilebebi<br />
Mmuclis marjvena<br />
zeda<br />
kvadrantis<br />
mgrZnobeloba<br />
insulinisadmi rezistentoba,<br />
Saqriani diabeti tipi2.<br />
barZayis Zvlis mTliani<br />
epifizolizi<br />
polikistozuri sakvercxeebis<br />
sindromi<br />
Tavis tvinis fsevdo simsivne<br />
naRvlis buStis daavadeba<br />
* aseve mozardTa simsuqnesTan dakavSirebuli metad mniSvnelovani klinikuri niSnebia<br />
depresia, SfoTva, kvebis moSliloba da sqesobrivi Zaladoba da unda Sefasdes<br />
ganwyobis disfunqciebis, saskolo warmatebebis, TanatolebSi urTierTobis da kvebis<br />
tipebTan mimarTebaSi.<br />
9
welis garSemoweriloba<br />
klinicistebs SeuZliaT gamoiyenon welis garSemoweriloba rogorc<br />
visceraluri <strong>simsuqnis</strong> sazomi. 102 sm an meti welis garSemowerilobis<br />
mqone mamakacebi an 88 sm an meti welis garSemowerilobis mqone qalebi<br />
arian kardiovaskularuli daavadebebis da sxva daavadebebis (rogoricaa<br />
Zilis darRvevebi da diabeti) gazrdili riksis mqoneni (Lean, 1998 [D]).<br />
sxeulis masis indeqsi iZleva informacias <strong>simsuqnis</strong> Sesaxeb, magram es<br />
informacia SeiZleba Seivsos damatebiTi informaciiT welis<br />
garSemowerilobis Sesaxeb. naCvenebi iyo, rom sxeulis masis indeqsi<br />
warmoadgens janmrTelobis mdgomareobis zust winaswar ganmsazRvrels,<br />
xolo momatebuli sxeulis masis indeqsi zrdis kardiovaskularuli<br />
daavadebebis, kardiovaskularuli sikvdilis, zogadi letalobis,<br />
Saqriani diabetis tipi 2-is, Zilis darRvevebis da uamravi sxva<br />
klinikuri daavadebis risks (Balkau, 2007 [D]). momatebuli welis<br />
garSemoweriloba aseve winaswar gvamcnobs paTologiebis umravlesobis<br />
Sesaxeb (Balkau, 2007 [D]; Davidson, 2008 [D]). amJamad debatebi mimdinareobs<br />
imis Taobaze, warmoadgens Tu ara welis garSemoweriloba damatebiT<br />
informacias, rodesac izomeba sxeulis masis indeqsTan erTad. aris<br />
garkveuli faqtebi imisa, rom pacientTa zog qvejgufSi welis<br />
garSemoweriloba iZleva damatebiT informacias janmrTelobis momavali<br />
mdgomareobis Sesaxeb (Janssen, 2002 [D]; Koster, 2008 [D]).<br />
Tumca, arsebobs xarjebi, romlebic dakavSirebulia rogorc sxeulis<br />
masis indeqsis, aseve welis garSemowerilobis regularul gazomvasTan.<br />
sxeulis masis indeqsis gazomva moiTxovs maTematikur gamoTvlas,<br />
romelic simaRlesa da wonazea damyarebuli. amrigad, sxeulis masis<br />
indeqsi SeiZleba avtomaturad iqnes gamoTvlili eleqtronuli<br />
samedicino Canawerebis (EMR) sistemis farglebSi. welis<br />
garSemowerilobis gazomva ki moiTxovs damatebiT dros <strong>pirvelad</strong><br />
<strong>jandacvaSi</strong>, amitom gazomvebi SeiZleba arazusti an cvalebadi iyos.<br />
saWiroa klinikebis personalis im wevrTa sistematuri swavleba,<br />
romlebic awarmoeben welis garSemowerilobis gazomvas (Panoulas, 2008 [C]).<br />
am kuTxiT, sxeulis masis indeqsis monacemebis sistematuri da<br />
perioduli Sefaseba da am informaciis gamoyeneba sasargebloa riskebis<br />
Sefasebisa da intervenciis warmarTvisaTvis. samuSao jgufis azriT,<br />
welis garSemowerilobis gazomva gamosadegia konkretul klinikur<br />
SemTxvevebSi, magram is ar SeiZleba gamoyenebul iqnes rogorc<br />
rutinuli, klinikaze dafuZnebuli RonisZieba, sanam ar iqneba damatebiTi<br />
monacemebi, Tu ramdenad sasargebloa welis garSemoweriloba, rogorc<br />
klinikuri niSani da ar iqneba damtkicebuli, rom damatebiTi xarjebi<br />
standartul (rutinul) safuZvelze Catarebuli welis<br />
garSemowerilobis gazomvebisaTvis gadaiqceva klinikur sargeblad<br />
maRali sxeulis masis indeqsis mqone pacientTaTvis, an maTTvis, visac<br />
normaluri sxeulis masis indeqsi aqvT (Freiberg, 2008 [C]; Klein, 2007 [R]).<br />
10
welis garSemoweriloba warmoadgens damatebiT risk-faqtors<br />
simsuqnesTan dakavSirebuli garTulebebisaTvis im mamakacebSi,<br />
romelTaTvis miRebuli sidide 102 sm toli an metia, da im qalebisTvis,<br />
romelTaTvis miRebuli sidide 88 sm toli an metia. marTalia, samuSao<br />
jgufs Segnebuli aqvs welis garSemowerilobis gazomvisas<br />
aRmocenebuli potencialuri sirTuleebi, faqtebi gviCvenebs welis<br />
garSemowerilobis gazomvis mniSvnelobas sxva risk-faqtorebis<br />
arsebobis gamo (Lean, 1998 [D]; Yusuf, 2005 [C]).<br />
welis garSemowerilobis gazomva<br />
welis garSemowerilobis gazomvisaTvis daadgineT barZayis Zvlebis zeda<br />
(barZayis Zvlebis Tavebi) adgilmdebareoba. ganaTavseT santimetri<br />
horizontalur sibrtyeSi muclis garSemo TeZos garSemowerilobis<br />
doneze. santimetris monacemebis wakiTxvamde darwmundiT, rom is<br />
mWidrodaa midebuli, magram ar awveba kans da iatakis paraleluria.<br />
gazomva keTdeba normaluri amosunTqvis bolos. (wyaro: gulis, filtvisa<br />
da sisxlis erovnuli instituti).<br />
Tanmxlebi daavadebebis Sefaseba<br />
sakvanZo punqtebi:<br />
mniSvnelovania sxva daavadebebis Sefaseba, vinaidan maTma arsebobam<br />
SeiZleba gavlena moaxdinos mkurnalobasTan dakavSirebul<br />
gadawyvetilebebsa da Sedegebze;<br />
welis garSemoweriloba, romelic 102 sm toli an metia mamakacebSi<br />
da 88 sm toli an metia qalebSi, warmoadgens damatebiT riskfaqtors<br />
simsuqnesTan dakavSirebuli garTulebebisaTvis;<br />
depresiebisaTvis da kvebis darRvevebisaTvis, Tu SesaZlebelia,<br />
unda Catardes mokle skriningi;<br />
Sefaseba unda moicavdes srul samedicino anamnezs, raTa moxdes im<br />
medikamentebis identificireba, romlebmac SeiZleba gamoiwvion<br />
wonis momateba an wonis klebis Seferxeba.<br />
11
Tanmxlebi<br />
daavadebebi<br />
0<br />
1-2<br />
nakleb<br />
mniSvnelovani<br />
Tanxmlebi<br />
daavadeba<br />
mniSvnelovani<br />
Tanmxlebi<br />
daavadebebi an<br />
3 nakleb<br />
mniSvnelovani<br />
Tanmxlebi<br />
daavadeba<br />
Tanxmlebi daavadebebis Sefaseba<br />
sxeulis wonis indeqsi (smi)<br />
25-30 30-35 35-40 40+<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
medikamenturi<br />
Terapia<br />
mxolod BMI-s 27ze<br />
meti indeqsis<br />
mqone<br />
pacientTaTvis<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
medikamenturi<br />
Terapia<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
*medikamenturi<br />
Terapia<br />
konsultirebaganaTleba:<br />
cxovrebis<br />
wesis Secvla<br />
qcevis<br />
menejmenti<br />
medikamenturi<br />
Terapia<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qcevis menejmenti<br />
medikamenturi<br />
Terapia<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qcevis menejmenti<br />
medikamenturi<br />
Terapia<br />
qirurgiuli Careva<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qccevis menejmenti<br />
medikamenturi<br />
Terapia<br />
qirurgiuli Careva<br />
naklebad mniSvnelovani Tanmxlebi daavadebebi<br />
cxrili #6<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qcevis menejmenti<br />
medikamenturi<br />
Terapia<br />
qirurgiuli Careva<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qcevis menejmenti<br />
medikamenturi<br />
Terapia<br />
qirurgiuli Careva<br />
konsultirebaganaTleba:<br />
cxovrebis wesis<br />
Secvla<br />
qcevis menejmenti<br />
medikamenturi<br />
Terapia<br />
qirurgiuli Careva<br />
sigaretis moweva<br />
hipertenzia (sisxlis wneva 140/90-ze meti an toli) an<br />
antihipertenziuli saSualebebis mimdinare moxmareba+<br />
LDL-qolesterini > 130mg/100ml<br />
HDL-qolesterini
mniSvnelovani Tanmxlebi daavadebebi<br />
welis garSemoweriloba (mamakacebi 102 sm, qalebi 88 sm).+<br />
dadgenili koronaruli arteriuli daavadeba<br />
_ anamnezSi miokardiumis infarqti<br />
_ anamnezSi angioplastika<br />
_ anamnezSi aortokoronaruli Suntireba<br />
_ anamnezSi mwvave koronaruli sindromebi<br />
periferiuli vaskularuli daavadebebi<br />
muclis aortis anevrizma<br />
saZile arteriis daavadeba<br />
Saqriani diabeti, tipi 2<br />
obstruqciuli Zilis apnoe.<br />
* termini prediabeti bolo dros iyo adaptirebuli amerikis diabetis asociaciis da<br />
sxvebis mier, da exeba imaT, visac aqvs uzmoze glukozis done 100 mg/ml-dan 125 mg/mlmde,<br />
aseve imaT, visac glukozis tolerantobis testis sidide 140 mg/ml-dan 200 mg/mlmde<br />
aqvT (75gr. GglukoziT datvirTvis 2 saaTis Semdeg.)<br />
+ am simptomebis dajgufeba aRwerilia rogorc metaboluri sindromi. arsebobs<br />
ramodenime formaluri gansazRvreba (de Ferranti, 2004 [C]; National Heart, Lung and Blood Institute,<br />
2003 [R]; World Health Organization, 2004 [R]; d.virsalaZe-“metabuluri sindromi _realoba da<br />
perspeqtivebi.” 2001w.)<br />
depresiis skriningi<br />
faqtebi, romlebic gviCvenebs kavSirs depresiasa da simsuqnes Soris,<br />
erTob Sereulia (DiPietro, 1992 [B]; Friedman, 1995 [D]; Jorm, 2003 [D]; Roberts, 2003<br />
[B]). depresia aRmoCenilia Zalian msuqan adamianebSi, gansakuTrebiT<br />
axalgazrda, sxeulis ulamazo formis mqone qalbatonebSi (Dixon, 2003 [C];<br />
Onyike, 2003 [D]). Zneli gamosakvlevia, meoradia Tu ara depresia<br />
<strong>simsuqnis</strong>aTvis an arsebuli Tanmxlebi daavadebisaTvis (Stunkard, 2003 [R]).<br />
wonis dakargva xSirad iwvevs depresiis maCveneblebis gaumjobesebas (Dixon, 2003 [C]).<br />
depresia ufro xSirad gvxvdeba msuqan qalebSi da TineijerebSi da<br />
SedarebiT naklebad mamakacebSi (Istvan, 1992 [D]; Jorm, 2003 [D]; Palinkas, 1996<br />
[C]; Stunkard, 2003 [D]). xandazmulebSi depresia xSirad asocirdeba wonis<br />
dakargvasTan, maSin roca axalgazrda qalebSi is SeiZleba<br />
dakavSirebuli iyos wonis matebasTan (DiPietro, 1992 [B]).<br />
depresia asocirebulia wonis daklebis cud SedegebTan (Linde, 2004 [C]).<br />
depresiis an SfoTviTi diagnozis mqone pacientebi, romelnic itareben<br />
bariatriul qirurgiul Carevas, imyofebian wonis aRdgenis didi riskis<br />
qveS, operaciis Semdgom, pirveli xuTi wlis periodis ganmavlobaSi<br />
(Waters, 1991 [D]). es fenomeri SeiZleba aixsnas rigi kvlevebiT, romelnic<br />
ikvlevdnen kavSirebs depresiul simptomebsa da momatebul simsuqnesa da<br />
13
wonis zrdas Soris. (Miller, 2003 [C]). mizanSewonilia meti gamokvlevebis<br />
Catareba am sakiTxTan mimarTebaSi.<br />
depresiis skriningi moicavs kiTxvebs:<br />
bolo Tvis ganmavlobaSi:<br />
dagikargavT Tu ara interesi an siamovneba raRacis keTebisas?<br />
cudi guneba_ganwyoba, uimedoba?<br />
Tu pacientebi dadebiTad pasuxoben zemoT moyvanili kiTxvebidan erTs<br />
mainc, unda Sefasdes misi Semdgomi klinikuri Sefasebis aucilebloba<br />
Rrma depresiaze.<br />
kvebis darRvevebis skriningi<br />
bulemiam (momatebuli madis fonze Warbma kvebam), gansakuTrebiT impulsurma<br />
gaumaZRrobam (Wamis arazomierma moTxovnilebam) SeiZleba<br />
gaarTulos <strong>simsuqnis</strong> mkurnaloba.<br />
kvebis darRvevebis skriningi SeiZleba moicavdes Semdeg kiTxvebs:<br />
migiRiaT Tu ara saWmeli didi raodenobiT drois mokle<br />
periodSi _ anu iRebT Tu ara met sakvebs?<br />
agrZelebT Tu ara Wamas danayrebis Semdeg?<br />
rodesac zedmet sakvebs miiRebT, ras akeTebT (magaliTad, xom ar<br />
gicdiaT `moiSoroT~ Tqvens mier Wamisas miRebuli zedmeti<br />
kaloriebi, safaRaraTo saSualebebis miRebiT? diuretikebis<br />
(Sardmdeni tabletebis) miRebiT? sigaretis moweviT? narkotikebis,<br />
magaliTad kokainis an meTamfetaminis miRebiT? Rebinebis<br />
gamowveviT?<br />
Tu pacienti zemoT mocemuli kiTxvebidan erTze mainc dadebiTad<br />
pasuxobs, unda daigegmos momdevno viziti an mimarTvis sakiTxi<br />
dietologTan an fsiqologTan, romelic specializirebulia kvebis<br />
darRvevebze an kvebis fsiqologiaze.<br />
medikamentebi, romelic xels uwyobs wonis momatebas<br />
msuqani pacientebis Sefaseba unda moicavdes srul samedicino anamnezs<br />
im medikamentebis Sesaxeb, romelmac SesaZloa gamoiwvios wonis momateba<br />
an wonis daklebis Sewyveta. arasteroiduli anTebissawinaaRmdego<br />
wamlebi da kalciumis arxis blokerebi ufro periferiul SeSupebas<br />
iwveven, vidre sxeulis wonis momatebas. aiv-proTeazis inhibitori<br />
asocirebulia lipodistrofiasTan (centralur simsuqnesTan), vinaidan es<br />
realurad cvlilebaa ufro sxeulis cximis ganawilebaSi, vidre sxeulis<br />
wonis momateba. Tu SesaZlebelia, unda SeirCes alternatiuli<br />
medikamenturi mkurnaloba romelic wonis matebasTan mimarTebaSi<br />
neitraluria an romelic wonis klebas iwvevs (Ganguli, 1999 [D]; Kushner,<br />
14
2003b [D]; Vanina, 2002 [D]). qalebsa da klinicistebSi zogadad arsebobs<br />
rwmena imisa, rom aris kavSiri hormonaluri kontraceptivebis<br />
kombinaciis gamoyenebasa da wonis momatebas Soris. amis gamo SeiZleba<br />
zogierTi qali Tavs aridebdes hormonaluri kontraceptivebis miRebis<br />
dawyebas an medikamenturi mkurnalobis naadrev Sewyvetas. 42 klinikuri<br />
kvleviT (maT Soris sami SemTxveva-kontrolirebadi, placebo_<br />
kontrolirebadi) uaxlesma mimoxilvam ver aRmoaCina pirdapiri kavSiri<br />
oraluri kontraceptivebis miRebasa da wonis matebas Soris. kvlevis<br />
avtorebi mividnen daskvnamde, rom arsebuli faqtebi arasakmarisia,<br />
imisaTvis, rom dadgindes kontracepciis gavlena wonaze, Tumca mcire<br />
mateba mainc aSkaraa (Gallo, 2004 [D]). (ix. danarTi 2)<br />
antidiabeturi medikamenturi mkurnaloba<br />
ramdenime meqanizmi, romelic xels uwyobs wonis matebas, asocirebulia<br />
antidiabetur preparatebTan, maT Soris:<br />
hiperglikemiis koreqcia, romelsac mivyavarT kataboluri<br />
mdgomareobis aRmofxvramde da cximis aRdgenamde;<br />
hiperglikemiis koreqcia, romelsac mivyavarT glukozuriis<br />
aRmofxvramde da kaloriebis Semcirebamde, romlebic manamde<br />
ikargeboda;<br />
hipoglikemia, romelic gamoixateba madis stimulirebiT;<br />
insuliniT gamowveuli (endogenuri da egzogenuri) lipolizis<br />
Seferxeba da lipogenezis stimulireba;<br />
adipocitebis (cximis ujredebi) diferenciacia;<br />
siTxis Sekaveba da SeSupeba.<br />
insulini<br />
ramdenime xanmokle da grZelvadianma kvlevam daadgina insulinis kavSiri<br />
wonis matebasTan. diabetis kontrolis da garTulebis kvlevam (DCCT)<br />
aCvena, rom insuliniT intensiuri mkurnaloba iwvevs wonis mniSvnelovan<br />
momatebas tradiciul TerapiasTan SedarebiT. (The Diabetes Control and<br />
Complications Trial Research Group, 1993 [A]). xuTi wlis mkurnalobis intensiuri<br />
kursis Catarebis Semdeg jgufSi Semavali pacientebi imatebdnen<br />
saSualod 4,6 kg-ze mets, vidre tradiciuli Terapiis jgufSi. wonis<br />
mateba grZeldeboda DCCT-is kohortaze momdevno dakvirvebisas da bevr<br />
pacients gamouvlinda metaboluri sindromis damaxasiaTebel niSnebi<br />
(Purnell, 1998 [A]; Williams, 1999 [B]).<br />
insulinis sekreciis stimulatori<br />
wonis mateba warmoadgens nateglinidiT da repaglidiniT mkurnalobis<br />
kargad cnobil gverdiT efeqts.<br />
15
metformini<br />
metformini warmoadgens naxSirwylovani cvlis maregulirebel<br />
medikaments, magram ufro xangrZlivi miRebisas is realurad wonis<br />
mimarT neitraluri gaxlavT. Mmetformini gamoiyeneba upiratesad msuqan<br />
pacientebSi antidiabetur preparatebTan kombinaciaSi,. (Fonseca, 2000b [A]).<br />
metforminis da Tiazolidindionebis kombinaciam SeiZleba Seamciros<br />
wonis mateba, romelic asocirebulia TiazolidindionTan (Fonseca, 2000b<br />
[A]; Gomez-Perez, 2002 [A]). insulinTan kombinaciaSi metformini iwvevs<br />
glikohemoglobinis (HbA1c) maCveneblis regulacias da wonaSi naklebad<br />
momatebas, vidre insuliniT monoTerapia (Avilés-Santa, 1999 [A]; Yki-Järvinen,<br />
1999 [A]).<br />
α-glukozidazis inhibitorebi<br />
α-glukozidazis inhibitorebi (magaliTad, akarboza da miglitoli)<br />
aferxeben naxSirwylebis Sewovas wvril nawlavSi, rac gamoixateba Wamis<br />
Semdgomi postprandialuri glikemiis donis SemcirebaSi. es preparatebi<br />
ar asocirdeba wonis matebasTan.<br />
Tiazolidindionebi<br />
klinikuri kvlevebis meSveobiT dadginda, rom TiazolidindionebiT<br />
mkurnaloba SeiZleba asocirebuli iqnes wonis matebasTan (Fonseca, 2003<br />
[R]). Tumca, glikemiis kontroli da insulinis mimarT mgrZnobeloba<br />
umjobesdeba Tiazolidindionebis Terapiisas. arsebobs dadebiTi<br />
korelacia sxeulis wonis matebas, Tiazolidindionebis gamoyenebasa da<br />
HbA1c-s Semcirebas Soris. wonis mateba aSkarad stabiluri xdeba HbA1c-s<br />
sawyisi Semcirebis Semdeg (Fonseca, 2003 [R]). yvelaze mkveTri wonis mateba<br />
xdeba maSin, roca Tiazolidindionebi gamoiyeneba insulinTan an sS<br />
(sulfanilSardovanasTan) kombinaciaSi da naklebia, rodesac gamoiyeneba<br />
monoTerapiisas an metforminTan kombinaciaSi (Fonseca, 2000b [A]).<br />
TiazolidindionebiT gamowveuli wonis matebis meqanizmebi<br />
lipogenezis receptorTa SeboWva, cximis ujredebis proliferacia,<br />
cximis gadanawileba kanqveSa cximis qsovilis momatebiT da<br />
visceruli cximis Semcvelobis Semcireba;<br />
leptinebis produqciis Sekaveba da momatebuli mada;<br />
Semcirebuli glukozuria da kaloriebi;<br />
mkacri dietis darRveva;<br />
siTxis Sekaveba da SeSupeba TirkmelSi natriumis rezorbciis<br />
stimulaciiT, simpaTikuri nervuli sistemis momatebuli aqtiuroba<br />
da qsovilSi ionTa Secvlili tranportireba.<br />
wonis momatebis minimalizirebasTan dakavSirebuli intervencia, romelic<br />
asocirebulia Tiazolidindionebis gamoyenebasTan<br />
16
swavleba (ganaTleba) kvebis da fizikuri aqtiurobis Sesaxeb<br />
medikamenturi mkurnalobis daniSvnisas;<br />
kaloriebis SezRudva maRali riskis mqone pacientebSi, rogoricaa<br />
gansakuTrebiT msuqani adamianebi, romlebic ver axerxeben fizikur<br />
aqtiurobaSi monawileobas, aqtiurobas da romlebic erTdroulad<br />
Rebuloben insulins da sulfanilSardovanas;<br />
dabalkaloriuli dieta metforminiT, daniSnulisamebr.<br />
wonis mateba xdeba diabetis medikamenturi mkurnalobis umetes<br />
SemTxvevaSi. wonis momateba zogadad asocirebulia<br />
TiazolidindionebTan da SeiZleba gakontroldes dieturi CareviT<br />
(Asnani, 2003 [D]). marTalia, Tiazolidindionebma SeiZleba gamoiwvios<br />
wonis mateba, magram mas aseve SeuZlia gaaumjobesos insulinis mimarT<br />
mgrZnobeloba da xeli Seuwyos cximis sasurvel gadanawilebas.<br />
metforminisa da Tiazolidindionebis kombinacia ar iwvevs damatebiT<br />
wonis matebas da SeiZleba damatebiTi efeqti iqonios insulinis mimarT<br />
mgrZnobelobaze (Fonseca, 2003 [D]).<br />
fsiqotropuli medikamentebi, romlebic asocirebulia wonis<br />
matebasTan<br />
zogierTi medikamenti, romlebic zogadad gamoiyeneba fsiqozis,<br />
depresiis da epilefsiis mkurnalobisas, iwveves wonis mniSvnelovan<br />
momatebas. wonis matebam SeiZleba uaryofiTi gavlena iqonios pacientis<br />
mier reJimis dacvaze. antifsiqotropuli (neiroleptikuri) saSualebebi,<br />
rogoricaa risperidoni, sertindoli, olanzapini da klozapini, iwveven<br />
wonis momatebas diapazonSi 2,1-4,5 kg Terapiis 10 dRiani kursis Semdeg.<br />
cnobilia, rom ziprazidoni iwvevs mxolod wonis mcire momatebas<br />
(0,04kg), wonis matebis ganmapirobebeli meqanizmi jerjerobiT ucnobia<br />
(Allison, 1999 [D]).<br />
<strong>simsuqnis</strong>a da diabetis dros, rekomendebulia wonis monitoringi 4, 8 da<br />
12 kviris ganmavlobaSi neiroleptikuri Terapiis dawyebis an Secvlis<br />
SemTxvevaSi, da Semdeg kvartalSi erTxel regularulad. Tu pacienti<br />
sakuTari wonis 5%-s an ufro bevrs imatebs, maSin unda ganixilebodes<br />
preparatebis Secvlis varianti (American Diabetes Association, 2004 [D]).<br />
antidepresantebs Soris mniSvnelovani wonis matebis riski yvelaze<br />
maRalia triciklur, monoaminoqsidazas inhibitorebsa da mirtazapinis<br />
SemTxvevaSi (Fava, 2000 [D]; Masand, 2000 [D]). nefazodoni TiTqosda wonis<br />
mimarT neitraluria, xolo bupropionis Sesaxeb cnobilia, rom is iwvevs<br />
wonis mcireoden klebas. (Croft, 2002 [A]).<br />
cnobilia, rom epilefsiis sawinaaRmdego valproati (Isojärvi, 1996 [C]) da<br />
gabapentini (De Toledo, 1997 [D]) iwveven wonis gansakuTrebul momatebas.<br />
lamotrigini savaraudod wonis mimarT neitraluria. 32 kvirian kvlevebSi<br />
lamotriginma gamoiwvia wonis saSualo momateba 0,6 kg-mde valproatis<br />
17
SemTxvevaSi 5,8 kg-is momatebasTan SedarebiT (Biton, 2001 [A]). marTalia,<br />
saWiroa momdevno kvlevebis Catareba, magram topiramati, rogorc Cans,<br />
aris unikaluri epilefsiis sawinaaRmdego saSualeba, romelic<br />
realurad iwvevs wonis Semcirebas. arakontrolirebadi erTwliani<br />
kvlevisas gamovlinda, rom msuqani pacientebi (sxeulis masis indeqsi 30ze<br />
meti), romlebmac daasrules erTwliani Terapiis kursi, ganicdidnen<br />
wonis saSualo klebas 4,2 kg-mde (4,3% ZiriTadidan) 3 Tvis Semdeg da 10,9<br />
kg-mde (11,0%) erTi wlis ganmavlobaSi (Ben-Menachem, 2003 [D]). aSkaraa, rom<br />
am preparatebs Soris gakeTebul arCevans SeuZlia didi zemoqmedebis<br />
moxdena pacientTa wonis kontrolze (Weiglss, 2003 [D]).<br />
5. Warbi wonis da <strong>simsuqnis</strong> mkurnaloba da xangrZlivi<br />
meTvalyureoba<br />
optimaluri wonis SenarCuneba, Warbi wonisa da <strong>simsuqnis</strong> <strong>marTva</strong> da<br />
mkurnaloba moiTxovs pacientis Rrma motivacias, gulmodgine Sromas da<br />
eqimTan mWidro TanamSromlobas.<br />
Warbi wonisa da <strong>simsuqnis</strong> mkurnaloba da <strong>marTva</strong> moicavs cxovrebis<br />
wesis Secvlis RonisZiebebs da medikamentur mkurnalobas.<br />
pacientis mzadyofnis Sefaseba<br />
pacientis mzadyofnis Sefaseba saSualebas iZleva ganvsazRroT<br />
misi motivaciis done, rac gvexmareba komunikaciis ukeT<br />
war<strong>marTva</strong>Si;<br />
pacients evaleba dasaxos realuri, miRwevadi miznebi da iyos<br />
pasuxismgebeli axal qcevaze, romlis meSveobiTac xorcieldeba<br />
wonis dakleba da SenarCuneba.<br />
cxovrebis wesis Secvla<br />
wonis <strong>marTva</strong> xelovnebaa. pacientma unda dasaxos miRwevadi miznebi da<br />
pasuxismgeblobiT moekidos mis miRwevas. wonis warmatebuli marTvisTvis<br />
mniSvnelovania konkretuli qcevis progresis Sesaxeb Canawerebis<br />
warmoeba an TviTmonitoringi. kaloriebis Semcirebis strategia<br />
gulisxmobs sakvebSi meti xilisa da bostneulis gamoyenebas, misaRebi<br />
kaloriebis da ulufis Semcirebas, jansaRi arCevanis gakeTebas maRaziis<br />
daxlTan da sazogadoebriv adgilebSi. aucilebelia procesSi<br />
yoveldRiurad meti fizikuri aqtiurobis CarTva.<br />
pacientebma da eqimebma unda gaacnobieron, rom naklebi kveba da meti<br />
fizikuri aqtiuroba dRevandel droSi Zalian wasaxalisebelia, procesi<br />
advili dasaZlevia, Tu pacients swams, rom aqvs nebisyofa. cudia Tu is<br />
18
fiqrobs, rom unda Sewyvitos Tavisi sayvareli yvela produqtis miReba<br />
da saaTobiT akeTos mosawyeni varjiSi.<br />
eqimma unda ixelmZRvanelos `5 A~-s principiT (Ask-SeekiTxe, Advise-urCie,<br />
Assist-daexmare, Assess-Seafase, Arrange-monitorireba gauwie). warmatebuli<br />
marTvis misaRwevad metad efeqturia procesSi eqimis CarTva, mas SeuZlia<br />
mniSvnelovani zegavlenis moxdena.<br />
Ask - SeekiTxe da Seafase wona/simaRle. pacients, umjobesia sawyis<br />
etapze ganesazRvros wona da gamoeTvalos sxeulis masis indeqsi.<br />
pacientebi informirebuli unda iyvnen TavianTi sxeulis masis<br />
indeqsis da riskis statusis Sesaxeb;<br />
Advise - urCieT wonaSi dakleba. garkveviT, mkveTrad, magram<br />
delikaturad aiZuleT yvela Warbi wonis mqone an msuqani pacienti<br />
wonaSi daiklos;<br />
Assess - SeafaseT wonaSi daklebisaTvis mzadyofna. yvela Warbi<br />
wonis mqone an msuqan pacients SeekiTxeT mzad aris Tu ara igi<br />
wonaSi daklebis mcdelobisaTvis, magaliTad momdevno 30 dRis<br />
ganmavlobaSi;<br />
Assist - daexmare wonaSi daklebis mcdelobaSi. daexmareT pacients<br />
wonaSi daklebis gegmis SemuSavebaSi. aswavleT Sesabamisi wyaroebi;<br />
Arrange - monitorireba gauwie. dagegmeT Semdgomi viziti adgilze<br />
an telefonis meSveobiT.<br />
ASK-SeekiTxe<br />
SeekiTxeT da gansazRvreT simaRle, wona da gamoTvaleT sxeulis masis<br />
indeqsi.<br />
ADVICE-urCieT wonaSi dakleba<br />
normaluri wonis mqone pacientebs unda vurCioT jansaRi kveba da<br />
fizikuri aqtiuroba, raTa samomavlod Tavidan aviciloT Warb wonasTan<br />
dakavSirebuli problemebi. Tu pacients aReniSneba Warbi wona an<br />
simsuqne, eqimi valdebulia Riad esaubros mas aRniSnuli problemis<br />
Sesaxeb da misces wonis daklebis rekomendaciebi. kvlevebiT dadgenilia,<br />
rom eqimis mier micemuli rekomendaciebis fonze wonaSi daklebis<br />
mcdeloba ufro martivad miiRweva. wonaSi daklebis warmatebuli<br />
mcdelobis SemTxvevebi samjer ufro meti iyo im pacientebTan SedarebiT,<br />
romlebsac eqimisgan ar miuRiaT rekomendaciebi aRniSnul problemasTan<br />
dakavSirebiT (Abid, 2005[M]). Semdgom mniSvnelovan etaps warmoadgens<br />
pacientis CarTva diskusiaSi, romelic misi motivaciis mimdinare dones<br />
exeba.<br />
ASSESS –SeafaseT wonaSi daklebis cvlilebisadmi mzadyofna<br />
gamomdinare iqidan, rom ar arsebobs cvlilebis etapis ganmsazRvreli<br />
zusti mtkicebuleba, pirovnebis mzadyofnis Sefaseba wonaSi daklebasTan<br />
mimarTebaSi dasaxuli miznis miRwevis mniSvnelovan etaps warmoadgens.<br />
19
arsebobs mtkicebuleba, rom wonaSi daklebis procesSi e.w. “moqmedebis”<br />
etapSi gadasvla da/an xangrZlivi droiT darCena wonis mxriv ukeTesi<br />
maCveneblebis gamovlenas uwyobs xels. magaliTad, proCaskam da misma<br />
kolegebma aRmoaCines, rom rac ufro adre miaRwies pacientebma am etaps,<br />
miT ufro warmatebuli aRmoCndnen isini mkurnalobis bolos (Prochaska,<br />
1992 A). Tumca, sxva avtorebma ver aRmoaCines kavSiri wonis daklebis<br />
cvlilebis bazisur etapsa da wonis xanmokle (Macqueen, 2002 C) da<br />
SedarebiT gaxangrZlivebul (mag, sami weli) gamosavals Soris (Jeffery 1999<br />
C). erTerTi gamoqveynebuli randomizebuli kvleva romelic afasebs<br />
transTeoriul models aRniSnulia, rom wonis dasaklebma intervenciam<br />
gamoiwvia wonis SenarCuneba, magram ara wonaSi dakleba (Logue,2005A).<br />
avtorebma aRniSnes, rom maTi Careva (mag, yovelTviurad satelefono<br />
rCeva-konsultacia) ar aRmoCnda sakmarisi mniSvnelovani klinikuri<br />
efeqtis misaRwevad. dadginda, rom kontaqtis intensiuroba da sixSire<br />
mniSvnelovanwilad gansazRvravs gamosavlis warmatebas (Jeffery 2000 R).<br />
wonaSi daklebis warmatebaze mniSvnelovan gavlenas axdens agreTve da<br />
cxovrebis stili da fsiqologiuri faqtorebi. magaliTad, kvlevebiT<br />
dadgenilia, rom depresiuli statusi arasasurvel zegavlenas axdens<br />
mkurnalobis gamosavalze (Linde, 2004 C) da gaTvaliswinebul unda iqnes<br />
pacientisTvis rekomendaciebis micemis procesSi. kvebisa da fizikuri<br />
aqtiurobis sferoSi cvlilebebis misaRwevad eqimma unda Sefasos<br />
pacientis motivacia da mxardaWera, cxovrebis stresuli movlenebi,<br />
fsiqiatriuli statusi, Tavisufali drois arseboba da SezRudvebi,<br />
miznebis da molodinis Sesabamisoba. cvlilebisadmi mzadyofnis Sefaseba<br />
gulisxmobs imaze mets, vidre martivad dasvaT SekiTxva, “mzad xarT Tu<br />
ara wonaSi daikloT?”<br />
Sefasebis procesSi daxmarebas gagiwevT cifrebiani skala, sadac<br />
cvlilebisadmi pacientis interesi da rwmena qulebiT aisaxeba. SeekiTxeT<br />
pacients “skalaze 0-dan 10-mde, sadac 0-ar aris mniSvnelovani, 10-Zalian<br />
mniSvnelovani _ ramdenad mniSvnelovania TqvenTvis axla wonaSi<br />
dakleba?” ganagrZeT SekiTxva “skalaze 0-dan 10-mde, sadac 0-ar aris<br />
darwmunebuli, 10-sakmaod darwmunebuli _ ramdenad darwmunebuli xarT<br />
imaSi, rom axla SeZlebT wonaSi daklebas?” aseve SegiZliaT hkiTxoT<br />
“ramdenad dainteresebuli xarT amJamad wonaSi daklebiT? 0-ar aris<br />
dainteresebuli, 10-Zalian dainteresebulia”.<br />
ASSIST – daexmare wonaSi daklebis mcdelobaSi<br />
pacienti ar aris dainteresebuli/motivirebuli wonaSi dasaklebad<br />
am kategoriis pacientebi ar fiqroben, rom maTi wona problemas<br />
warmoadgens, ar arian dainteresebulni cvlilebis ganxorcielebaSi<br />
(precontemplator), uaryofen TavianT problemas, magram iwyeben cvlilebaze<br />
fiqrs (contemplator). simsuqnesTan dakavSirebuli risk-faqtorebis da<br />
wonaSi daklebis potenciuri sargeblis Sesaxeb informaciis miwodeba<br />
metad efeqturia maTTvis vinc jer kidev ar aris dainteresebuli<br />
20
cvlilebiT. cvlilebasTan dakavSirebuli barierebis ganxilva<br />
mniSvnelovani strategiaa im pacientebTan mimarTebaSi, romlebsac<br />
dawyebuli aqvT cvlilebaze fiqri. wonis daklebasTan dakavSirebiT<br />
pacientis mzadyofnis Sefaseba regularuli intervalebiT unda<br />
ganxorcieldes.<br />
pacienti dainteresebulia/motivirebuli wonaSi dasaklebad<br />
wonaSi dasaklebad motivirebul pacientebs rekomendacia unda<br />
mivawodoT Sesaferisi kvebis, aqtiurobis da qcevis Sesaxeb. davexmaroT<br />
aRniSnuli cvlilebebis ganxorcielebaSi. qvemoT warmodgenili<br />
informacia detalurad aRwers aRniSnul rekomendaciebs. eqims evaleba<br />
kargad icodes Sesaferisi referaluri wyaroebi, rogorc sakuTar<br />
klinikaSi aseve adgilobriv dasaxlebaSi.<br />
ARRANGE – monitorireba gauwie<br />
miuxedavad imisa, rom eqimi SeiZleba pirdapir ar monawileobdes wonis<br />
marTvis procesSi, wonis daklebis programis dawyebidan daaxloebiT<br />
sami Tvis Semdeg rekomedebulia ganmeorebiTi vizitis dagegmva progresis<br />
Sesafaseblad. programis dasrulebamde ganmeorebiTi Sefasebebi<br />
grZeldeba Sesabamisi intervalebiT da yovel vizitze xdeba miznebisa da<br />
risk-faqtorebis ganmeorebiTi Sefaseba da wonis SenarCunebasTan<br />
dakavSirebuli sakiTxebis ganxilva.<br />
kvebis mowesrigeba da dieta<br />
kvebiTi rekomendaciebi gulisxmobs kaloriebis Semcirebas ulufis<br />
zomis da raodenobis SefasebiT;<br />
fizikuri aqtiurobis fiziologiuri efeqtebi mniSvnelovnad aris<br />
damokidebuli moZraobis sixSireze, xangrZlivobasa da<br />
intensivobaze;<br />
cxovrebis stilis modifikacia (kveba da fizikuri aqtiuroba)<br />
farmakoTerapiasTan (6 Tvidan 1 wlamde) erTad kombinaciaSi<br />
ganapirobebs wonaSi daklebas msuqan pacientebSi;<br />
bariatriuli qirurgia (<strong>simsuqnis</strong> qirurgiuli mkurnaloba: kuWis,<br />
gastroplastika,) naCvenebia gansakuTrebuli jgufis pacientebSi,<br />
romelTa sxeulis masis indeqsi 40-ze metia an utoldeba 35-39.9-s,<br />
romlebic naadrevi sikvdilis an invalidobis absoluturi riskis<br />
winaSe arian. pacientebi unda iyvnen fsiqologiurad<br />
gawonasworebuli, motivirebuli, kargad informirebuli daavadebis<br />
marTvis da operaciuli riskis Sesaxeb. bariatriuli qirurgia<br />
iZleva mniSvnelovan da xangrZliv Sedegebs, Tumca ar aris<br />
cnobili Soreuli Sedegebi;<br />
mniSvnelovania yoveldRiuri, yovelkvireuli da xanmokle miznebis<br />
dasaxva.<br />
21
kvebis Sefaseba da mkurnaloba<br />
pacientTan SeTanxmebiT xdeba wonis marTvisTvis Sesaferisi kvebis gegmis<br />
Terapiis SemuSaveba. dietologi afasebs mdgomareobas da iZleva rCevadarigebebs<br />
aRniSnuli sakiTxis irgvliv. wonis marTvisTvis aucilebelia<br />
eqims kargad esmodes kvebiTi rekomendaciebis zogadi principebi.<br />
anamnezi kvebis Sesaxeb<br />
kvebis Cvevis Sesaxeb informaciis mopoveba SesaZlebelia miRebuli<br />
sakvebis sixSiris da Semadgenlibis aRricxviT, sami dRis, erTi kviris<br />
ganmavlobaSi miRebuli sakvebis dafiqsirebiT.<br />
kvebis Sefaseba<br />
SeafaseT kvebis Cveva. sakvebi da sasmeli, romelsac pacienti irCevs.<br />
Sefaseba gulisxmobs ganisazRvros:<br />
sakvebiT da sasmeliT miRebuli kaloriebi da cximi;<br />
ulufis zoma da sakvebis yvela jgufi;<br />
sakvebi nivTierebebis gadaWarbebuli an arasakmarisi moxmareba;<br />
sakvebi danamatebis gamoyeneba;<br />
specifikuri qcevis Secvlis etapi, rogoricaa xilisa da<br />
bostneulis miReba;<br />
kvebis SesaZlo darRvevis simptomebi _ sakvebis gadaWarbebuli<br />
moculobiT miRebis ganmapirobebeli faqtorebi;<br />
sakvebis miRebis dro, jeradoba da racioni.<br />
kvebiTi rekomendaciebi.<br />
SearCieT pacientisaTvis sasurveli kvebis ganrigi. dieturi<br />
rekomendaciebi unda iyos individualuri da moqnili kaloraJis<br />
SemcirebisaTvis (National Heart, Lung and Blood Institute, 2000 y).<br />
rekomendebulia:<br />
wonaSi dakleba kaloriebis Semcirebis gziT. kaloriebis zomieri<br />
SemcirebiT (500-1000 kkal dReSi) SesaZlebelia kviraSi 0,5-1kg-iT<br />
wonaSi dakleba (National Heart, Lung and Blood Institute, 2000 D);<br />
kvebis gegmis SemuSaveba wonaSi dasaklebad, romelic gulisxmobs<br />
1000-1200 kkal/dReSi qalebisaTvis da 1200-1600 kkal/dReSi<br />
mamakacebisaTvis (National Heart, Lung and Blood Institute,1998 D);<br />
kvebis reJimis SemuSaveba, romelic balansirebulia da Seesabameba<br />
kvebiT gaidlainebs (Esposito, 2003 A). uzrunvelyaviT dReSi sul<br />
mcire 5 ulufa xilis da bostneulis miReba. SezRudeT cximis<br />
miReba cximidan miRebuli kaloraJis 30%-mde, najeri cximidan<br />
miRebuli kaloraJis 7-10%-mde, ujeri cximi unda iyos 1%-ze<br />
22
naklebi an ar unda aRematebodes mas. gansakuTrebuli mniSvneloba<br />
eniWeba marcvleulis da ujredisis miRebas (dReSi 35 grami an meti);<br />
miRebuli ujeri cximi unda Seadgendes kaloraJis 1%-ze naklebs.<br />
rac ufro dabalia sakvebiT miRebuli qolesterini, najeri da<br />
ujeri cximis kombinirebuli miReba, miT metia sargebeli<br />
kardiovaskularuli sistemis mxriv (USDA, 2005 D). restoranSi, maT<br />
Soris swrafi kvebis obieqtebSi damzadebuli sakvebis umetesoba<br />
didi raodenobiT Seicavs “gansxvavebul cxims” (es cximi<br />
mcenareuli warmoSobisaa, magram is qimiurad Secvlilia<br />
xelovnurad, hidrogenizaciis saSualebiT), da gaurkveveli<br />
Semadgenlobis aris. “gansxvavebuli cximis” miRebis Semcireba<br />
SesaZlebelia “nawilobriv hidrogenizebuli” mcenareuli cximebis<br />
Semcveli sakvebis SezRudviT, rogoricaa magaliTad zogierTi<br />
saxeobis margarini, comisTvis sifxvieris mimcemi specialuri cximi,<br />
krekerebi, tkbileuli, namcxvrebi, wasaxemsebeli/Semwvari sakvebi,<br />
salaTis Sesakmazi sousebi da gadamuSavebuli sakvebi.<br />
dabal-kaloriuli kvebis gegma wonaSi dasaklebad<br />
sakvebi nivTiereba rekomendirebuli norma<br />
kaloriebi Cveuli dRiuri kaloraJis Semcireba<br />
dReSi 500-1000 kkal-iT<br />
saerTo cximi saerTo kaloriebis 30% an naklebi<br />
“gansxvavebuli cximi”* saerTo kaloriebis 1% an naklebi<br />
Nnajeri cximi saerTo kaloriebis 7-10%<br />
ujeri cximi saerTo kaloriebis 15%-mde<br />
cila saerTo kaloriebis 15%<br />
naxSirwylebi-rTuli, sxvadasxva saxis<br />
bostneulis, xilis da marcvleulisgan<br />
miRebuli.<br />
saerTo kaloriebis 55%<br />
boWko 25-35 grami an meti<br />
cxrili #7<br />
naxSirwylebis dasaSvebi norma mozrdilebisa da bavSvebisaTvis<br />
ganisazRvra dReSi minimum 130 grami (Institute of Medicine of the National Academies,<br />
2002).<br />
* gansxvavebuli cximi”_esaa cximi mcenareuli warmoSobisaa, magram is qimiurad<br />
Secvlilia xelovnurad, hidrogenizaciis saSualebiT.<br />
yvela dabal-kaloriuli dieta iwvevs wonaSi swraf daklebas (3-dan<br />
12 Tvemde) (Bravata, 2003:Freedman, 2001, National Heart, Lung and Blood<br />
23
Institute,1998). meti kvlevebia saWiro wonaSi daklebis samomavlo<br />
efeqturobis gansazRvrisaTvis da naxSirwylebiT Raribi (100<br />
gramze naklebi) dietis SesanarCuneblad. Cveulebriv<br />
dabalkaloriul dietasTan SedarebiT wonaSi daklebis swrafi<br />
efeqti (3-dan 6 Tvemde) aRiniSna naxSirwylebiT Raribi dietis<br />
fonze, Tumca erTi wlis Semdeg sxvaoba mniSvnelovani ar iyo. erTi<br />
wlis ganmavlobaSi naxSirwylebiT Raribi dietis fonze<br />
trigliceridebis da (maRali simkvrivis lipoproteidi)<br />
qolesterinis maCveneblebis gaumjobeseba aRiniSna. sadReisod<br />
gaurkvevelia Tu ra gavlenas axdens zemoT aRniSnuli dieta<br />
kardiovaskularuli risk-faqtorebis gaumjobesebaze, ramdenad<br />
usafrTxo da efeqturia igi xangrZlivad wonaSi daklebisaTvis;<br />
janmrTelobis riski matulobs da sakvebi elementebis deficiti<br />
SeiZleba aRiniSnos wonaSi daklebis rekomendaciebis gamo,<br />
romelic sakvebis garkveul jgufebs gamoricxavs da zRudavs makro<br />
elementebs (Bonow, 2003, Freedman, 2001);<br />
wonaSi daklebis mizniT Zalian dabal-kaloriuli dietis<br />
rutinulad gamoyeneba rekomendebuli ar aris, amisTvis saWiroa<br />
gamocdili praqtikosis gansakuTrebuli meTvalyureoba. aRniSnuli<br />
dietis gamoyenebis Sedegad pirveli 6 Tvis manZilze wonaSi<br />
dakleba mosalodnelia 20 kg-iT, Tumca 6-12 Tvis ganmavlobaSi<br />
wonis xelaxali namati aRiniSneba. kvebis da qcevis mimdinare<br />
zedamxedvelobis gareSe wonis SenarCuneba praqtikulad<br />
SeuZlebelia (Paisey 2002, Torgerson 1999);<br />
bolo periodSi Catarebuli kvlevebiT dadginda, rom wonaSi<br />
daklebisa da SenarCunebisaTvis dabali glikemiuri indeqsis mqone<br />
dieta efeqturi ar aris. meti kvlevebia saWiro SimSilisa da<br />
maZRrobis Soreuli efeqtebis gansazRvrisaTvis (Ebbeling, 2005).<br />
ixileT danarTi 8. `kvebis dagegmva da wonis koreqcia.”<br />
kvebis gamosavali da miznebi<br />
wonis daklebis da SenarCunebis ukeTesi Sedegis misaRwevad<br />
aucilebelia fizikuri aqtiurobis gazrdis xarjze kaloriebis<br />
gaZlierebuli daxarjva (Esposito, 2003, Miller, 1997, National Heart, Lung and<br />
Blood Institute,2000, Rejeski, 2002);<br />
xangrZlivi periodis ganmavlobaSi wonaSi daklebis ukeTesi Sedegi<br />
im SemTxvevaSi miiRweva, rodesac kaloraJis Semcireba<br />
kombinirebulia fizikuri aqtiurobis gazrdasTan da qceviT<br />
TerapiasTan (Chao, 2000, Diabetes Prevention Program Research Group 2002.<br />
Freedman, 2001. Miller, 1997. National Heart, Lung and Blood Institute,1998, 2000.<br />
Rejeski, 2002. Tuomilehto, 2001);<br />
wonaSi daklebis procesis efeqturobisTvis rekomedebulia<br />
jandacvis muSakis mxridan xSiri meTvalyureoba da<br />
24
saganmanaTleblo saubrebi (Chao, 2000. National Heart, Lung and Blood<br />
Institute, 2000. Rejeski, 2002.Tuomilehto, 2001);<br />
kaloraJis Semcirebis da fizikuri aqtiurobis gazrdis<br />
erTobliobiT miiRweva wonis SenarCuneba (Franz, 2007. Freedman, 2001.<br />
McGuire, 1998. Wing, 2001). wonis kontrolis nacionaluri saagentos<br />
mier gamoqveynebuli monacemebiT gamovlinda, rom wonis<br />
SenarCunebisTvis rekomendebulia dReSi saSualod 1400 kkal miReba,<br />
yoveldRiurad 1 saaTi zomieri fizikuri aqtiuroba da diliT<br />
sauzmis miReba.<br />
fizikuri aqtiuroba<br />
fizikur aqtiurobas miekuTvneba sxeulis yvela saxis da intensivobis<br />
moZraoba, yoveldRiuri aqtiurobis CaTvliT. termini varjiSi<br />
galisxmobs datvirTvis intensivobis gazrdas, xSirad aRiqmeba rogorc<br />
valdebuleba da uaryofiT gavlenas axdens zogierT msuqan pacientze.<br />
fizikuri aqtiuroba metad miRwevadi, yovlismomcveli da Sesaferisi<br />
terminia.<br />
fizikuri aqtiuroba didi xnis win ganisazRvra cxovrebis jansaRi wesis<br />
da dRegrZelobis mniSvnelovan komponentad (Paffenbarger, 1986). amerikis<br />
gulis asociaciis mier kardiovaskularuli daavadebis damoukidebel<br />
risk-faqtorad ganisazRvra fizikuri umoZraoba da cxovrebis mjdomare<br />
stili (Fletcher, 1992). <strong>simsuqnis</strong> problemis mTavar mizezs fizikuri<br />
umoZraoba warmoadgens. amerikis SeerTebul StatebSi mozrdilTa<br />
daaxloebiT 60%-s Warbi wonis problemebi aReniSnebaT (Flegal, 2002).<br />
<strong>simsuqnis</strong> prevenciisa da marTvisTvis aucilebelia fizikuri aqtiurobis<br />
xelSewyoba.<br />
fizikuri aqtiurobis specifikuri roli <strong>simsuqnis</strong> <strong>marTva</strong>Si<br />
<strong>simsuqnis</strong> <strong>marTva</strong>Si fizikur aqtiurobas gaaCnia ramodenime specifikuri<br />
roli: prevencia, wonis mkveTri dakleba, wonis dakleba xangrZlivi<br />
periodis ganmavlobaSi, wonis SenarCuneba da normaluri metaboluri<br />
maCveneblebi wonis daklebiT an mis gareSe. qvemoT warmodgenilia<br />
TiToeuli maTganis mokle mimoxilva.<br />
fizikuri aqtiuroba da <strong>simsuqnis</strong> prevencia<br />
arsebobs zogadi mosazreba, rom fizikuri aqtiurobis dros daxarjul<br />
energias aqvs unari zemoqmedeba moaxdinos energetikul balansze da<br />
wonis regulaciis processze. arsebobs mtkicebuleba, rom fizikuri<br />
aqtiuroba minimumamde amcirebs wonaSi matebis process (Jakicic, 2002).<br />
Tumca, mxolod fizikuri aqtiuroba ver daZlevs araswori kvebis Cvevebs.<br />
Warbi wonis prevenciisTvis orive am faqtoris balansirebaa saWiro. jer<br />
kidev ver dadginda wonaSi matebis prevenciisTvis fizikuri aqtiurobis<br />
optimaluri doza. igi individualuri iqneba asakis, sqesis, profesiuli<br />
25
energiis xarjvis da Cveuli kaloraJis miRebis mixedviT. zogadad<br />
rekomendebulia kviraSi 5 dRe, 30-dan 60 wuTamde saSualo intesivobis<br />
fizikuri aqtiuroba (American College of Sports Medicine, 2001).<br />
fizikuri varjiSi da wonaSi mkveTri dakleba<br />
kvlevebiT dadgenilia, rom kaloraJis kontrolis gareSe mxolod<br />
varjiSiT wonaSi dakleba sakmaod rTulia. varjiSiT miRweuli Sedegi<br />
sqesTa Soris gansxvavebulia. wonaSi kleba mamakacebSi ufro mkveTrad<br />
aRiniSneboda, maSin rodesac qalebi mxolod wonis SenarCunebas<br />
aRwevdnen (Doneelly, 2003). Caatares cikluri ergometriis amtanobis kvleva,<br />
romelic kviraSi 3 dRe 20 kviris ganmavlobaSi mimdinareobda. kvlevaSi<br />
monawileobas Rebulobda sxvadasxva rasis (Savi da TeTri), sqesis, asakis<br />
(16-65 wlis) da gansxvavebuli sxeulis aRnagobis mqone pirebi. varjiSis<br />
Sedegad cximis maCveneblebi Semcirda da cximisgan Tavisufali masa<br />
gaizarda. am cvlilebebis maStabi CaTvales rom aris mcire<br />
mniSvnelobis. varjiSis Sedegad sqesTa Soris sxvaoba aRiniSna (Wilmore,<br />
1999).<br />
fizikuri aqtiuroba da wonis SenarCuneba xangrZlivi periodis<br />
ganmavlobaSi<br />
dadgenilia, rom wonis xelaxla matebis prevenciisTvis fizikur<br />
aqtiurobas gansakuTrebuli mniSvneloba eniWeba (Jeffery, 1984. Pronk, 1994).<br />
aerobika da Zlieri varjiSi wonis totaluri daklebisTvis imdenad<br />
efeqturi ar aris, rogorc misi roli wonis SenarCunebaSi (Wadden, 1998).<br />
xangrZlivi periodis ganmavlobaSi wonis SesanarCuneblad fizikuri<br />
aqtiuroba saWiroa iseTive sixSiriT, rogorc iyo rekomedebuli<br />
daklebis procesSi. rogorc zemoT iyo aRniSnuli, wonis<br />
SenarCunebisTvis saWiroa yoveldRiurad 1 saaTi an meti zomieri<br />
fizikuri aqtiuroba.<br />
normaluri metaboluri maCveneblebi wonis daklebiT an mis gareSe<br />
fizikuri aqtiurobis dadebiTi zemoqmedeba cdeba wonis daklebis<br />
farglebs. arsebobs sarwmuno mtkicebuleba, rom fizikuri aqtiuroba<br />
Zalian mniSvnelovania tipi II Saqriani diabetis da kardiovaskularuli<br />
daavadebis (masTan dakavSirebuli risk-faqtorebis) prevenciis da marTvis<br />
sakiTxSi. arsebobs monacemebi, rom 5-dan 10%-mde wonaSi dakleba<br />
mniSvnelovan zegavlenas axdens metabolur sindromze (Goldstein, 1992).<br />
saSualo <strong>simsuqnis</strong> mqone qalebSi perioduli varjiSi, dReSi orjer 15<br />
wuTiani Cqari siarulis saxiT ar iwvevs wonaSi daklebas, magram<br />
mkveTrad aumjobesebs maRali simkvrivis lipoproteidisa da insulinis<br />
maCveneblebs (Donnelly, 2000). mamakacebSi, kaloraJis SezRudvis gareSe<br />
wonaSi dakleba yoveldRiuri fizikuri aqtiurobis momatebis xarjze,<br />
amcirebs insulinis rezistentobas da muclis areSi gacximovnebis<br />
xarisxs. varjiSi wonaSi daklebis gareSe amcirebs muclis areSi cxims,<br />
26
dadebiT zegavlenas axdens kardiovaskularul sistemaze, magram ar<br />
moqmedebs insulinis doneze (Ross, 2000).<br />
glukozis darRveuli tolerantobis mqone msuqan pirebSi, romlebmac<br />
Secvales cxovrebis stili da daiwyes fizikuri aqtiuroba, daikles<br />
wonaSi da mniSvnelovnad Seamcires diabetis progresireba (Tuomilehto,<br />
2001).<br />
arsebobs kvlevebi fizikuri aqtiurobis Sesaxeb, sadac naTlad Cans, rom<br />
wonaSi daklebis gareSe damoukideblad metaboluri efeqtis miRweva<br />
SeuZlebelia. msuqan qalebSi aerobikisa da gamudmebuli varjiSis<br />
Sedegad dietis gareSe ver iqna miRweuli wonaSi kleba, adgilobrivi<br />
gacximovnebis Semcireba, lipidebisa da insulis maCveneblebis<br />
normalizeba.<br />
fizikuri aqtiurobis gegmis Sedgena<br />
daaxloebiT 20 wlis win iyo miRebuli eqimis mier varjiSis<br />
individualuri gegmis Sedgena (Gibson, 1983). zemoT aRniSnuli zusti<br />
rekomendaciis Sedgena dResac ucxoa <strong>pirvelad</strong>i jandacvis eqimebisaTvis.<br />
fizikuri aqtiuroba SeiZleba gansxvavdebodes moZraobis sixSiris,<br />
xangrZlivobis da intensivobis mixedviT. varjiSis fiziologiuri efeqti<br />
mniSvnelovnad aris damokidebuli aqtiurobis moculobaze. qvemoT<br />
ganxiluli iqneba TiToeuli maTgani.<br />
sixSire<br />
fiziologiuri adaptaciis gamomuSavebisTvis fizikuri aqtiurobis<br />
minimaluri sixSire kviraSi sami dRiT ganisazRvreba. yoveldRiuri<br />
varjiSi rekomendebulia arteriuli wnevis da insulinis maCveneblebis<br />
gaumjobesebisTvis. varjiSiT gamowveuli sargeblis misaRwevad<br />
rekomendebulia fizikuri aqtiuroba kviraSi xuTi dRe an meti. varjiSis<br />
dawyeba umjobesia TandanTanobiT, sixSiris Semdgomi gazrdiT. sxvadasxva<br />
saxis aqtiuroba iZleva sixSiris gazrdis saSualebas da naklebad<br />
mosawyens xdis mas. fizikuri aqtiurobiT siamovnebis miReba misi zusti<br />
Sesrulebis garantiaa.<br />
xangrZlivoba<br />
varjiSis rekomendirebuli xangrZlivoba cvalebadobs. tradiciuli<br />
kardiovaskularuli gaidlainebis mixedviT fizikuri aqtiuroba<br />
gulisxmobs 60-80% gulis cemis maqsimaluri sixSiris fonze kviraSi<br />
samidan xuTi dRis ganmavlobaSi 30 wT varjiSs. amerikis sportuli<br />
medicinis kolejis mier rekomendebulia TiTqmis mTeli kviris<br />
ganmavlobaSi 30 wT. saSulo intensivobis fizikuri aqtiuroba (American<br />
ollege of Sports Medicine, 2001). kardiovaskularuli sistemisTvis da wonaSi<br />
dasaklebad aseve efeqturi aRmoCnda xanmokle periodis ganmavlobaSi (10<br />
wT) xSirad varjiSi (Jakicic, 1995).<br />
27
wonis kontrolisTvis rekomendebulia fizikuri aqtiuroba dReSi 60 wT<br />
ganmavlobaSi (mowodebulia samedicino institutis mier). Warbwonian<br />
pacientebSi wonaSi klebis procesi ukeTesad warimarTa kviraSi 2500<br />
kkal (300 kal/dReSi) daxarjviT. aRniSnuli maCvenebeli adre Seadgenda<br />
standartul 1000 kkal/kviraSi (150 kkal/dReSi) (Jeffery, 2003).<br />
intensiuroba<br />
konkretuli pacientisTvis fizikuri aqtiurobis Sesaferisi intensivobis<br />
SerCeva rTulia. msuqan pacientebs varjiSisTvis esaWiroebaT didi<br />
Zalisxmeva. Sesaferisi intensivobis dadgena SesaZlebelia aqtiurobis<br />
procesSi pacientis laparakis unaris gansazRvriT. saubris procesSi<br />
sirTule metyvelebs pacientis did fizikur datvirTvaze, rac didxans<br />
ver gastans. gadaWarbebuli fizikuri aqtiuroba zianis momtania da<br />
drois fuWi kargvaa. umjobesia fizikuri aqtiurobis mcire intensivobiT<br />
dawyeba da misi TandaTanobiT gazrda. sunTqvis gaumjobesebisTvis da<br />
varjiSis dasrulebisTvis umjobesia tempis Semcireba.<br />
fizikuri aqtiurobis intensivobis gansazRvra SesaZlebelia wuTSi an<br />
saaTSi daxarjuli kaloriebis mixedviT. misaRebi kaloraJis dadgena<br />
damokidebulia wonasa da moZraobis intensivobaze. arsebobs vrceli<br />
cxrili kaloraJis xarjvis Sesaxeb sxvadasxva datvirTvis mqone pirebSi<br />
(Katch, 1993). (ix. cxrili #8).<br />
konkretuli fizikuri aqtiurobis dros daxarjuli energia<br />
msubuqi<br />
(4 kkal/wT naklebi)<br />
saSualo<br />
(4-7 kkal/wT)<br />
mZime<br />
(7 kkal/wT meti)<br />
neli siaruli cocxlad siaruli cocxlad siaruli<br />
aRmarTze an tvirTiT<br />
neli curva curva zomieri<br />
ZalisxmeviT<br />
zogadi varjiSi, msubuqi<br />
daWimva<br />
velosipediT seirnoba velosipediT swrafi<br />
siaruli an rbolaSi<br />
monawileoba<br />
swrafi curva<br />
zogadi varjiSi, aerobika zogadi varjiSi, kibis<br />
ergometria<br />
_ magidis CogburTi CogburTi<br />
golfi _ _<br />
boulingi _ _<br />
Tevzaoba mjdomare Tevzaoba fexze damdgari Tevzaoba mdinareSi<br />
cxrili #8<br />
28
naosnoba neli kanoe swrafi kanoe<br />
diasaxlisoba, xaliCis<br />
dagva<br />
diasaxlisoba, zogadi<br />
dalageba<br />
balaxis moTibva balaxis moTibva eleqtro<br />
danadgariT<br />
avejis gadaadgileba<br />
balaxis moTibva xeliT<br />
saxlSi xeze muSaoba xatva _<br />
mosvenebul mdgomareobaSi yofnis an kiTxvis dros ixarjeba 1<br />
kkal/wuTSi. saSualo wonis adamiani siarulis dros xarjavs<br />
daaxloebiT 5 kkal/wuTSi, 10 wuTis ganmavlobaSi ZunZuliT sirbilis<br />
dros 10 kkal/wuTSi da 7 wuTis ganmavlobaSi sirbiliT 15 kkal/wuTSi.<br />
igive datvirTva 300 lbs. wonis mqone adamianisTvis energiis daaxloebiT<br />
gaormagebul xarjvas ganapirobebs.<br />
fizikuri aqtiurobis intensivobis gansazRvris meore meTods<br />
warmoadgens metaboluri eqvivalentoba. metaboluri eqvivalentoba<br />
ganisazRvreba rogorc energiis xarjva mosvenebul mdgomareobaSi<br />
yofnisas. saSualo asakis mozrdilisaTvis es udris sxeulis 1 kg-ze 1<br />
kkal/sT-Si. aqtiurobis mTeli CamonaTvali metabolur eqvivalentobis<br />
maCvenebelTan erTad gamoiyeneba energiis sruli danaxarjis dasadgenad:<br />
(aqtiurobis metaboluri eqvivalentobis maCvenebeli) X (wona<br />
kilogramebSi) X (aqtiurobis dro) Ainsworth, 1993, Ainsworth, 2000.<br />
fizikuri aqtiurobis rekomendebuli dRiuri maCvenebeli meryeobs 150<br />
kkal-dan 300 kaloriamde. fizikuri aqtiurobis sawyisi done unda<br />
ganisazRvros wonis daklebisTvis aucilebeli zomieri xangrZlivobiT.<br />
organizmis cximis 453,6 gr Seicavs energiis 3500 kalorias, rac saSualo<br />
wonis adamianisTvis 35 milis gavlas uzrunvelyofs. fizikuri<br />
aqtiurobiT daxarjuli energiis Sevseba advilad xorcieldeba<br />
kaloraJis arakontrolirebuli miRebiT. 30 wuTis ganmavlobaSi zomieri<br />
fizikuri aqtiuroba (5 kkal/wuTSi) ganapirobebs 150 kkal-is xarjvas. es<br />
udris Semwvari kartofilis 5 naWers, 2 qila tkbil sasmels, 15 cal<br />
“Cipss. nebismieri wonis problemis marTvisTvis aucilebelia fizikuri<br />
aqtiurobisa da kvebiTi rekomendaciebis erToblioba.<br />
miuxedavad imisa, rom <strong>simsuqnis</strong> <strong>marTva</strong>Si fizikuri aqtiurobis Sesaxeb<br />
konsensusi miRweulia, ar arsebobs misi rekomendebuli formati.<br />
literaturaSi msgavs magaliTs warmoadgens proeqti PACE (Physician-based<br />
Assessment and Counseling for Exercise) (Patrick, 1994) da Norstrom at Park Nicollet<br />
HealthSource-is mier SemuSavebuli fizikuri aqtiurobis piramida (Park<br />
Nicollet medical Foundation, 1999).<br />
fizikuri aqtiurobis ambulatoriuli Sefaseba <strong>pirvelad</strong> mowodebuli<br />
iqna proeqt PACE-is mier. erT gverdiani kiTxvaris meSveobiT xdeba<br />
pacientis fizikuri aqtiurobis donis da aqtiurobis gazrdisadmi<br />
mzadyofnis Sefaseba. mravali protokoli arsebobs aRniSnuli miznis<br />
29
misaRwevad sxvadasxva saWiroebis mqone pacientebisaTvis. aRniSnuli<br />
programis ganxorcieleba SeuZliaT eqimebs, eqTnebs an jandacvis sxva<br />
profesionalebs (Patrick, 1994).<br />
aRmoCnda, rom varjiSis werilobiTi rekomendacia ufro efeqturia,<br />
vidre verbalurad gadacemuli (Swinburn, 1998). medikamentis gamoweraze<br />
gacilebiT rTulia fizikuri aqtiurobis rekomendaciis dawera.<br />
fizikuri aqtiurobis individualuri daniSnuleba sakmaod<br />
damokidebulia konteqstze. gaTvaliswinebul unda iqnes individualuri<br />
motivacia, TviTkmayofileba, aqtiurobis saxeoba an SesaZlo samedicino<br />
winaaRmdegCvenebebi (CME Resource, 2004). sxvadasxva pacientSi mosalodneli<br />
Sedegis dro gansxvavebulia.<br />
fizikuri aqtiurobis gasaumjobeseblad sakmaod informatiulia<br />
pacientis saganmanaTleblo bukletebi.<br />
cxovrebis wesis Secvla da TviTmonitoringi<br />
wonis, kvebis da fizikuri aqtiurobis TviT-monitoringi<br />
wonis daklebisa da SenarCunebisaTvis aucilebel faqtors warmoadgens<br />
energiis miReba-xarjvis da wonis TviT-monitoringi. is vinc<br />
regularulad uwevs TviT-monitorings dietas da fizikur aqtiurobas,<br />
wonaSi daklebis ukeTesi maCveneblebi aReniSnebaT (Boutelle, 1999,1998).<br />
wonis regularuli monitoringi wonis kontrolis saukeTeso saSualebaa.<br />
wonis kontrolis nacionaluri saagentodan (National Weight Control Registry -<br />
NWCR) mowodebuli mtkicebuleba cxadyofs, rom pirovnebebma, romlebmac<br />
warmatebiT daikles sul mcire 13,6 kg. da aRniSnuli wona SeinarCunes<br />
erTi wlis ganmavlobaSi, monawileTa 75%-ze meti wonis TviTmonitorings<br />
awarmoebdnen kviraSi erTxel (Klem, 1997).<br />
pacientebma mudmivad unda akontrolon kaloriebis miReba, fizikuri<br />
aqtiuroba da wona. kaloriebis miRebisa da fizikuri aqtiurobis<br />
aRricxva unda moxdes yoveldRiurad, wonis Sefaseba ki kviraSi erTxel.<br />
aswavleT cxovrebis unar-Cvevebi<br />
imis miuxedavad, Tu ramdeni xania da ratom aqvs pacients Warbi wona an<br />
simsuqne, ZiriTad mizans warmoadgens pacientis mier sakmaod<br />
permanentuli cxovrebis stilis cvlilebebis ganxorcieleba, rac<br />
kaloriebis miRebis SemcirebaSi da fizikuri aqtiurobis gazrdaSi<br />
gamoixateba. gansaxorcielebeli cvlilebebis raodenoba cvalebadia imis<br />
mixedviT, Tu ra raodenobis wonis dakleba gvWirdeba. patara<br />
cvlilebebs didi zegavlena dasWirdeba. magaliTad, 0,33ml tkbili<br />
gaziani sasmelis Cveulebrivi wyliT Canacvleba yoveldRiurad,<br />
weliwadSi 13,5kaloriis dazogvas ganapirobebs.<br />
30
wonis warmatebuli daklebisa da SenarCunebisTvis damatebiTi qceviTi<br />
modifikaciis strategiebi gulisxmobs:<br />
stimulis kontrols: stimulis kontroli gulisxmobs iseTi qcevis<br />
Camoyalibebas, romelic exmareba adamianebs kvebis qcevasa da<br />
inertulobasTan dakavSirebuli garemo impulsebis SemcirebaSi.<br />
pacientebs unda vaswavloT, Seamciron maRali kaloriebis/cximebis<br />
Semcveli, arajansaRi sakvebis SeZena saxlSi, naklebi dro<br />
gaataron dRis manZilze im adgilas, sadac ikvebebian, moeridon<br />
kvebis dros yuradRebis gafantvas (mag, televizoris yureba) da<br />
ikvebon SedarebiT nela;<br />
SemecnebiT restruqturizacias: negatiuri fiqrebi (mag,<br />
perfeqcionistuli, gaorebuli “yvela an arcerTi”, pesimisturi<br />
fiqrebi da eWvi sakuTar TavSi) xSirad arasasurvel gavlenas<br />
axdens qcevis cvlilebis Zalisxmevaze. pirovnebebs unda vaswavloT<br />
negatiuri fiqrebis identificireba da xeli SevuwyoT dadebiTi<br />
muxtis SeZenaSi, rac ganapirobebs jansaRi kvebis da fizikuri<br />
aqtiurobis rekomendaciebis zust Sesrulebas;<br />
miznebis dasaxvas: motivaciis gazrdisTvis pirovnebebs unda vaswavloT<br />
xanmokle miznebis dasaxvis mniSvneloba, kvebisTvis misaRebi da<br />
miRwevadi yoveldRiuri da kvireuli miznebis dasaxva. fizikuri<br />
aqtiuroba da wonaSi dakleba unda iqnes SenarCunebuli;<br />
problemis gadaWras: wonaSi daklebis intervenciis umniSvnelovanes<br />
komponents warmoadgens kvebisa da fizikuri aqtiurobis<br />
cvlilebebTan dakavSirebuli barierebis gadalaxva. amis miRweva<br />
SesaZlebelia problemis gadaWris strategiis swavlebiT.<br />
rekomendebulia iseTi strategiebi, rogoricaa problemis<br />
gansazRvra, tvinis SturmiT miRebuli gadawyvetilebebi,<br />
gadawyvetilebis SerCeva da misi warmatebis Sefaseba;<br />
socialur mxardaWeras: wonaSi daklebis warmatebaze, rogorc dadebiTi<br />
ise uaryofiTi zegavlenis moxdena SeuZliaT meuRleebs, ojaxis<br />
wevrebs, megobrebs da TanamSromlebs;<br />
Cavardnis (recidivis) prevencias: qcevis cvlilebis dros xSiria<br />
warumatebloba da ganmeorebiT mcdelobis aucilebloba. pacienti,<br />
romelac erTxel ar gaumarTlebs, unda gavamxnevod da vurCioT<br />
scados maSin, rodesac amisTvis mzad iqneba. faqtiurad, srul<br />
gankurnebas SeiZleba ver mivaRwioT; sjobs mTeli cxovreba<br />
vibrZoloT, vidre maSinve davnebdeT.<br />
31
medikamenturi mkurnaloba<br />
<strong>simsuqnis</strong> mkurnalobaSi qceviTi Terapia (kvebisa da fizikuri aqtiurobis<br />
CaTvliT) xSirad umniSvnelo gaxanrZlivebul Sedegs iZleva, ris gamoc<br />
medikamenturi mkurnalobisadmi interesi izrdeba. iTvleba, rom wonis<br />
daklebis da SenarCunebis procesi metad warmatebuli iqneba, Tu qceviT<br />
reJims (kveba da fizikuri aqtiuroba) davumatebT medikaments. wonaSi<br />
daklebisTvis cxovrebis stilis modifikaciisa da farmakoTerapiis<br />
Sesaxeb Catarebuli randomizebuli kvleviT gamovlinda, rom<br />
sibutraminisa da cxovrebis stilis intensiuri modifikaciis<br />
erTobliobiT wonaSi klebis ukeTesi maCveneblebi aRiniSna, vidre<br />
mxolod medikamentis an cxovrebis stilis modifikaciis SemTxvevaSi<br />
(Wadden, 2005).<br />
amrigad, <strong>simsuqnis</strong> medikamenturi mkurnaloba dasaSvebia mxolod wonaSi<br />
daklebis specialuri programis paralelurad, romelic gulisxmobs<br />
dabal-kaloriuli dietis, momatebuli fizikuri aqtiurobis da qceviTi<br />
Terapiis erTobliobas. farmakoTerapiis dawyeba rekomendebulia im<br />
SemTxvevaSi, Tu aRniSnuli specialuri programis fonze wonaSi kleba<br />
kviraSi 0,45kg-iT ar aRiniSneba.<br />
farmakoTerapia eniSnebaT pacientebs, visac sxeulis masis indeqsi (s.m.i)<br />
aqvT 27-30 da meti, agreTve aReniSnebaT simsuqnesTan dakavSirebuli<br />
Tanmxlebi daavadebebi da risk-faqtorebi. 27-29.9 s.m.i-is fonze SesaZlo<br />
daavadebebs da risk-faqtorebs miekuTvneba: hipertenzia, dislipidemia,<br />
gulis koronaruli daavadeba, tipi 2 Saqriani diabeti da Zilis apnoe.<br />
konkretul pacientSi preparatis efeqturobis gansazRvrisTvis<br />
mizanSewonilia erTi preparatis daniSvna sacdeli periodis<br />
gansazRvriT. im SemTxvevaSi, Tu mkurnalobis fonze wonaSi klebis<br />
sasurveli maCveneblebi ar fiqsirdeba, saWiroa mkurnalobis procesis<br />
xelaxla gadaxedva da dozis regulireba. preparatis miReba unda<br />
Sewydes im SemTxvevaSi, Tu pacienti ar eqvemdebareba mkurnalobas an<br />
seriozuli gverdiTi efeqtebi aRiniSna.<br />
farmakoTerapiis dawyebidan oTxi kviris ganmavlobaSi wonaSi kleba unda<br />
aRiniSnos 2 kilogramiT (4.4 lb). Tu aRniSnuli maCvenebeli ar<br />
dafiqsirda samomavlo efeqturoba naklebsavaraudoa. pirveli oTxi<br />
kviris ganmavlobaSi miRebuli SedegiT SeiZleba vimsjelod momdevno<br />
mkurnalobaze. medikamenturi Terapiis gagrZeleba mizanSewonilia<br />
Sesaferisi sapasuxo kriteriumis mqone pacientebSi. iq sadac pirveli<br />
oTxi kviris ganmavlobaSi sasurveli efeqti ar aRiniSna rekomendebulia<br />
mkurnalobis Sewyveta. medikamenturi mkurnalobis gagrZeleba<br />
mizanSewonilia im SemTxvevaSi, Tu pirveli 6 Tvis ganmavlobaSi<br />
aRiniSneba wonaSi dakleba an klebis sawyisi fazis Semdeg wonis<br />
SenarCuneba. gverdiTi efeqtebis gamovlenisTanave unda Sewydes<br />
preparatis miReba.<br />
32
msuqan pacientebSi wonaSi daklebas ganapirobebs cxovrebis stilis<br />
modifikaciasTan (kveba da fizikuri aqtiuroba) erTad warmoebuli<br />
farmakoTerapia (6 Tvidan 1 wlamde). wonaSi klebis saSualo maCvenebeli<br />
4-12%-s Seadgens.<br />
wonaSi daklebis medikamenturi mkurnalobisTvis ZiriTadad gamoiyeneba<br />
anoreqsantebi da madis damTrgunveli saSualebebi. kvebisa da<br />
medikamentebis administrirebis saagentom (FDA) daamtkica agreTve<br />
preparatebi sibutramini (Sibutramine) da orlistati (Orlistat). sibutramini<br />
axdens norepinefrinisa da serotoninis ukuSeboWvis inhibirebas.<br />
orlistati ar miekuTvneba madis damTrgunvel saSualebas da moqmedebis<br />
gansxvavebuli meqanizmi aqvs. orlistati axdens pankreasis lipazis<br />
inhibirebas da cximis Sewovis daaxloebiT 1/3-is blokirebas axdens.<br />
ix. danarTi #3. <strong>simsuqnis</strong> samkurnalo medikamentebis nusxa, romelic<br />
damtkicebulia FDA_s mier.<br />
mcenareuli medikamentebi ganusazRvreli raodenobiT Seicaven aqtiur<br />
nivTierebebs da potenciurad sazianoa. wonaSi daklebis programaSi<br />
aRniSnuli preparatebis ganxilva dauSvebelia.<br />
farmakoTerapiis dawyebamde aucilebelia TiToeuli pacientis Sesaxeb<br />
sruli medikamenturi anamnezis Sekreba (warsulSi sxva daniSnulebis<br />
gamoyenebis, wonaSi daklebis mizniT recepturuli, ararecepturuli an<br />
mcenareuli preparatebis CaTvliT).<br />
usafrTxoeba da gverdiTi efeqtebi<br />
wonaSi daklebis medikamenturi mkurnalobis dros pacientebSi aRiniSna<br />
gverdiTi efeqtebi. mkurnalobis dawyebidan maleve SeiZleba gamovlindes<br />
dozasTan dakavSirebuli mcire efeqtebi, romelic saSualo simZimisaa da<br />
droTa ganmavlobaSi TavisTavad gaqreba. sawyisi gverdiTi efeqtebis<br />
Tavidan acileba an minimumamde Semcireba SesaZlebelia:<br />
dozirebis da miRebis sqemis SedgeniT,<br />
gverdiTi efeqtebis mimarT maRali riskis jgufebis gamovleniT da<br />
sworad SerCeuli medikamenturi mkurnalobiT,<br />
pacientis ganaTlebiT da gverdiTi efeqtebis monitoringiT<br />
mkurnalobis dasawyisSi an dozis cvlilebis dros.<br />
iSviaTi, magram potenciurad seriozuli gverdiTi efeqtebi SeiZleba<br />
gamovlindes mkurnalobis sakmaod gvian etapze.<br />
ix. danarTi #4. FDA_s mier <strong>simsuqnis</strong> samkurnalod damtkicebuli<br />
medikamentebis uaryofiTi efeqtebi.<br />
33
sibutramini<br />
placebo-kontrolirebadi kvlevebiT miRebuli gverdiTi efeqtebis<br />
gavrceleba<br />
gverdiTi efeqti sibutramini placebo<br />
Tavis tkivili 30.3% 18.6%<br />
piris simSrale 17.2% 4.2%<br />
yabzoba 11.5% 6.0%<br />
anoreqsia 13.0% 3.5%<br />
insomnia 10.7% 4.5%<br />
momatebuli art. wneva 2.1% 0.9%<br />
cxrili #9<br />
placebosTan SedarebiT sibutraminis fonze normotenziul da<br />
kontrolirebadi hipertenziis mqone pacientebSi aRiniSna sistoluri an<br />
diastoluri wnevis (1-3 mm Hg) da gulis cemis sixSiris (4-5 dartyma/wT)<br />
saSulod gazrda. kardiovaskularuli gverdiTi efeqtebis<br />
seriozulobidan gamomdinare, sibutramini winaaRmdegnaCvenebia<br />
arakontrolirebadi an cudad kontrolirebadi hipertenziis dros.<br />
wonaSi dasaklebad daniSnuli zogierTi preparatis fonze gamovlinda<br />
<strong>pirvelad</strong>i filtvismieri hipertenzia, gansakuTrebiT Tu mkurnaloba 3<br />
Tveze metxans grZeldeboda (Abenhaim, 1996, McCann, 1997). fiqroben, rom<br />
aRniSnuli mdgomareoba ganpirobebulia serotoninis momatebuli doniT.<br />
serotoninis momatebuli raodenoba iwvevs filtvis vazokonstriqcias.<br />
sibutraminis moqmedebis meqanizmi damyarebulia serotoninis ukuSeboWvis<br />
inhibirebaze da ara serotoninis gamomanTavisuflebel faqtorebze.<br />
moqmedebis gansxvavebuli meqanizmi amcirebs sibutraminiT ganpirobebuli<br />
gulis sarqvelebis dazianebis risks.<br />
dispnoe, gulmkerdis areSi tkivili, sinkope da SeSupeba is siptomebia,<br />
romlebic SeiZleba aRiniSnos xangrZlivi periodis ganmavlobaSi<br />
mkurnalobisas. mkurnalobis procesSi an misi Sewyvetidan 1 wlis<br />
ganmavlobaSi zemoT aRniSnuli simptomebis gamovlenisTanave unda<br />
ecnobos eqims da Sewydes preparatis miReba.<br />
34
orlistati<br />
orlistatis gverdiTi efeqtebi ZiriTadad gastrointestinaluri<br />
sistemiT Semoifargleba. preparatis Sewova minimaluria.<br />
cxrili #10:<br />
mkurnalobis pirveli wlis ganmavlobaSi gamovlenili gverdiTi efeqtebi<br />
gverdiTi efeqti orlistati Placebo<br />
cximovani oflianoba 26.6% 1.3%<br />
meteorizmi 23.9% 1.4%<br />
kuWis moqm. gaxSireba 22.1% 6.7%<br />
cximovani ganavali 20.0% 2.9%<br />
cximiani kuWis moqmedeba 11.9% 0.8%<br />
defekaciis gazrda 10.8% 4.1%<br />
ganavlis Seukavebloba 7.7% 0.9%<br />
gverdiTi efeqtebis umetesoba saSualo da gardamavali xasiaTis iyo,<br />
maTi Semcireba aRiniSna mkurnalobis meore wlisTvis. aRniSnuli<br />
movlenebi mkurnalobis dawyebidan pirveli sami Tvis ganmavlobaSi<br />
dafiqsirda. gastrointestinalur sistemasTan dakavSirebuli movlenebis<br />
daaxloebiT 50%-i erT kviraze nakleb periodSi aRiniSna, danarCeni ki<br />
araumetes 4 kvirisa.<br />
cximis miRebiT gamowveuli gverdiTi efeqtebis Semcirebis an Tavidan<br />
acilebis mizniT rekomendirebulia cximis dabali raodenobis Semcveli<br />
dietis dacva, romelic cximidan miRebuli kaloriebis 30%-ze naklebs<br />
Seicavs. gamomdinare iqidan, rom orlistatis miReba umjobesia<br />
garkveuli raodenobiT cximis Semcvel sakvebTan erTad, dozis<br />
gamotoveba rekomendebulia araSesaferisi sakvebis arsebobis dros.<br />
orlistatis gamoyenebis fonze kardialuri darRvevebi ar gamovlenila.<br />
gverdiTi efeqtebis sixSiris gazrdas ganapirobebs medikamentebis<br />
kombinireba. mdgomareobas arTulebs isic, rom kombinirebuli<br />
mkurnalobis usafrTxoebis Sesaxeb mwiri informacia moipoveba.<br />
umjobesia am jgufis preparatebis monoTerapiaSi gamoyeneba. gverdiTi<br />
efeqtebis ganviTarebis albaTobas amcirebs agreTve preparatis SesaZlo<br />
minimaluri doziT gamoyeneba.<br />
orsul da meZuZur qalebSi wonaSi dasaklebi preparatebis usafrTxoeba<br />
Seswavlili ar aris. aRniSnuli jgufis arcerTi preparatis gamoyeneba<br />
ar aris rekomendirebuli orsulebsa da meZuZur qalebSi. 12-16 wlamde<br />
asakis mozardebSi <strong>simsuqnis</strong> samkurnalod kvebisa da medikamentebis<br />
administrirebis saagentom (FDA) daamtkica preparati orlistati.<br />
geriatriul (65 welze meti) populaciaSi orlistatis da sibutraminis<br />
usafrTxoeba da efeqturoba Seswavlili ar aris. preparat orlistatiT<br />
35
mkurnaloba dasaSvebia ori wlis, sibutraminiT ki erTi wlis<br />
ganmavlobaSi. ori wlis Semdeg maTi gamoyenebis usafrTxoeba da<br />
efeqturoba Seswavlili ar aris.<br />
wamalTSorisi urTierTqmedeba<br />
wonaSi dasaklebi saSualebebiT mkurnalobis dawyebamde unda Sefasdes<br />
preparatTa urTierTqmedebis albaToba.<br />
ix. danarTi #5. FDA_s mier <strong>simsuqnis</strong> samkurnalod damtkicebuli<br />
medikamentebis urTierTqmedeba.<br />
ar aris rekomendebuli preparat sibutraminis gamoyeneba wonis dasakleb<br />
sxva preparatebTan erTad. serotoninis sindromis ganviTarebis riski<br />
matulobs sibutraminis kombinirebiT sxva serotonergul saSualebasTan,<br />
rac ganpirobebulia sibitraminis unariT moaxdinos serotoninis<br />
ukuSeboWvis inhibireba. unda moveridoT aRniSnuli kombinaciis<br />
gamoyenebas. serotoninis sindromis damaxasiaTebeli niSnebia:<br />
agznebadoba, foriaqi, gonebis dakargva, gonebis nawilobrivi dabindva,<br />
dezorientacia, hipomania, konfuzia, aJitireba, mamoZravebeli kunTebis<br />
Sesusteba, tremori, hiperrefleqsia, ataqsia, koordinirebis darRveva,<br />
hiperTermia, diaforezi (oflis didi raodenobiT gamoyofa), Rebineba da<br />
taqikardia (Sporer, 1995).<br />
pacientebi, romlebic orlistatiT mkurnalobis paralelurad<br />
Rebuloben sxva medikamentebs, ciklosporinis donis monitoringi unda<br />
awarmoon xSirad. cximis malabsorbciis saziano zegavlenis gamo,<br />
gaxSirebuli monitoringi esaWiroeba agreTve mcire Terapiuli indeqsis<br />
mqone preparatebis (mag, varfarini) miRebis drosac.<br />
orlistatiT mkurnalobis fonze agreTve aRiniSna SratSi cximSi xsnadi<br />
vitaminebis (vitaminebi A, D, E, K) Semcireba. miuxedavad imisa, rom<br />
klinikuri kvlevis procesSi pacientTa umravlesobas plazmis done<br />
normis farglebSi hqondaT, yoveldRiurad, Zilis win rekomendebulia<br />
cximSi xsnadi multivitaminis miReba.<br />
efeqturoba<br />
momatebuli fizikuri aqtiurobis da kvebis kombinireba medikamentur<br />
TerapiasTan ganapirobebs wonis zomier (2-10 kg) klebas. wonis sawyisi<br />
kleba aRiniSneba mkurnalobis dawyebidan pirveli 6 Tvis ganmavlobaSi.<br />
farmakoTerapiis dawyebidan eqvsi Tvis Semdeg wonaSi damatebiTi kleba<br />
iSviaTad aRiniSneba, Tumca mkurnalobis gagrZelebis fonze<br />
SesaZlebelia wonis SenarCuneba. arsebobs monacemebi, mkurnalobis fonze<br />
wonis matebasTan dakavSirebiT. pacientebs xSirad aReniSnebaT wonis<br />
mateba mkurnalobmdel an ufro maRal maCveneblebamde, mas Semdeg rac<br />
isini Sewyveten medikamentur mkurnalobas.<br />
36
orlistati<br />
pacientebi, romlebic kvebisa da fizikuri aqtiurobis specialuri<br />
programis paralelurad Rebuloben preparat orlistats, erTi wlis<br />
Semdeg wonaSi mosalodnelia, rom gaxdnen 3.9-10.6 kg-iT, ori wlis Semdeg<br />
4.6-7.6 kg-iT. erT weliwadSi sawyisi wonis 5%-iT Semcireba aRiniSna 30%-<br />
70%-Si (vs 13%-45%-mde placebo jgufSi); erT weliwadSi sawyisi wonis<br />
10%-iT Semcireba aRiniSna 10%-41%-Si (vs 4%-21%-mde placebo jgufSi)<br />
(Grade I: Conclusion Grading Worksheet A – Annotation # 10 Orlistat, Institute for Clinical Systems<br />
Improvement, 2003).<br />
sibutramini<br />
pacientebisaTvis, romlebic kvebisa da fizikuri aqtiurobis specialuri<br />
programis paralelurad Rebuloben preparat sibutramins, mkurnalobis<br />
dawyebidan 24-52 kviris Semdeg wonaSi kleba mosalodnelia 4.4-16.6 kg-iT.<br />
erTi wlis ganmavlobaSi sawyisi wonis 5%-iT Semcireba aRiniSna 39%-77%-<br />
Si (vs 11%-40%-mde placebo jgufSi); erTi wlis ganmavlobaSi sawyisi<br />
wonis 10%-iT Semcireba aRiniSna 14%-46%-Si (vs 0%-8%-mde placebo<br />
jgufSi) (Grade I: Conclusion Grading Worksheet B – Annotation # 10 Sibutramine, Institute for<br />
Clinical Systems Improvement, 2003).<br />
Sejameba<br />
sibutraminiT mkurnalobis fonze regularulad unda warmoebdes<br />
arteriuli wnevis da gulis cemis sixSiris monitoringi, raTa<br />
droulad gamovavlinoT momatebuli maCveneblebis mqone pacientebi;<br />
orlistatiT mkurnalobisTvis damaxasiaTebelia gastrointestinuri<br />
gverdiTi efeqtebi. maTi sixSire da simZime droTa ganmavlobaSi<br />
(erTi kviris Semdeg) klebulobs. maT Semcirebas ganapirobebs<br />
agreTve sakvebSi cximis Semcvelobis gakontroleba;<br />
placebosTan SedarebiT, cxovrebis stilis cvlilebebTan erTad<br />
sibutraminisa da orlistatis fonze wonaSi klebis ukeTesi<br />
maCveneblebi aRiniSna;<br />
orive preparatze, pacientTa 5%-25%-ma warmatebiT ver daasrula<br />
kvlevis mosamzadebeli periodi; orive jgufis (samkurnalo da<br />
placebo) randomizebul pacientTa 9%-54%-ma warmatebiT ver<br />
daasrula kvlevis samkurnalo faza. udidesi sargebeli SeiZleba<br />
aRiniSnos pacientebSi visac Tanmxlebi daavadebis saxiT diabeti<br />
aReniSnebaT;<br />
pacientTa 50%-ze meti, romlebmac sawyisi wonis 5%-ze meti daiklo<br />
da 30%-ze meti, romlebmac sawyisi wonis 10%-ze meti daiklo gaiares<br />
placeboze yofnis winaswari mosamzadebeli periodi, romlis drosac<br />
gamoikveTa survili da unari ganexorcielebinaT cxovrebis wesis<br />
cvlilebebi;<br />
37
aRniSnuli preparatebis gamoyenebis Sesaxeb dakvirvebis maqsimaluri<br />
periodi 2 weliwads Seadgens. mcire informacia moipoveba ori wlis<br />
Semdeg wonis klebis procesSi farmakoTerapiis efeqturobaze.<br />
medikamenturi mkurnaloba da pacientebis monitoringi<br />
wonis medikamenturi mkurnalobis dawyebisTanave aucilebelia pacientTa<br />
monitoringi. monitoringis sqema gulisxmobs pacientebis Sefasebas<br />
oridan oTxi kviris SualedSi, TveSi erTxel momdevno 3 Tvis<br />
ganmavlobaSi da yovel sam TveSi erTxel mkurnalobis dawyebidan 1<br />
wlis ganmavlobaSi. aRniSnuli vizitebis dros fasdeba wona, welis<br />
garSemoweriloba, arteriuli wneva, gulis cemis sixSire, gverdiTi<br />
efeqtebis arseboba, warmoebs laboratoriuli testebi da pacientis<br />
SekiTxvebs eZleva pasuxebi.<br />
mkurnaloba warmatebulad iTvleba, Tu preparatis miRebis fonze ar<br />
aRiniSneba gverdiTi efeqtebi da mkurnalobis dawyebidan 6 Tvis Semdeg<br />
wonaSi kleba aRiniSneba 10% an meti. 6 Tvis Semdeg wonaSi klebis<br />
procesi aRwevs platos da upiratesoba eniWeba wonis SenarCunebas.<br />
SemdgomSi wonaSi dasaklebad saWiroa cxovrebis stilis modifikacia,<br />
rac kaloraJis Semcirebas da fizikuri aqtiurobis gazrdas gulisxmobs.<br />
ori wlis ganmavlobaSi welis garSemowerilobis Semcireba sul mcire 4<br />
sm-iT da namati 3 kg-ze (6.6 lb.) naklebi - wonis warmatebuli<br />
SenarCunebaa (National Heart, Lung and Blood Institute, 1998).<br />
alternatiuli medicina<br />
wonaSi dasaklebi ara-recepturuli preparatebis farTo arCevania<br />
sadReisod. aRniSnuli produqcia didi raodenobiT Seicavs sxvadasxva<br />
saxis ingredients, rogorc calke aseve kombinaciaSi.<br />
<strong>simsuqnis</strong> mkurnalobaSi alternatiuli samkurnalo saSualebebi metad<br />
popularulia. Tvlian, rom recepturul preparatebTan SedarebiT<br />
balaxeuli da sakvebis Camanacvlebeli saSualebebi gacilebiT<br />
usafrTxoa. aRniSnuli saSualebebis gamosayeneblad pacients ar<br />
esaWiroeba profesiuli samedicino daxmarebis Zieba. SezRuduli<br />
finansuri SesaZleblobis mqone msuqani pacientebisTvis es SesaZloa<br />
ufro iafi gamosavalic iyos. pacientTa nawili, vinc tradiciuli<br />
mkurnalobis mravaljeradi cdis miuxedavad Sedegs ver miaRwia, irCevs<br />
mkurnalobis alternatiul meTods.<br />
ar moipoveba informacia aRniSnuli saSualebebis xangrZlivad (1 welze<br />
meti) gamoyenebis Sesaxeb. miuxedavad balaxeuli saSualebebiT<br />
mkurnalobis mzardi popularobis, wonaSi dasaklebad maTi gamoyenebis<br />
Sesaxeb sakmarisi informacia ar moipoveba. ucnobia am saSualebebis<br />
axlo da Soreuli gverdiTi efeqtebi. gamomdinare iqidan, rom<br />
38
alaxeuli warmoSobis produqciis umetesoba arastandartizebulia,<br />
etiketze warmodgenili CamonaTvali SesaZloa mniSvnelovnad<br />
gansxvavdebodes produqciis Semcvelobisgan (Gurley, 2000). pacientebi,<br />
romlebic arafarmakologiur an balaxeul samkurnalo saSualebebs<br />
iyeneben informirebuli unda iyvnen SesaZlo gverdiTi efeqtebis da<br />
wamalTa urTierTqmedebis Sesaxeb (Miller 1998, Winslow 1998).<br />
6. <strong>simsuqnis</strong> marTvis algoriTmi<br />
simsuqne qronikuli, multifaqtoruli daavadebaa, romelsac<br />
kompleqsuri politikuri, socialuri, fsiqologiuri, garemo pirobebi,<br />
ekonomikuri da metaboluri mizezebi da Sedegebi gaaCnia. faqtobrivad,<br />
simsuqne sxeulis TiTqmis yvela Sinagan organoze axdens gavlenas;<br />
ojaxis eqimis praqtikaSi yvela pacients, simsuqnesTan da masTan<br />
dakavSirebuli riskis identificirebis mizniT, unda daudgindes<br />
sxeulis masis indeqsi da welis garSemoweriloba (A);<br />
gamoTvaleT sxeulis masis maCvenebeli; moaxdineT individebis<br />
klasificireba gamomdinare sxeulis masis maCvenebelTa<br />
kategoriebidan. moaxdineT informireba Tqveni pacientebis, maTi<br />
sxeulis masis maCveneblebis da masTan dakavSirebuli riskebis Sesaxeb;<br />
arsebobs wonis regulirebis efeqturi strategiebi, rac moicavs<br />
kvebas, fizikur aqtiurobas, cxovrebis stilis modificirebas,<br />
medikamentur mkurnalobas da qirurgiul Carevas;<br />
eqimma unda daicvas xuTi `A~-s principi (ask, advice, assess, assist, arrange)<br />
(kiTxva, rCeva, Sefaseba, daxmareba, mowesrigeba <strong>marTva</strong>). eqimis Careva<br />
efeqturi unda iyos, eqims SeuZlia mniSvnelovani gavlena iqonios da<br />
Sesabamisad wonis warmatebuli regulireba savsebiT SesaZlebelia;<br />
wonis regulireba gundur midgomas moiTxovs. gaTviTcnobierebuli<br />
unda gqondeT klinikuri da sazogadoebrivi resursebi. pacients<br />
sWirdeba mudmivi urTierToba ojaxis eqimTan da meTvalyureoba<br />
jandacvis gundis mxridan. wonis kontroli mTeli cxovrebis<br />
savaldebulo saqmea da jandacvis gundma unda moaxerxos<br />
pacientisTvis konkretuli miznebis dasaxvis xelSewyoba;<br />
nebismier pacients, sxeulis masis indeqsis da welis<br />
garSemowerolobis miuxedavad, unda Cautardes konsultireba jansaRi<br />
kvebisa da varjiSis Taobaze (C);<br />
pacientebs, romelTa smi > 25-ze, xolo welis garSemoweriloba<br />
mamakacebSi 94sm-s da qalebSi 80-s aRemateba, esaWiroebaT Semdgomi<br />
39
konsultacia da gamokvlevebi <strong>simsuqnis</strong> dadgenisa da misi marTvis<br />
adekvaturi gegmis SemuSavebis mizniT (C).<br />
garda Tavisi klinikuri rolisa, <strong>pirvelad</strong>i daxmarebis eqimebs Segnebuli<br />
unda hqondeT maTi rogorc sazogadoebis liderebis da janmrTelobis<br />
damcvelebis roli.<br />
prioritetuli miznebi<br />
1. gaacnobiereT sxeulis masis indeqsis mniSvneloba;<br />
2. gaaZliereT im pacientTa konsultireba da informirebuloba,<br />
romelTac aReniSnebaT Warbi sxeulis masis indeqsi, da darwmundiT,<br />
rom maT miewodaT saTanado konsultaciebi wonis klebasTan<br />
dakavSirebiT;<br />
3. gaaumjobeseT <strong>simsuqnis</strong> mkurnalobis Sedegi;<br />
4. gaaumjobeseT <strong>simsuqnis</strong> prevenciasa da mkurnalobaSi sazogadoebis<br />
(mosamsaxureTa, moswavleTa) CarTulobis done.<br />
Sesabamisi RonisZiebebi:<br />
1. gaaTviTcnobiereT sxeulis masis indeqsis gansazRvris aucilebloba.<br />
SesaZlo RonisZiebebi am miznis misaRwevad:<br />
a) im pacientTa procentuli raodenoba, visac Cautarda skriningi,<br />
daudginda sxeulis masis indeqsi da monacemebi dafiqsirda<br />
samedicino CanawerebSi (baraTSi) bolo 12 Tvis ganmavlobaSi;<br />
b) im pacientTa procentuli raodenoba, romelTa samedicino<br />
baraTebSi arsebuli dokumentacia mianiSnebs imaze, rom maT<br />
gaTviTcnobierebuli aqvT informacia sakuTari sxeulis masis<br />
indeqsis Sesaxeb bolo 12 Tvis ganmavlobaSi.<br />
2. daafiqsireT momatebuli sxeulis masis imdeqsis mqone pacientTa<br />
procentuli raodenoba, romlebmac miiRes saTanado ganaTleba da<br />
rCevebi wonis klebasTan dakavSirebiT.<br />
SesaZlo RonisZiebebi am miznis misaRwevad:<br />
a) dokumenturad dafiqsirebuli momatebuli sxeulis masis indeqsis<br />
mqone pacientTa procentuli raodenoba, romlebmac miiRes<br />
saTanado ganaTleba da rCevebi wonis klebasTan dakavSirebiT,<br />
rac moicavs kvebas, fizikur aqtiurobas, cxovrebis wesis<br />
cvlilebebs, medikamentur mkurnalobas da/an qirurgiul Carevas:<br />
smi 25-30: cxovrebis wesis Secvla da qcevis menejmenti;<br />
smi 30-35: cxovrebis wesis Secvla, qcevis menejmenti da<br />
medikamenturi mkurnaloba;<br />
smi 35-40: cxovrebis wesis Secvla, qcevis menejmenti da<br />
medikamenturi mkurnaloba;<br />
40
smi 40+: cxovrebis wesis Secvla, qcevis menejmenti, medikamenturi<br />
mkurnaloba da qirurgiuli Carevis SesaZlebloba.<br />
b) dokumenturad dafiqsirebuli, 25-is an ufro meti sxeulis masis<br />
indeqsis da Tanmxlebi daavadebebis mqone pacientTa procentuli<br />
raodenoba, romlebmac miiRes Sesatyvisi ganaTleba da rCevebi.<br />
3. gaaumjobeseT <strong>simsuqnis</strong> mkurnalobis Sedegi.<br />
SesaZlo RonisZiebebi am miznis misaRwevad:<br />
a) 25-is an meti sxeulis masis indeqsis mqone pacientTa procentuli<br />
raodenoba, samedicino baraTebSi arsebuli dokumenturi<br />
informaciiT, romelic mianiSnebs imaze, rom maT stabiluri<br />
sxeulis masis indeqsi aqvT an aReniSnebaT sxeulis masis indeqsis<br />
Semcireba bolo 12 Tvis ganmavlobaSi;<br />
b) im pacientTa procentuli raodenoba, romelTa samedicino<br />
baraTebSi arsebuli dokumenturi informaciis mixedviT maTi<br />
fizikuri aqtiuroba Seadgens 30 wuTs, kviraSi xuTjer;<br />
g) im pacientTa procentuli raodenoba, romlebmac individualuri<br />
mizani daisaxes, sxeulis masis indeqsis Semcirebis dagegmil<br />
periodSi;<br />
d) im pacientTa procentuli raodenoba, romlebmac sxeulis masis<br />
indeqsTan dakavSirebiT dasaxul mizans dagegmil vadaSi miaRwies.<br />
4. gaaumjobeseT sazogadoebis (damsaqmeblebis, skolebis) CarTulobis<br />
done <strong>simsuqnis</strong> prevenciasa da mkurnalobaSi.<br />
SesaZlo RonisZiebebi am miznis misaRwevad:<br />
a) im damsaqmeblebisa da skolebis raodenoba, romlebic sTavazoben<br />
an mxars uWeren wonis optimizaciis programebs;<br />
b) im damsaqmeblebisa da skolebis raodenoba, romlebic sTavazoben<br />
janmrTeli kvebis arCevans;<br />
g) im damsaqmeblebisa da skolebis raodenoba, romlebic mxars<br />
uWeren fizikur aqtiurobas im doneze, romelic SesaZlebelia<br />
samuSao an sazogadoebriv adgilebSi.<br />
41
<strong>simsuqnis</strong> prevencia da menejmenti (mozardebisa da mozrdilebisTvis)<br />
prevenciis da diagnostikis algoriTmi.<br />
1<br />
simaRlis da wonis gazomva<br />
da sxeulis masis<br />
indeqsis gamoTvla<br />
7<br />
Tanmxlebi daavadebebis<br />
Sefaseba (komorbiduli<br />
daavadebebi)<br />
8<br />
mzadaa pacienti<br />
wonis daklebisTvis?<br />
6<br />
rCeva wonis kontrolis<br />
da sxva risk-faqtorebis<br />
<strong>marTva</strong> A<br />
3<br />
normaluri masa<br />
smi 18,5-24,9<br />
4<br />
sxeulis masis<br />
deficiti smi 40<br />
riski dabali zomieri maRali ukiduresi<br />
kveba X X X X<br />
fiz. aqtiuroba X X X X<br />
qcevis menejmenti X X X X<br />
medikamentebi *X+ X X X<br />
qirurgiuli Careva ? *X X<br />
* SeiZleba mxedvelobaSi iqnes miRebuli Tu arsebobs Tanmxlebi,<br />
simsuqnesTan dakavSirebuli risk-fatorebi da daavadebebi<br />
+ SeiZleba daiwyos, Tu smi aRwevs 27-s an metia<br />
? operaciuli Careva droebiT kvlevis sagans warmoadgens<br />
diax<br />
2<br />
smi≥25?<br />
diax<br />
diax<br />
11<br />
ganmeorebiTi Sefaseba<br />
12 kviris Semdeg<br />
12<br />
mizani<br />
miRweulia<br />
ara<br />
ara<br />
ara<br />
13<br />
5<br />
gaidlainSi ar<br />
ganixileba<br />
10a<br />
ixileT rekomendaciebi<br />
menejmentis<br />
Sesaxeb,<br />
dafuZnebuli smi/daavadebebis<br />
riskze<br />
ganmeorebiTi Sefaseba miznebisa<br />
da risk-faqtorebis da wonis<br />
ganxilva A<br />
42
algoriTmis anotaciebi<br />
1. gazomeT simaRle da wona da gamoiangariSeT sxeulis masis indeqsi<br />
sakvanZo punqtebi:<br />
janmrTelobisaTvis metad saSiSia da simsuqne warmoadgens<br />
multifaqtorul, qronikul daavadebas;<br />
sxeulis masis indeqsi, sasurvelia, gamoiTvalos yovelwliurad<br />
skriningiT (mosaxleobis masobrivi gamokvleva) da mkurnalobis<br />
SemTxvevaSi saWiroebisamebr;<br />
sxeulis masis indeqsis gamoTvla yvela asakobriv jgufze<br />
vrceldeba. taneris skaliT me-5 donis mozardebi da bavSvebi unda<br />
Sefasdnen arsebuli zrdis diagramebis mixedviT.<br />
detaluri rekomendaciebisTvis ix. `diagnozi da Sefaseba~, `sxeulis<br />
masis indeqsis gamoTvla~, `sxeulis masis indeqsis Sefaseba~, `sxeulis<br />
masis Sefaseba mozardebSi~, `welis garSemoweriloba~.<br />
2. rCevebi wonis SenarCunebisa da sxva risk-faqtorebis marTvisTvis<br />
metad mniSvnelovania wonis SenarCunebis sakiTxi maTTvis, visac<br />
sxeulis masis indeqsi normaluri aqvs;<br />
wonis SenarCunebis RonisZiebebi moicavs fizikuri aqtiurobis,<br />
kvebis da cxovrebis stilis marTvis strategias.<br />
mniSvnelovania, wonis SenarCunebis sakiTxis imaTzec mi<strong>marTva</strong>, visac,<br />
sxeulis masis indeqsi normalur diapazonSi (18,5-dan 24,9-mde) aqvT.<br />
wonis normaluri maCvenebeli moiTxovs mTeli cxovrebis manZilze mudmiv<br />
yuradRebas, rac niSnavs: fizikur aqtiurobas, swor kvebas, cxovrebis<br />
stilisa da yuradRebas fsiqo-socialuri faqtorebis swor <strong>marTva</strong>s.<br />
pirvel yovlisa, ecadeT regularulad iyoT fizikurad<br />
datvirTulni, TqvenTvis mocemuli rekomendaciis mixedviT.<br />
regularuli fizikuri aqtiuroba pirdapir aris dakavSirebuli<br />
normaluri wonis SenarCunebasTan. fizikuri aqtiurobis tipis<br />
SerCevisas mniSvnelovania gaiTvaliswinoT pacientis asaki, Zvalsaxsrovani<br />
da kunTovani sistemis mdgomareoba (SezRuduloba) da<br />
savarjiSo mowyobilobebis arseboba. araaqtiuri pacientebisTvis is<br />
SeiZleba moicavdes rogorc minimum 10 wuTian fizikur aqtiurobas<br />
dReSi. idealuria 30-dan 60 wuTamde saSualo fizikuri aqtiuroba<br />
rekomendebuli kviris umetesi dReebis ganmavlobaSi. Tumca,<br />
maTTvis, vinc sakmaod daiklo wonaSi, wonis SenarCunebisTvis<br />
43
SesaZloa dasWirdes ufro didi moculobis fizikuri datvirTva.<br />
fizikuri aqtiuroba da misi mravalferovneba warmoadgens ZiriTad<br />
faqtors wonis SenarCunebisaTvis;<br />
meore, ganixileT sxvadasxva variantebi cxovrebis stilis modificirebasTan<br />
dakavSirebiT, romlebic moicavs konkretul<br />
rekomendaciebs ganaTlebas da xSir kontaqts jandacvis muSakebTan,<br />
dietologebTan. gaamaxvileT yuradReba kaloriebze, gamoiyeneT<br />
fizikuri aqtiurobis farglebSi Semcirebuli kaloriebis<br />
moxmarebisa da gazrdili raodenobiT kaloriebis xarjvis<br />
kombinaciebi. CarTeT kvebasTan dakavSirebuli ganaTleba<br />
(magaliTad, gaecaniT sakvebi produqtebis etiketebs); miiReT<br />
informacia sazogadoebrivi kvebis situaciebis organizaciebSi,<br />
gaakeTeT arCevani jansaRi kvebis sasargeblod; yuradReba miaqcieT<br />
ulufebis zomas da sakvebis ingredientebs, sakvebis damzadebas da<br />
kaloraJs.<br />
arsebobs gasaTvaliswinebeli faqtebi imisa, rom is pirebi,<br />
romlebic dabalkaloriul, cximis mcire Semcvelobis dietas<br />
iyeneben, warmatebiT axerxeben wonis mudmiv daklebas 12 Tvis da<br />
ufro meti drois ganmavlobaSi. “wonis kontrolis erovnuli<br />
registris” monacemebi cxadyofs, rom isini, vinc wonas warmatebiT<br />
inarCunebs, iyeneben dabalkaloriul dietebs, romelic moicavs ~40g<br />
cxims (kaloriebis 24%), 200g naxSirwyals (kaloriebis 56%) da 70g<br />
cilebs (kaloriebis 19%). cximis mcire Semcvelobis dietebi<br />
(kaloriebis 25-30%-s miReba cximidan) ganixileba rogorc<br />
sayovelTaod miRebuli Terapia <strong>simsuqnis</strong> mkurnalobisas.<br />
mesame, xeli SeuwyeT cxovrebis stilis marTvis strategias,<br />
romelic moicavs wonis yovelkvireul Semowmebas, kvebis Jurnalis<br />
warmoebas da yoveldRiuri reJimis monitorings, rac niSnavs<br />
dabalansebul cxovrebis stils, moicavs sauzmes gaRviZebidan rac<br />
SeiZleba mokle xanSi da SemdgomSi balansirebuli kerZebis<br />
miRebas erTi da igive intervalebiT; gasarTob fizikur aqtiurobas<br />
dRis ganmavlobaSi; kviris dagegmvas, rac samuSaosTan, skolasTan<br />
da saojaxo valdebulebebTan erTad dasvenebas, TamaSs da<br />
socialur urTierTobas moicavs.<br />
konkretuli strategiuli gegmebi, romlebic ganapirobeben<br />
cxovrebis stilis cvlilebebs, moicaven cxovrebis stilis zogierTi<br />
aspeqtis TviTmonitorings, rac, Tavis mxriv, gamoixateba<br />
qcevis cvlilebaSi; kvebis kontrols, stresebis menejments,<br />
problemebis gadaWrasa da pacientebisTvis warmatebis miRwevis<br />
xelSewyobaSi.<br />
detaluri rekomendaciebisTvis ix. `Warbi wonis da <strong>simsuqnis</strong> mkurnaloba<br />
da xangrZlivi meTvalyureoba~, `cxovrebis wesis Secvla~.<br />
44
3. mzad aris pacienti daiklos wonaSi?<br />
pacientis mzadyofnis Sefaseba saSualebas iZleva ganvsazRroT<br />
misi motivaciis done, rac gvexmareba komunikaciis ukeT<br />
war<strong>marTva</strong>Si;<br />
pacients evaleba dasaxos realisturi, miRwevadi miznebi da iyos<br />
pasuxismgebeli axal qcevaze, romlis meSveobiTac xorcieldeba<br />
wonis dakleba da SenarCuneba.<br />
eqimma unda ixelmZRvanelos `5 A~-s principiT (Ask-SeekiTxe, Advise-urCie,<br />
Assist-daexmare, Assess-Seafase, Arrange-monitorireba gauwie). warmatebuli<br />
marTvis misaRwevad metad efeqturia procesSi eqimis CarTva, mas SeuZlia<br />
mniSvnelovani zegavlenis moxdena.<br />
detaluri rekomendaciebisTvis ix. `Warbi wonis da <strong>simsuqnis</strong> mkurnaloba<br />
da xangrZlivi meTvalyureoba~, `pacientis mzadyofnis Sefaseba~ da<br />
`cxovrebis wesis Secvla~.<br />
4. wonaSi daklebis misaRwevad dasaxeT miznebi da marTvis strategia.<br />
saWiroebisamebr mimarTeT riskis Sesabamis wyaroebs.<br />
kvebiTi rekomendaciebi gulisxmobs kaloriebis Semcirebas ulufis<br />
zomis da raodenobis SefasebiT;<br />
fizikuri aqtiurobis fiziologiuri efeqtebi mniSvnelovnad aris<br />
damokidebuli moZraobis sixSireze, xangrZlivobasa da<br />
intensivobaze;<br />
cxovrebis stilis modifikacia (kveba da fizikuri aqtiuroba)<br />
farmakoTerapiasTan (6 Tvidan 1 wlamde) erTad kombinaciaSi<br />
ganapirobebs wonaSi daklebas msuqan pacientebSi;<br />
bariatriuli qirurgia (<strong>simsuqnis</strong> qirurgiuli mkurnaloba: kuWis,<br />
gastroplastika,) naCvenebia gansakuTrebuli jgufis pacientebSi,<br />
romelTa sxeulis masis indeqsi 40-ze metia an utoldeba 35-39.9-s,<br />
romlebic naadrevi sikvdilis an invalidobis absoluturi riskis<br />
winaSe arian. pacientebi unda iyvnen fsiqologiurad<br />
gawonasworebuli, motivirebuli, kargad informirebuli daavadebis<br />
marTvis da operaciuli riskis Sesaxeb. bariatriuli qirurgia<br />
iZleva mniSvnelovan da xangrZliv Sedegebs, Tumca ar aris<br />
cnobili Soreuli Sedegebi;<br />
mniSvnelovania yoveldRiuri, yovelkvireuli da xanmokle miznebis<br />
dasaxva.<br />
detaluri rekomendaciebisTvis ix. `Warbi wonis da <strong>simsuqnis</strong> mkurnaloba<br />
da xangrZlivi meTvalyureoba~.<br />
45
7. praqtikaSi danergvis ZiriTadi rekomendaciebi<br />
1. gaidlainis gavrceleba <strong>pirvelad</strong>i jandacvis qselSi;<br />
2. samedicino personalis ganaTleba: uwyveti samedicino programebis<br />
SemuSaveba da treningebis organizeba eqimebisa da eqTnebisaTvis.<br />
mokle fokusirebuli rCevebi kvebasTan, fizikur aqtiurobasa da<br />
cxovrebis stilis cvlilebebeTan dakavSirebiT, medikamenturi<br />
mkurnalobis efeqturobis damadasturebeli kvlevebi da<br />
mticebulebebi;<br />
3. pacientebis ukeT informirebulobisa da ganaTlebis mizniT<br />
samkurnalo dawesebulebebSi TvalsaCino adgilze smi-is diagramis<br />
ganTavseba, posterebis da broSurebis gamoyeneba, romlebic xels<br />
Seuwyobs pacientTa codnis amaRlebas jansaRi cxovrebis stilis,<br />
smi-is Sesaxeb;<br />
4. samedicino Canawerebis sistemis gaumjobeseba: rutinuli vizitebis<br />
dros smi-is gamoTvla;<br />
5. pjd dawesebulebebSi yovelwliuri auditis Catareba.B<br />
auditis kriteriumebi<br />
miRweuli warmatebis Sefaseba<br />
dokumenturad dafiqsirebuli gazrdili sxeulis masis indeqsis mqone<br />
pacientTa procentuli raodenoba, romlebmac miiRes saTanado ganaTleba<br />
da rCevebi wonis klebis strategiebis Sesaxeb, rac moicavs kvebas,<br />
fizikur aqtiurobas, cxovrebis wesis Secvlas, medikamentur<br />
mkurnalobas da/an qirurgiul Carevas.<br />
samizne mosaxleoba<br />
pacientebi Semdeg diapazonSi gazrdili sxeulis masis indeqsiT:<br />
25-30<br />
30-35<br />
35-40<br />
40+<br />
46
auditis kriteriumebis gamoTvla<br />
mricxveli: gazrdili sxeulis masis indeqsis mqone pacientTa<br />
raodenoba, romlebmac miiRes saTanado ganaTleba da<br />
rCevebi wonis daklebis mizniT, rac moicavs kvebas,<br />
fizikur aqtiurobas, cxovrebis wesis Secvlas,<br />
medikamentur mkurnalobas da/an qirurgiul Carevas<br />
Sesabamis pacientebSi.<br />
mniSvneli: gazrdili sxeulis masis indeqsis mqone pacientebi.<br />
monacemTa Segrovebis meTodi/wyaro:<br />
SearCieT 20 pacienti, romlebic gasinjul iqnen bolo Tvis ganmavlobaSi<br />
da romlebsac gazrdili sxeulis masis indeqsi aqvT. Tu sxeulis masis<br />
indeqsi ar aris dafiqsirebuli dokumentebSi, gamoiyeneT smi-is<br />
gamoTvlis meTodi: wona (kg-Si) gayofili simaRlis kvadratze an<br />
mimarTeT sxeulis masis indeqsis diagramas.<br />
unda ganxilul iqnes samedicino baraTebi raTa dadgindes, erTi an meti<br />
wonis SenarCunebuli strategia dokumentebSi iyo dafiqsirebuli Tu ara.<br />
komentarebis an procesis ganxorcielebis sqemis arseboba, TandarTuli<br />
gegma Semdgom CamoTvlili wonis SenarCunebuli strategiebidan erTis an<br />
metis Sesaxeb. es strategiebia: kveba, fizikuri aqtiuroba, cxovrebis<br />
wesis Secvla, medikamenturi mkurnaloba da/an qirurgiuli Careva.<br />
auditis Catarebis dro<br />
savaraudo drois periodia konsultaciebi 12 Tvis ganmavlobaSi.<br />
8. gaidlainis gadasinjvis da ganaxlebis vada: 2 weli.<br />
9. gaidlainis miRebis xerxi/wyaro:<br />
gaidlaini emyareba gaidlains - ~simsuqne _ prevencia da menejmenti<br />
(mozardebis da mozrdilebis),” ICSI meoTxe gamocema, 20009) da<br />
warmoadgens mis adaptirebul variants.<br />
47
mtkicebulebis done da rekomendaciebis xarisxi<br />
done mtkicebulebis done<br />
I<br />
II<br />
III<br />
IV<br />
Vა<br />
Vბ<br />
Zlieri mtkicebuleba, eyrdnoba minimum<br />
erT sistemur mimoxilvas, romelic<br />
efuZneba swori dizainis mqone<br />
randomizebul kontrolirebad kvlevas<br />
Zlieri mtkicebuleba, eyrdnoba minimum<br />
erT swori dizainis mqone<br />
randomizebul kontrolirebad kvlevas<br />
klinikuri kvleva randomizaciis<br />
gareSe, kohortuli da SemTxvevakontrolis<br />
kvlevebi<br />
araeqsperimentuli multicentruli<br />
kvlevebi<br />
avtoritetul profesionalTa<br />
mosazreba<br />
klinikuri gamocdileba, aRwerilobiTi<br />
kvlevebi an eqspertTa angariSi<br />
xarisxi<br />
10. alternatiuli gaidlaini ar arsebobs.<br />
11. gamoyenebuli literatura<br />
A<br />
B<br />
C<br />
D<br />
rekomendaciis xarisxi<br />
eyrdnoba I donis<br />
mtkicebulebas da<br />
Sesabamisad mtkiced<br />
rekomendebulia<br />
eyrdnoba II donis<br />
mtkicebulebas da<br />
Sesabamisad<br />
rekomendebulia<br />
eyrdnoba III donis<br />
mtkicebulebas, SeiZleba<br />
CaiTvalos Sesabamisad<br />
eyrdnoba IV da V donis<br />
mtkicebulebas,<br />
saWiroebs konsesuss<br />
1. “Prevention and Management of obesity ( Mature Adolescents and Adults).- “ ICSI – Fourts<br />
Edition January 2009.<br />
2. Abenhaim L, Moride Y. Brenot, et al. Appetite suppressant drugs and the risk of primary pulmonary<br />
hypertension. N Engl J Med 1996;335:609-16. (Class C)<br />
3. Abid O, Galuska D, Khal KL, et al. Are health care professionals advising obese patient to lose<br />
weight? A trend analysis. Medscape Gen Med 2005;7:3-12. (Class M)<br />
4. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J<br />
Med 2007;357:753-61. (Class B)<br />
5. Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of physical activities: classification of<br />
energy costs of human physical activities. Med Sci Sports Exerc 1993;25:71-80. (Class R)<br />
48
6. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of<br />
activity codes and metabolic equivalency intensities. Med Sci Sports Exerc 2000;32:S498-S516.<br />
(Class R)<br />
7. Algomy G. Crookes PF, Anthone GJ. Longitudinal gastrectomy as a treatment for the high-risk<br />
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150. Lee CM. Laparoscopic vertical sleeve gastrectomy for morbid obesity in 216 patients: report of twoyear<br />
results. Surg Endosc 2006; 20:S255. (Class C)<br />
151. Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body<br />
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152. Linde JA, Jeffery RW, Levy RL, et al. Binge eating disorder, weight control self-efficacy, and<br />
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153. Lindström J, Louheranta A, Mannelin M, et al. The Finnish diabetes prevention study (DPS).<br />
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154. Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor<br />
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155. Logue E, Sutton K, Jarjoura D, et al. Transtheoretical model-chronic disease care for obesity in<br />
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156. Logue EE, Jarjoura DG, Sutton KS, et al. Longitudinal relationship between elapsed time in the<br />
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55
162. McGuire MT, Wing RR, Klem ML, et al. Long-term maintenance of weight loss: do people who<br />
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56
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60
12. avtorTa jgufi<br />
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda<br />
saqarTvelos ojaxis eqimTa asociaciis mier<br />
avtorebi:<br />
marina SixaSvili (ojaxis eqimi), eka faRava (ojaxis eqimi), Tamar<br />
zuraSvili (ojaxis eqimi), manana koplataZe (endokrinologi),<br />
givi javaSvili (redaqtori), guram kiknaZe (redaqtori).<br />
eqspertebi:<br />
q. asaTiani _ saqarTvelos <strong>simsuqnis</strong> Semswavleli asociacia;<br />
saqarTvelos saojaxo medicinis profesionalTa kavSiri;<br />
lela woworia _ saqarTvelos Sromis, janmrTelobisa da<br />
socialuri dacvis saministros janmrTelobis dacvis<br />
departamenti;<br />
Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da<br />
socialuri dacvis saministros janmrTelobis dacvis<br />
departamenti;<br />
Tamar ZagniZe _ saqarTvelos Sromis, janmrTelobisa da<br />
socialuri dacvis saministros janmrTelobis dacvis<br />
departamenti;<br />
61
danarTebi<br />
danarTi 1. smi gamosaxuli centilebSi asakis mixedviT<br />
gogonebi: 2-dan 20 wlamde. saxeli, gvari______<br />
62
iWebi 2-dan 20wlamde saxeli, gvari_________<br />
63
danarTi 2. wonis matebasTan dakavSirebuli medikamentebi<br />
medikamentTa klasi<br />
neiroleptikebi (Aronne 2003 [R]):<br />
fenoTiazinebi<br />
atipiuri neiroleptikebi:<br />
klozapini > olanzapini > risperidoni = qetiapini<br />
normoTimikebi:<br />
liTiumi<br />
antidepresantebi:<br />
tricikluri (Masand 2000 [R])<br />
amitriptilini > imipramini<br />
monoaminoqsidazas inhibitorebi (araseleqtiuri)<br />
izokarboqsazidi, fenelzini, tranilcipromini<br />
seleqtiuri serotoninis ukumitacebis<br />
inhibitorebi (Sussman 2001 [M]):<br />
paroqsetini > citaloprami, fluvoqsamini,<br />
sertralini<br />
mirtazapini<br />
epilefsiis sawinaaRmdego saSualebebi:<br />
gabapentini, valproati, karbamazepini, pregabalini<br />
antiepileptikebi/neiroleptikebi gamoyenebuli<br />
bipolaruli aSlilobisas (Nemeroff, 2003 [R])<br />
valproati, karbamazepini, klozapini, olanzapini,<br />
risperidoni<br />
steroiduli hormonebi:<br />
hormonaluri kontraceptivebi<br />
kortikosteroidebi<br />
progestaciuri steroidebi:<br />
megestrolis acetati<br />
diabetis sawinaaRmdego saSualebebi:<br />
insulini<br />
silfonilureazi<br />
Tiazolidindionebi<br />
hipertoniis sawinaaRmdego saSualebebi:<br />
beta da alfa-1 adrenomablokirebeli saSualebebi<br />
antihistaminebi:<br />
ciproheptadini<br />
alternatiuli<br />
varianti<br />
ziprazidoni,<br />
aripiprazoli<br />
nefazodoni, bupropioni,<br />
venlafaqsini<br />
lamotrijini, topiramati<br />
lamotrijini, topiramati,<br />
ziprazidoni<br />
eTinil-estradiolis da<br />
drospirenonis kombinacia<br />
wonis kleba, aromatazas<br />
inhibitorebi<br />
metformini, akarboza,<br />
eqsenatidis ineqcia<br />
agf-inhibitorebi, arb-ebi,<br />
diuretikebi, kalciumis<br />
arxebis blokerebi<br />
difenhidramini,<br />
dekongestantebi (SeSup.<br />
saw.), inhalatorebi<br />
(adaptirebulia Greenway, 2003 [R]; Kushner. 2003b [R]; Weigle, 2003 [R])<br />
64
saxeobis<br />
saxelwodeba<br />
benzfetamini<br />
dieTilpropioni<br />
meTamfetamini<br />
fendimetrazini<br />
fentermini<br />
fentermini<br />
fisis<br />
kompleqsi<br />
sibutramini<br />
orlistati<br />
danarTi 3. <strong>simsuqnis</strong> samkurnalo medikamentebis nusxa,<br />
romelic damtkicebulia FDA 2 _s mier 3<br />
moqmedebis<br />
meqanizmi<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
simpaTomimetiki, iwvevs centraluri nervuli<br />
sistemis stimulacias da moqmedebs rogorc<br />
anoreqtiki (madis damTrgunveli)<br />
Terapiuli efeqti miiRweva norefinefrinis,<br />
serotoninisa da dopaminis STanTqmis Sene-<br />
lebiT. sibutramini da misi ZiriTadi<br />
farmakologiurad aqtiuri metabolitebi (M 1<br />
da M 2 ) ar moqmedeben monoaminebis<br />
gamonTavisuflebis gamo; Sedegi gaZRomis<br />
gaumjobesebuli SegrZnebaa<br />
lipazebis Seqcevadad moqmedi inhibitori;<br />
Tavis Terapiul aqtiurobas amJRavnebs mci-<br />
re nawlavSi gastralur da pankreatiul<br />
lipazebTan kovalentuli bmis formirebiT<br />
da trigliceridebis hidrolizis momdevno<br />
SemcirebiT, da maT Soris qolesterinis<br />
STanTqmiT<br />
miTiTeba<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia egzogenuri (gare) <strong>simsuqnis</strong> mkurnalobisaTvis<br />
rogorc moklevadiani xelSemwyobi saSualeba (ramodenime<br />
kvira) kaloriebis SezRudvaze dayrdnobili wonis<br />
daklebis mkurnalobis sqemis dros<br />
gankuTvnilia <strong>simsuqnis</strong> mkurnalobisaTvis, maT Soris wonis<br />
daklebisa da gagrZelebisaTvis; unda gamoyenebul iqnes<br />
kaloriebis Semcirebi dros dietasTan erTad<br />
gankuTvnilia <strong>simsuqnis</strong> mkurnalobisTvis, maT Soris wonis<br />
daklebisa da gagrZelebisaTvis, rodesac gamoiyeneba<br />
kaloriebis Semcireba dietasTan erTad; aseve gankuTvnilia<br />
wonis aRdgenis riskis SemcirebisaTvis, wonis daklebis<br />
Semdeg an manamde<br />
2 sakvebi produqtebisa da medikamentebis saagento (Food and Drug Administration).<br />
3 miTiTebulia mxolod generiuli dasaxelebebi.<br />
65
danarTi 4. FDA_s mier <strong>simsuqnis</strong> samkurnalod damtkicebuli<br />
medikamentebis uaryofiTi efeqtebi 4<br />
saxeobis<br />
saxelwodeba<br />
benzfetamini<br />
dieTilpropioni<br />
meTamfetamini<br />
fendimetrazini<br />
fentermini<br />
fentermini<br />
fisis<br />
kompleqsi<br />
sibutramini<br />
orlistati<br />
uaryofiTi efeqti gafrTxileba da ukuCvenebebi<br />
Tavis tkivilebi, uZiloba, aRznebadoba<br />
(nerviuloba), gaRizianeba, taqikardia,<br />
hipertenzia da aCqarebuli guliscema<br />
cns-is aRznebadoba, Tavbruxvevebi, Tavis<br />
tkivilebi, kuWSi Sekruloba, simSrale pirSi,<br />
Rebineba, uZiloba RebinebiT, SfoTva,<br />
arteriuli wnevis mcire momateba, aCqarebuli<br />
guliscema/msubuqi taqikardia<br />
cns-is aRznebadoba, Tavbruxvevebi, Tavis<br />
tkivilebi, kuWSi Sekruloba, simSrale pirSi,<br />
Rebineba, uZiloba RebinebiT, SfoTva,<br />
arteriuli wnevis mcire momateba, aCqarebuli<br />
guliscema/msubuqi taqikardia<br />
cns-is aRznebadoba, Tavbruxvevebi, Tavis<br />
tkivilebi, kuWSi Sekruloba, simSrale pirSi,<br />
Rebineba, uZiloba RebinebiT, SfoTva,<br />
arteriuli wnevis mcire momateba, aCqarebuli<br />
guliscema/msubuqi taqikardia<br />
filtvebis <strong>pirvelad</strong>i hipertenzia da/an<br />
SeqceviTi kardiovaskularuli daavadeba,<br />
aCqarebuli guliscema, taqikardia, arteriuli<br />
wnevis momateba, gaRizianeba, SfoTva,<br />
Tavbruxvevebi, uZiloba, eiforia, tremori,<br />
Tavis tkivilebi<br />
filtvebis <strong>pirvelad</strong>i hipertenzia da/an Seqce-<br />
vadi kardiovaskularuli daavadeba,<br />
aCqarebuli guliscema, taqikardia, arteriuli<br />
wnevis momateba, gaRizianeba, SfoTva,<br />
Tavbruxvevebi, uZiloba, eiforia, disforia,<br />
tremori, Tavis tkivilebi<br />
normasTan Seusabamo ekg, hipertenzia,<br />
aCqarebuli guliscema, taqikardia, simSrale<br />
pirSi (17%), Tavis tkivilebi (30%), uZiloba<br />
(10%), anoreqsia (madis dakargva) (13%), kuWSi<br />
Sekruloba (11,5%)<br />
muclis tkivilebi/diskomforti, cximiani<br />
ganavali, kuWSi gasvlis xSiri survili,<br />
nawlavTa aSliloba<br />
naadrevi aTeriosklerozi, hipertenzia, hiperTiroidizmi,<br />
glaukoma<br />
naadrevi aTeriosklerozi, aRznebuli mdgomare-<br />
oba,hiperTreoidizmi monoaminoqsidazas inhibitorebis<br />
miRebisas 14 dRis farglebSi, glaukoma, narkotikebis<br />
moxmareba anamnezSi, hiper- an mometebuli mgrZnobeloba<br />
(idiosinkrazia) simpaTomimetikis aminebisadmi,<br />
hiperTiroidizmi, Zlieri hipertenzia<br />
glaukoma, naadrevi aTeriosklerozi, simptomaturi<br />
kardiovaskuluri daavadeba, hipertenzia, hiperTiroidizmi,<br />
monoaminoqsidazas inhibitorebis miRebisas<br />
naadrevi aTriosklerozi, simptomaturi kardiovaskuluri<br />
daavadeba, hipertenzia, hiperTiroidizmi, glaukoma, cns-is sxva<br />
stimulatorebi maT Soris monoaminoqsidazas inhibitorebi,<br />
naadrevi aTeriosklerozi, kardiovaskularuli daavadeba,<br />
hipertenzia, hiperTiroidizmi, glaukoma<br />
naadrevi aTriosklerozi, kardiovaskuluri daavadeba,<br />
hipertenzia, hiperTiroidizmi, glaukoma<br />
nervuli anoreqsia, monoaminoqsidazas inhibitorebis<br />
Tanmxlebi gamoyeneba, gulis koronaruli daavadeba, gulis<br />
mwvave ukmarisoba, insulti , ariTmia, arakontrolirebadi<br />
hipertenzia, narkotikebis moxmareba anamnezSi, orsuloba an<br />
ZuZus woveba, neirogenuri bulimia, medikamentebis Tanmxlebi<br />
miReba, romelic mavned moqmedebs hemostazsa da<br />
trombocitebis funqciaze, qolestazi, RviZlis dazianeba,<br />
glaukoma, filtvebis hipertenzia, Tirkmlebis ukmarisoba da<br />
gulyrebi anamnezSi<br />
qolestazi qronikuli malabsorbciis sindromi, kuW-nawlavis<br />
daavadeba, pacientebi cximSi xsnadi vitaminebis deficitis<br />
riskiT<br />
4 miTiTebulia mxolod generiuli dasaxelebebi<br />
66
danarTi 5. FDA_s mier <strong>simsuqnis</strong> samkurnalod damtkicebuli<br />
medikamentebis urTierTqmedeba<br />
saxeobis<br />
saxelwodeba<br />
benzfetamini<br />
dieTilpropioni<br />
meTamfetamini<br />
fendimetrazini<br />
fentermini<br />
fentermini<br />
fisis<br />
kompleqsi<br />
sibutramini<br />
orlistati<br />
medikamentebis urTierTqmedeba<br />
cns-is stimulatorebi,<br />
monoaminoqsidazas inhibitorebi<br />
tricikluri antidepresantebi<br />
hipertenziis sawinaaRmdego saSualebebi<br />
guaneTidini<br />
monoaminoqsidazas inhibitorebi<br />
sibutramini<br />
Tioridazini<br />
insulini<br />
guaneTidini<br />
monoaminoqsidazas inhibitorebi<br />
fenoTiazinebi<br />
tricikluri antidepresantebi<br />
amfetamini<br />
monoaminoqsidazas inhibitorebi<br />
sibutramini<br />
monoaminoqsidazas inhibitorebi<br />
sibutramini<br />
krazana<br />
pirdapiri qmedebis madis damTrgunvelebi<br />
deqstromeTorfani<br />
dihidroergotamini<br />
droperidoli<br />
ergotamini<br />
fentanili<br />
liTiumi<br />
meperidini<br />
monoaminoqsidazas inhibitorebi<br />
pentazocini<br />
serotoninis SeboWvis seleqtiuri inhibitorebi (SSRIs)<br />
krazana<br />
triptofani<br />
iohimbini<br />
67
danarTi 6. fizikuri aqtiurobis recepti (daniSnuleba)<br />
saxeli _____________<br />
TariRi _____________<br />
dakvirvebis intervali _______________<br />
janmrTelobis mdgomareoba fizikuri aqtiurobisaTvis<br />
amJamindeli diagnozi (ix. ukuCvenebebi): amJamindeli mkurnaloba<br />
1. 1.<br />
2. 2.<br />
3. 3.<br />
Sefaseba:<br />
_______ Tanxmoba TviT-monitoringiT aqtiurobis programaze<br />
_______ Tanxmoba mxedvelobis qveS aqtiurobis programaze (mi<strong>marTva</strong> eqimTan)<br />
_______ moiTxovs varjiSisadmi testirebas (mi<strong>marTva</strong> eqimTan)<br />
aqtiurobis mgegmavi: sezoni _________<br />
saSinao pirobebSi – marto saSinao pirobebSi _ sxvebTan erTad<br />
1. aqtiurobis 1. aqtiurobis<br />
resursi resursi<br />
a) a)<br />
b) b)<br />
g) g)<br />
2. aqtiurobis 1. aqtiurobis<br />
resursi resursi<br />
a) a)<br />
b) b)<br />
g) g)<br />
gareT _ marto gareT – sxvebTan erTad<br />
1. aqtiurobis 1. aqtiurobis<br />
resursi resursi<br />
a) a)<br />
b) b)<br />
g) g)<br />
2. aqtiurobis 1. aqtiurobis<br />
resursi resursi<br />
a) a)<br />
b) b)<br />
g) g)<br />
aqtiuroba:<br />
siaruli<br />
curva<br />
velosipedi<br />
mebaReoba<br />
CogburTi<br />
gazonebis<br />
gaTibva<br />
golfi<br />
ioga<br />
eqskursia<br />
gorgolaWebiT<br />
sriali<br />
fexburTi<br />
aerobika<br />
cekva<br />
pacientma unda moaxdinos minimum ori SesaZlo aqtiurobis identificireba TiToeul<br />
garemoebaSi mravalferovnis misaRwevad.<br />
nebismieri arCeuli aqtiurobisaTvis daadgineT is mTavari resursebi, romlebic<br />
saWiroa mis gansaxorcieleblad. resursebi moicavs rogorc fizikur (mag.,<br />
aRWurviloba, mwvrTneli, dro), aseve fsiqologiur aspeqtebs (mag., socialuri<br />
mxardaWera, miznebi).<br />
miznebSi Sedis aqtiurobis gegmis SeTavseba sezonebsa da amindTan, mowyenilobis<br />
minimalizacias, isini ganmartavs socialur mxardaWeras da aqtiurobis individualur<br />
SerCevas.<br />
68
danarTi 7. fizikuri aqtiurobis rekomendacia<br />
fizikuri aqtiurobis gaumjobesebis mimarTulebebi:<br />
sixSire – kviraSi dReebis is raodenoba, romelic rekomendirebulia arCeuli<br />
aqtiurobis gansaxorcieleblad.<br />
1. kardiovaskularuli daavadebebi – dasawyisSi 3-jer kviraSi da Semdgom gavrceleba<br />
kviris ufro met dReebze;<br />
2. Zala _ dasawyisSi 2-3 jer kviraSi da Semdgom or dReSi erTxel;<br />
3. plastiuroba – dasawyisSi or dReSi erTxel, xolo SemdgomSi gavrceleba kviris<br />
rac SeiZleba met dReze. gansakuTrebiT moTelva aerobikis dros.<br />
xangrZlivoba _ drois rekomendirebuli xangrZlivoba an aqtiurobisas mTlianad<br />
Sesrulebuli samuSao drois xangrZlivoba. sixSire da xangrZlivoba yvelaze mniSvnelovania<br />
kaloriebis mTliani xarjvisaTvis da wonis regulirebisaTvis. isini unda<br />
gaizardos intensiurad.<br />
intensivoba _ moZraobis siCqare (siarulis siCqare). intensivobis gazrda aris mudmivi<br />
da TandaTobiTi gaumjobesebis sawindari mocemuli sixSirisTvis da aqtiurobis<br />
xangrZlivobisTvis fiziologiuri adaptaciis Semdeg. intensivobis monitoringi<br />
SeiZleba Borg Perceived Exertion Scale-is (specialuri skala, romlis mixedviT geZlevaT<br />
warmodgena miRebul datvirTvaze) meSveobiT. tipiurad samizne intensivoba borgis 6-20<br />
quliani skalis mixedviT aris Semdegi: 10-12 qulidan _ sakmaod msubuqi; 13-14-mde _<br />
mZime.<br />
aseve `salaparako testi~ gamoxatavs intensivobis Semcirebis moTxovnas, Tu giWirT<br />
laparaki aerobikis Sesrulebis dros.<br />
aqtiurobis recepti: CamowereT receptiT dadgenili aqtiuroba da drois<br />
xangrZlivoba kviris TiToeuli dRis mixedviT.<br />
Sin:<br />
(aqtiuroba)<br />
(aqtiuroba)<br />
gareT<br />
(aqtiuroba)<br />
(aqtiuroba)<br />
Sin:<br />
(aqtiuroba)<br />
(aqtiuroba)<br />
gareT<br />
(aqtiuroba)<br />
(aqtiuroba)<br />
I kvira<br />
kvira orSab. samSab. oTxSab. xuTSab. parask. SabaTi<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
II kvira<br />
kvira orSab. samSab. oTxSab. xuTSab. parask. SabaTi<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
_____<br />
muSaoba ----- wuTamde -------- kviris ganmavlobaSi.<br />
muSaoba -------- kg. daklebamde --------- kviris ganmavlobaSi.<br />
veTanxmebi am aqtiurobis recepts da Tanaxma var Sevinaxo Cemi aqtiurobis Jurnali Cems kalendarSi<br />
----- dan ----mde.<br />
pacientis xelmowera -------------------------- samedicino muSakis xelmowera ---------------<br />
69
danarTi 8. ,,kvebis dagegmva da wonis koreqcia’’<br />
sakvebi produqtebi:<br />
1. puri da pureuli<br />
2. xorci da xorceuli<br />
3. xili<br />
4. bostneuli<br />
5. rZe da rZis produqtebi<br />
6. cximebi<br />
nebismieri saWmeli am jgufis produqtebis sxvadasxvagvari kombinaciaa;<br />
purisa da pureulis jgufi ZiriTadaT naxSirwylebs Seicavs. aseve<br />
naxSirwylebis wyaroa xili da bostneuli;<br />
rZe da rZis produqtebi Seicavs naxSirwylebs, naklebi raodenobiT<br />
cilebs da kidev ufro naklebi raodenobiT cximebs. calke unda gamoiyos<br />
xorceulis jgufi produqtebi - cilis ZiriTadi wyaro.<br />
pureulis siaSi Semavali TiToeuli produqtis erTi erTeuli (ulufa)<br />
Seicavs Tanabari raodenobiT naxSirwyals, cilas, cxims kvalis saxiT<br />
da TiToeuli maTganis erTi erTeuli (ulufa) gvaZlevs 80kkalorias.<br />
purisa da pureulis 1<br />
ulufa<br />
zoma wona grami<br />
TeTri puri 1 naWeri 30<br />
Wvavis puri 1 naWeri 30<br />
Cveulebrivi funTuSa 1 cali 30<br />
mWadi 1 cali 30<br />
hamburgeris funTuSa 1 cali 30<br />
brinji moxarSuli 1/2½ Wiqa 70<br />
Svria herkulesi 1/2½ Wiqa 70<br />
wiwibura 1/2½ Wiqa 70<br />
mananis burRuli 1/2½ Wiqa 70<br />
spageti 1/2½ Wiqa 70<br />
makaroni 1/2½ Wiqa 70<br />
atria 1/2½ Wiqa 70<br />
simindis fqvili 2 1/2 C.k 20<br />
fqvili 2 1/2 C.k 20<br />
simindi 1/2½ Wiqa 100<br />
70
lobio wiTeli 1/2½ Wiqa 65<br />
ospi 1/2½ Wiqa 75<br />
ugrexeli 1/2½ Wiqa 75<br />
mwvane barda 1/2½ Wiqa 100<br />
karTofili 1 patara 80<br />
karTofilis piure 1/2½ Wiqa 100<br />
gogra 1 Wiqa 200<br />
yabayi 1/4 Wiqa 200<br />
wabli 12 c.saSualo 200<br />
sistema gaZlevT saSualebas erTmaneTs SeunacvloT TqvenTvis sasurveli<br />
produqtebi ise, rom sakvebis kaloraJi ar Seicvalos.<br />
xili: xilis erTi ulufa Seicavs saSualo 15 gr. naxSirwyals da 60kkal.<br />
xili naxSirwylebis erT-erTi wyaroa, cilebsa da cximebs es jgufi<br />
TiTqmis ar Seicavs.<br />
bostneuli: naxSirwylebis didi Semcvelobis gamo bostneulis siidan<br />
amoRebulia da pureulis siaSia Setanili barda, karTofili, gogra,<br />
yabayi, bostneulis siaSi Semavali danarCeni produqtebis 1 ulufa<br />
Seicavs 5gr. naxSirwyals, 2gr. cilas, 25 kkal.<br />
bostneulSi Sedis: Warxali, kombosto, stafilo, yvavilovani kombosto,<br />
badrijani, mwvane lobio, mwvane wiwaka, pomidori, wiTeli fxali, ispanaxi,<br />
soko, xaxvi, mJave kombosto. SezRudviT SeiZleba miiRoT oxraxuSi,<br />
boloki, tarxuna, wiwmati, kama, kitri.<br />
rZe da rZis produqtebi: Seicavs naxSirwylebs, cilebs da cximebs. rZis<br />
da rZis produqtebis cximianoba ganisazRvreba naRebis procentuli<br />
SemcvelobiT. amis mixedviT iyofa 3-jgufad: 1-moxdili; 2-dabal cximiani;<br />
3-mouxdeli. rZis produqtebSi Sedis: rZe, mawoni, iogurti.<br />
xorci da xorceuli - cilis ZiriTad wyaros warmoadgens.<br />
isini ar Seicaven naxSirwylebs magram Seicaven cximebs sxvadasxva<br />
raodenobiT. maTi kaloriuloba damokidebulia cximis Semcvelobaze.<br />
ulufa<br />
xorceuli<br />
naxSirwylebi<br />
gramebSi<br />
cilebi cximebi kkaloriebi<br />
mWle xorci 0 7 3 55<br />
saSualo cximiani 0 7 5 75<br />
qoniani xorci 0 7 8 100<br />
71
ogorc mWle, aseve saSualo da Zalian qoniani xorcis 1 ulufa udris<br />
30 grams. am jgufs miekuTvneba:<br />
saqonlis, xbos, Rors, kurdRlis, cxvris, Txis, ciknis da batknis<br />
xorci;<br />
indauri, ixvi, wiwila, bati, qaTami, xoxobi;<br />
axali da gayinuli Tevzeuli.<br />
xorceulis erT ulufas agreTve Seesabameba Semdegi: xamanwka – 85 gr.,<br />
kvercxis cila – 100 gr., Tavmoxdili qarTuli yveli – 40 gr., Tevzi –<br />
30gr,. sosisi – 30gr., Zexvi – 30 grami.<br />
sakvebad sjobs uqono, mWle xorcis gamoyeneba. umjobesia frinvelis<br />
xorci miirTvaT kangaclili. xorcs nu SewvavT da nu moxrakavT cximSi.<br />
gamoiyeneT iseTi tafa, romelic ar ikravs. umjobesia moxarSuli, an<br />
Samfurze da quraSi Semwvari xorcis gamoyeneba.<br />
cximi: iyofa najer da ujer cximebad. 1 grami cximi iZleva daaxloebiT<br />
9 kilokalorias. cximis erTi ulufa Seicavs daaxloebiT 5 gr. cxims da<br />
45 kilokalorias. yvelanairi cximi maRalkaloriulia. upiratesoba<br />
eniWeba ujer cximebs.<br />
najer cximebs Seicavs: karaqi, kvercxis guli, lori, Roris qoni,<br />
araJani;<br />
ujer cximebs Seicavs: margarini, dieturi margarini, mcenareuli<br />
zeTi, maionezi, nuSi, miwis Txili, nigozi, Txili, zeTisxili,<br />
mzesumzira.<br />
72
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