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The methodical recommendations are made with the participation of the employees of Institute of nutrition ÀÌS(Academy of Medical Sciences), the USSR and the experts of the other establishments: corresponding member of ÀÌS, professor M.A.Samsonov, professor J.S.Nikolaev, professor A.N.Kokosov, professor O.N. Ganich, professor L.D. Kunitsa, professor J.I. Polishuk, professor E.I. Tkachenko, M.D. V.A. Mesheryakov, M.D. V.A. Maksimov; associated professor V.M. Luft, senior scientific worker S.G. Osinin,
senior scientific worker G.R. Pokrovskaya, senior scientific worker O.A. Plotnikova, M.D. A.L. Chernishov, M.D. V.I. Panaikin, M.D. S.N. Zelentsov, M.D. E.I. Arhiy, V.A. Mironov, N.S. Strahova, H.H. Sharafetdinov, T.M. Golovrina, S.D. Karataev, L.A. Redzuk.
World and domestic literature testify to wide application and noticeably increased interest to medical starvation - unloading dietary therapy (UDT) in practical public health services. The accumulated experience confirms expressed therapeutic efficiency of the UDT at a number of diseases of internal bodies (bronchial asthma, food allergy, hypertonic illness, ischemic illness of heart, etc.), and also at psychological diseases.
However, in the majority of the publications, devoted to application of UDT at diseases of internal bodies the estimation of medical effect of UDÒ is carried out mainly on the basis of the account of dynamics of general clinical and subjective data, and also inadequately informative laboratory parameters not reflecting to the full specificity of UDÒ action on adjusting systems of an organism, condition of metabolism, change of functions of other bodies and systems.
In this connection, despite a significant amount of experimental researches and clinical supervision which have been saved up by the present time, there are no precise criteria of indications and contra-indications for carrying out UDÒ when treating diseases of internal bodies
Optimum terms of UDÒ are not certain also, there is no unified technique of the differentiated application in view of the accompanying diseases excluding an opportunity of serious complications.
Taking into consideration all this and the Resolution of Presidium of the AMS USSR and Scientific Medical Board, ¹ 157 dated by 06.05. 1985, a number of researches devoted to the development of scientific base of the unloading dietary therapy were carried out in 1986-1988 in the Institute of Nutrition of the AMS USSR and others.
In controllable conditions of a hospital influence of various terms of starvation on a functional condition of the central and vegetative nervous system, on immunologic reactance, power balance and condition of albuminous, lipid, carbohydrate, vitamin, mineral and alkaline balance was studied, as well as dynamics of endocrine-hormonal structure, and also on a functional condition of bodies of blood circulation, breath, digestion, and physical activity at patients with a bronchial asthma, hypertonic illness, ischemic illness of heart, chronic gastritis, chronic cholecystitis, chronic pancreatitis, rheumatoid arthritis, Bekhterev's illness, deforming poliosteoarthrosis at various stages of UDÒ and some psychological diseases.
Materials of these researches are put in the basis of the development of present methodical recommendations and definitions of criteria of differentiated application of UDÄÒ in a medical practice depending on character of pathological process, specificity of illness, its phase and a stage, presence of accompanying diseases and other factors.
Mechanisms of medical effect of unloading dietary therapy
In the opinion of the leading experts in the field of unloading dietary therapy the biological essence of alimentary starvation is adaptive, i.e. it is necessary to consider it as a variant of stress-therapy (G. Selie), strengthening the adaptive mechanisms underlying processes of sanogenesis and recovery.
P. K. Anokhin, K.B. Sudakov (1971) consider that hunger and feeling of saturation are caused by the reflex activation and as a result a subsequent braking of hypothalamus, directly influenced on by the level of sugar in blood. The important role in the achievement of medical effect of UDÒ belongs to sympathoadrenal system (SÀS). According to words of different authors, UDÒ influences on twice increase of a tone - in an initial stage of starvation and at the end of the first and the beginning of the second stage of the regenerative period.
Thus the authors believe, that UDÒ is more indicated to the patients with mental infringements when decrease of a tone of SÀS takes place
The increase of functional activity of vegetative and central nervous system under the influence of UDÒ, as a number of authors specify, is accompanied by the increase of nonspecific reactance of an organism of patients, some strengthening of a carbohydrate-phosphoric exchange and oxidizing processes that are of essential value in achievement and stabilization of medical effect.
As the saved up experience of UDÒ application shows, in clinic of psychiatric illnesses when the patient is deprived of food there are changes in the albuminous exchange, characterized by the fact that in the first stage of starvation the level of serum albumin rises and decreases in its third stage. In the first stage of the regenerative period the content of albumin in serum of blood decreases comparing to the third stage of starvation as well as to its initial level, however by the end of the regenerative period the level of the serum albumin comes back to an initial level.
Average quantity of the general nitrogen in daily urine does not essentially change in first two stages of medical starvation, and in the third stage its level, in comparison with initial, decreases. In the first two stages of the regenerative period the decrease of general nitrogen in urine proceeds. In the third stage of the regenerative period the quantity of the general nitrogen of urine increases and reaches an initial level.
Percentage of nitrogen of urea decreases during medical starvation and raises up to an initial level at the end of the regenerative period.
First days of starvation carbohydrates, which stock is being quickly exhausted, are intensively spent and organism starts using fats as a power material. At the same time in conditions of deficiency of carbohydrates oxidation of fats leads to rise in blood the metabolites level of fatty exchange of acetone and aceto-acetic acids that causes development of metabolic acidosis with the subsequent activation of buffer systems for its indemnification.
However, with a decrease of alkaline reserve of blood and accumulation of acetic bodies, acidotic shift all the same arises and reaches its maximum on the 7th-10th day of starvation. Thus, during medical starvation on the 5th-7th-10th day of starvation there comes a shift in acid-base balance aside the prevalence of acidosis, and " acidotic crisis" develops during which secretion of acetic bodies with urine considerably increases, and then decreases. According to the parameters of acid-base balance in the first stage of medical starvation acidosis is compensated, in the second stage (5-8 days) subcompensated. On the 9th-12th day of the second stage and in the third stage of medical starvation acidosis again becomes compensated. Many authors consider that development of acidotic crisis during full alimentary deprivation is a criterion of sufficient adaptable opportunities of an organism at its transition to endogen nutrition.
Medical starvation influence on the changes in immunobiological condition of the organism, characterized by described by some oppression immunologic reactance during the medical starvation period, increase in immunologic protection and parameters of nonspecific reactance of an organism in the regenerative period.
Some histologic, histochemical and microscopic researches of a mucous membrane of a stomach resulted in the conclusion that UDT causes a number of passing changes in it, characterized by the dystrophic phenomena, oppression of secretory activity and digesting ability of gastric juice. With the beginning of a regenerative feeding the specified changes gradually reduce.
UDÒ renders complex influence on gastric secretion. If there is an oppression of secretion during full period of starvation it is normalized after the restoration, both at initially raised and lowered secretory functions.
Exterosecretory function of a liver undergo essential changes under the influence of UDÒ. According to the parameters of step-by-step chromatic duodenal sounding UDÒ leads to liver secretion increase, renders corrective effect on sphincteral apparatus of the biliary systems, (the tone of sphincters goes down at initially raised tone and rises at initially lowered), leads to increase in reactivity of sphincteral apparatus to irritant.
Thus, long-term, two-three-four-week starvations are accompanied by essential shifts in the basic adjusting systems of an organism, in its physiological biochemical, metabolic and psycho-emotional status. The degree of changes of metabolism and clinical displays of the illness under the influence of UDÒ is defined on the one hand, by an initial condition of an organism of the patient, and on the other hand by the adequacy of the UDÒ method, clinical-pathogenetic essence of illness.
Indications to UDÒ and determination of optimum terms of alimentary deprivation should be strictly differentiated depending not only on the phase and the stage of the basic disease, but also on the character of accompanying illnesses. Thus psychological awareness of the patient, i.å. his readiness to take advantage of this method of treatment, is a very essential condition for indicating UDÒ.
Indications to applying UDÒ
Taking into the consideration that UDÒ is serious metabolic stress and causes radical changes in metabolism, its application at internal diseases is reduced to the limited number of nosologic forms of illnesses at the differentiated determination of term of starvation (advisable optimum is two-three weeks), individual indications, and, if results of medical starvation are higher than those of traditional medical methods or the last do not render essential medical effect.
As clinical experience and results of physiologic-biochemical and instrumental-graphic researches show, UDT renders a beneficial effect on diseases, in which sensitization, allergic and immune infringements play an essential role.
So, at overwhelming majority of patients with bronchial asthma (BA) application of UDT results in reduction and disappearance of attacks of expiratory asthmas - basic symptom of BÀ that corresponds to reduction of obstructive infringements. Restoration of a mucous trachea and bronchial tubes with improvement of bronchial passableness is observed.
Positive influence of starvation on parameters both nonspecific resistency of an organism and specific antibacterial immunity is observed at patients with infectious-allergic BÀ. The mechanism of positive medical action of UDÒ at patients with BÀ is connected with suppression of an allergic inflammation which is testified by the reduction of eosinophiles in peripheral blood s, decrease in frequency of pulmonary antigene circulating in the blood serum and frequency and a degree of marked positive intraskin tests with autolymphocytes. These data objectivise beneficial effect of UDÒ on immunologic mechanism of pathogenesis of BA.
On the other hand UDÒ is a kind of soft prolonged stress which is realized, first of all, through stimulation and improvement of function of adrenal glands. It occurs as a result of direct simulation of synthesis of corticosteroids in a bark of adrenal glands, and indirectly by reduction of connecting ability of transcarotene.
The most indicated cases are at patients with BÀ of heavy and middle-heavy level with prevalence of allergic and neurogenic component in the clinical picture.
Application of UDT to patients with rheumatoid arthritis with active rheumatoid process of the I-II stages promotes to the improvement of patients' condition within two weeks.
During starvation the mitigation of an arthrous syndrome occurs and it becomes possible to reduce a medicamentous therapy, and some patients with rheumatoid arthritis of 1st stage of activity have an opportunity to completely exclude pharmacotherapy. The therapeutic effect of UDÒ at rheumatoid arthritis is expressed in decrease in the arthrous phenomena and improvement of parameters of rheumatoid process activity.
Special researches on application of UDÒ carried out at patients with Bekhterev's illness with a low degree of activity of inflammatory process have shown that full food deprivation influences on the painful syndrome decreases and the amplitude of movements in a backbone increases, and also parameters of peripheral blood vary positively. In the regenerative period this effect decreases, that demands constant observance of the diet recommended at the given pathology.
Now there is an experience of application of UDT at polyosteoarthrosis. For the majority of patients with polyosteoarthrosis, as the researches have shown, 2-3 weeks of medical starvation result in decrease in a painful syndrome and increase in amplitude of movement in joints. At the same time In parallel the majority of patients loose weight, parameters of fluid-and-electrolyte exchange improve.
UDÒ has also confirmed its sufficient efficiency at treatment of hypertonic illness. Reliable observations and researches in the field of UDT brought to the conclusion concerning it is possible to conclude applications ÐÄÒ, that at hypertonic illness it is necessary to consider not only a stage of illness, features of haemodynamic and metabolic infringements, but also a character of accompanying disease.
So, it is not necessary to apply UDÒ at hypertonic illness of the 1st stage, because to achieve an effect one should correct his way of life and nutrition. At hypertonic illness of the II stage UDÒ with the period of starvation 2-3 weeks leads, as a rule, to decrease in level of arterial pressure, reduction of superfluous weight of a body, improvement of the general condition. Some positive shifts in fluid-and-electrolyte balance which degree decreases a little in the regenerative period are marked.
The precise regulation of application of UDÒ is required at ischemic illness of heart. As the saved up experience shows UDÒ is indicated at ischemic illness of heart, accompanied with stenocardia of I-II functional class, without Myocardial infarction and stable infringement of cardiac rhythm in the anamnesis. At stable stenocardia of the I-II functional class UDT may be individually indicated for no more than 2 weeks.
There is a significant experience of application of UDÒ at diseases of digestive system which has allowed to define a range of use of this method. So, UDT in most cases of chronic gastritises with any type of the secretion, not complicated forms of stomach ulcer in the phase of scarring of ulcer defect, chronic noncalculous cholecystitis and various forms of biliary dyskinesia, chronic pancreatitis and chronic enteritis with the phenomena of enzymopatia, chronic prick, chronic nonspecific ulcer prick gives a positive effect often surpassing the one from traditional methods of treatment.
UDT is also applied at an aggravation of chronic pancreatitis but the period of starvation should not exceed 7-8 day as there is an increase of the inflammatory phenomena.at the prolonged starvation. In a sharp phase of a stomach ulcer application of UDÒ leads to increase of "aggression" of gastric juice, clinical symptoms of illness, formation of new ulcer defects and other infringements. At the second type of the diabetes which has not been complicated by expressed vascular frustration, UDÒ in some cases is very effective. UDT is admissible at many forms of neurodermatitises, eczema, recidivating urticaria.
Especially wide experience of application of UDT is saved up by a psychiatric practice. On the basis of clinical observations and results of special researches it has been established, that application of this method of treatment in a psychiatric practice is mostly indicated to the patients who, according to their mental condition, are capable to abstain voluntary from food during long time period and express desire to be treated by the given method.
Patients with nonpsychotic conditions and boundary mental infringements meet these criteria. So, UDÒ is mostly indicated at attacks of slow schizophrenia with depressive neurotism, cyclothymia with long depressions; prolonged neurotism of exogenous (posttraumatic, postinfective, vascular) origins.
Positive effect reach patients with hypochondria, senesthopathic-hypochondriacal, dismorthophobiacal, dismorthomaniacal, supervaluable, persuasive, phobiacal frustrations.
UDÒ applied at alimentary adiposity has appeared insufficiently effective. Decrease in weight of a body during starvation almost does not exceed its decrease at traditional methods of treatment. At the same time, after the period of starvation the weight of a body accrues more quickly than after applying traditional methods of treatment.
Considering the fact, that UDT influences on the essential changes in the basic adjusting systems of the organism, proceeding on a background of the generated illness, there can be a various sort of the complications demanding urgent medical actions during starvation period. Therefore unloading-dietary therapy should be spent strictly differentiated, taking into account indications and contra-indications only in stationary conditions of the versatile establishment having a block of intensive therapy.
Contra-indications to application of UDT at the internal and psychological diseases
1. The expressed activity of inflammatory process (II, III degree) of any localization.
2. Rheumatoid arthritis with a high degree of activity of rheumatoid process, and also in cases of system disturbance of kidneys, heart and other bodies. Use of steroid therapy is an absolute contra-indication for this category of patients.
3. Malignant new growths or suspicions on them and illnesses of blood.
4. All the diseases proceeding with expressed asthenia and hypotrophy.
5. Diseases of a gastroenteric path during the period of aggravation, accompanied with complications, decompensation.
6. Cholelithiasis with frequent attacks bilious colic.
7. Disturbance of purine exchange and gout.
8. Diabetes of 1st type and high hyperglycemia.
9. Crone' disease.
10. Active forms of a tuberculosis of lungs.
11. Period of pregnancy and lactation.
12. Helminthism.
13. Decompensation of functions of liver, kidneys, cardiovascular system.
14. Mental diseases: schizophrenia in progressive form (nuclear, paranoid, paranoic, attack-progressive forms), epilepsy, oligophrenia and the phenomena of dementia, forms of psychomotor excitation of the various nature, deep disturbing depressions.
Possible complications at unloading -dietary- therapy and their preventive maintenance
Usually, if patient before the treatment has been well surveyed and all contra-indications have been considered it is not necessary to interrupt medical starvation prematurely due to the somatic complications. During acidotic shift and acidotic crisis there can be nausea, headache, feeling of the general indisposition. In such cases it is recommended to increase daily quantity of alkaline mineral waters or baking soda and spend more time outdoors.
General massage usually improves state of health. During medical starvation aggravations of some chronic disease can be observed. During starvation those tended to arterial hypotonia and fast decrease in arterial pressure can suffer from collapse, disturbance of cardiac rhythm. Fast change of position of a body from horizontal into vertical can result in orthostatic collapse.
With the preventive purpose patients are recommended to rise slowly and not to make sharp movements. Occasionally at long-term medical starvation there can be tonic spasms caused by deducing of chloride sodium, salts of calcium and phosphorus from the organism. When, first, spasms of fingers and then gastrocnemius and sometimes chewing muscles spasms occur. In such cases 20 ml of warm 1 % salt solution is appointed.
During the regenerative feed period some complications can arise due to infringement of diet. It is important to follow the rules of realimentation no to suffer from possible dispeptic frustrations. In cases when dispeptic frustrations occur it is necessary to wash out a stomach and to appoint laxative.
It is sometimes expedient to appoint one-day starvation.
Complications include puffiness of subcutaneous fat which can result from the premature use of salt.
Puffiness is more expressed on the face, in infraorbital hollows. They will disappear within a day if a saltless diet is appointed.
When the complications connected with an aggravation of the basic disease during UDÒ occur it is necessary to stop medical starvation and appoint adequate therapy. If attributes of an aggravation of the basic disease are expressed slightly the adequate pharmacotherapy can be appointed and on a background of medical starvation.
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