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Obesity





Obesity, popularly considered to be an over-accumulation of fat, is
sometimes thought to exist only when there is the large development of
abdomen which is more properly designated corpulency. In its strictly
scientific sense it represents excessive over-weight, that is, above
twenty per cent. more of weight than is normal for the height of the
particular individual. (See table of weight for height in chapter
Weight and Good Feeling.) The Latin derivation of the word gives also
its etiology. Ob-ese means having eaten too much. It is a question of
failure of due proportion between the taking of nutrition and the
oxidation processes within the body. More food being taken than is
needed, there is an accumulation of it in the form of fat, and this is
deposited by natural preference in certain places, such as the
abdomen, the breasts and in the panniculus adiposus beneath the
skin. The fats and starches are most readily converted into this fat,
but under certain circumstances proteid material may be turned into
fat, and then a true pathological condition develops resembling
diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by
bad habits. When such large quantities of sugar-making materials are
taken that they are beyond the power of the normal metabolism to
dispose of, they are excreted in the urine with the production of what
is known as physiological glycosuria. In the same way, the
eating of a superabundance of fat-forming food leads to the deposition
of fat in the tissues where, when in excess, it is just as much wasted
as if it were excreted. Physiological glycosuria is, however, usually
considered to be dangerous, inasmuch as its frequent occurrence may
disturb the normal metabolism of sugar, and lead to diabetes. In the
same way, the over-consumption of fat-forming materials may disturb
the fatty metabolism, and lead even to the changing of proteid
materials into fat. This represents a real disease requiring careful
management, while ordinary obesity needs only the exercise of the
patient's will to secure such proportion between the amount of food
taken, and the amount of exercise and fresh air, as will not only
prevent accumulation of fat but will lead to the reduction of any
accumulation that may, through neglect of this care, already have
taken place.


Over-eating.--The putting on of weight depends on the individual's
craving for food, and his satisfaction of his appetite. While it is
not ordinarily looked at from this standpoint, this craving for food
and the habit of satisfying it which is developed, is not very
different from the craving for stimulants and the habit that forms
with regard to them. People insist that they can not eat less--that
their appetite simply requires them to eat. We have all heard this
story over and over again from the man who craves alcoholic
stimulation. Usually the obese can be persuaded more easily than the
inebriate to break off their habit, but they relapse into it even more
easily than he does. It is comparatively easy to limit the appetite,
or rather to forego the satisfaction of eating abundantly, for a week
or two weeks or even a month, but the effort finally becomes appalling
and the consequence is a relapse. If the patient really wants to lose
weight, in nine cases out of ten it is a comparatively simple matter.
The trouble is that they want to lose in weight without giving up the
satisfaction of eating.


Under Exercise.--The second factor in obesity--lack of sufficient
exercise, is even more important than the habit of over-eating. This
is illustrated very well by the cases of certain animals who, without
any tendency to fat accumulation by nature, but rather the contrary,
acquire fat to a marked degree, owing to the habits that are forced on
them by their relations to human beings. A typical example is the pet
dog. Dogs living their natural active lives, have little tendency to
put on superfluous flesh. Kept in the house in cities, they
practically always put on weight until, after some years, many of them
are quite incapable of moving except in an awkward waddle, often
comically symbolizing their mistresses in this respect. Besides the
inactivity, the dog is subject to the influence of the other cause of
obesity, the over-eating of fat producing material. Another typical
example, and one that provides evidence of the pathological tendency
to fat accumulation, is found in the Strasburg geese from whom the
fatty goose livers for pates de foie gras are obtained. Geese are
placed in a warm underground room, in a mass of cement that gradually
hardens round their feet keeping them almost completely inactive, and
then they are fed abundantly with fat-forming materials. The absence
of light and air, and the immobility, leads to the production of the
fatty changes, eventually producing the enlarged fatty livers, which
delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of
all other animals. The fattening process is well understood by
butchers--keep the animal inactive and supply an abundance of
fattening food. The inactivity is even more important than the food.


Prophylaxsis.--Of course, if obesity is to be successfully treated,
cases must be seen early and before there has been a large
accumulation of fat. When people are more than 10 per cent. over
weight they are in the danger zone, and with 20 per cent. above the
normal, decrease must come or the condition becomes inveterate. It is
between these two points and not when they are forty or fifty pounds
over weight that they need the advice of a physician and the careful
institution of regular life to prevent further fat accumulation. After
the body has carried thirty or forty pounds over weight for some time,
it has acquired the habit of accumulating fat, rather than using it,
and this, once acquired, is hard to break. Every additional pound
tempts to the formation of lazy or sluggish habits because of the
additional weight that has to be carried around. Everyone knows how
hard it is to walk a few blocks a little briskly carrying a suit case
that weighs thirty pounds. Even twenty pounds soon proves to be a
burden. Fat in the tissues, though it seems to be a portion of the
individual, is really quite outside of him and consists of extra food
material that the body is carrying round, having accumulated it for
the purpose, apparently, of using it at some time when it should be
necessary. While carrying this burden, people have little inclination
to an active life. Inactivity lowers oxidation processes and leaves
them with an additional tendency to fat accumulation because of lack
of oxidation. In a word, a vicious circle of cause and effect is
formed. Accumulation of fat prevents the taking of proper exercise,
and lack of exercise leads to further accumulation of fat!

Not only should the treatment of obesity begin early in a particular
case, but, in families where there is a recognized tendency to take on
fat, it should begin early in life.

Children should not be so fed that they become mere specimens,
illustrative of how early fat accumulation may occur, and to what a
degree it may go. Just as soon as baby shows signs of an accumulation
of fat above its normal weight for age and size, there should be just
such a regulation of its diet as would be considered necessary if it
were an older person, and showed the same unfortunate tendency. This
is particularly important if the parental relatives on either or both
sides of the house show tendencies to fat accumulation. We are sure
that in diabetes the over-eating of starchy and sugary substances
produces what is, at the beginning, an alimentary or so-called
physiological glycosuria, though it is doubtful whether any glycosuria
is ever absolutely physiological. This may lead to a pathological
glycosuria and the production of a true diabetes. So, also, the
tendency to accumulation of fat, as the result of what might be called
alimentary obesity, may lead eventually to the production of an
essential obesity in which even the proteid materials of the food may
be changed into fats, just as in the case of diabetes they are changed
to sugar. This fat is then stored up in the tissues though there is no
need at all for such an accumulation, and the food stuff is wasted
quite as much as in diabetes.


The Will in Treatment.--The important element in the treatment of
obesity is the readiness of the patient to follow directions. Nine out
of every ten stout people are thoroughly able to control the
accumulation of fat and even to bring themselves down to about normal
weight, if only they will to do so. This is no easy matter. It is
not an affair of a few weeks, or even a few months. Just as in the
case of over-indulgence in alcohol, it will probably be a life
struggle. It is well worth the while, however, for life is longer and
is larger without the accumulation of fat, which is not only so
uncosmetic, but is so preventive of real enjoyment of life.
Unfortunately, the cosmetic side of it, that is, the absurdity of
going round among one's friends with a very prominent abdomen, or with
noticeable protuberances, is the particular motive that appeals to
most people. While women may be quite ready to stand many discomforts
for cosmetic effect when dictated by fashion, they are not ordinarily
persistent enough in their efforts to prevent fat accumulation to be
successful in this much more important purpose.

Such patients make the rounds from physician to physician, and from
quack to quack, and go from patent medicine to patent medicine, to
find something that will enable them to lose weight without the
necessity for their taking any trouble. It is the old, old story that
the nerve specialist who is known occasionally to treat his patients
by hypnotism has so often presented to him. Patients who are sufferers
from alcoholism, or drug addiction, or some other vicious habit,
present themselves and ask if they cannot be hypnotized and then lose
their tendency to fall back into the old habit. There is no
possibility of this. If they are willing to cooperate, all of these
habits may be overcome, but a constant effort will be required and,
even after the habit is broken, there always remains a distinct danger
of relapse. Patients suffering from obesity want to transfer the
burden of working it off to someone else's shoulders, or they want
some specific remedy that will bring about reduction in weight yet
permit them to indulge in all the pleasures of their artificially
excited appetite. They follow directions for a few weeks, often
half-heartedly, and then give up the struggle.


Food Temptations.--With obesity, as with indulgence in alcohol, the
main difficulty is the occasion. Most of these fat people are placed
in circumstances in which tempting food passes them three times a day,
and it is hard to refuse it. If a hot punch or a fragrant cocktail
were several times every day passed under the nose of a man with a
tendency to inebriety it would be beyond the bounds of reason to hope
that he should withstand his craving. Just as soon as those who want
to reduce in weight are put in conditions in which only simple food,
though there may be a reasonably good variety of it, is presented to
them, the difficulty of limiting the amount they eat is comparatively
easy. This necessitates, as a rule, refusing invitations to dinner at
friends' houses, especially at the beginning of a reduction cure,
avoiding hotel menus and giving up various social functions. It may
even involve changing home customs from those of luxury back to
simplicity. The question is whether this is worth while or not. When a
husband is likely to indulge over much in alcoholic liquors a wife is
apt to consider it easy to deny herself the privilege of such liquors
on her table and of avoiding places where he is likely to be tempted.
The rest of the family are usually quite satisfied to stand some
self-denial so that unfortunate results may not follow.

Where father or mother are suffering from obesity this same thing may
be necessary with regard to rich and highly seasoned foods. This would
be a hardship to inflict on the family were it not for the fact
that the health of all the members will be distinctly benefited and a
return to simple food, nutritious and with a variety that makes it
eminently wholesome, will be good for them as a prophylactic measure.


Motives for Self-Control.--The task of keeping the weight down is so
difficult that very few people with a tendency to over-weight are
equal to it. They need the help of every motive possible for
encouragement. It is well to make these persons realize that
over-weight, according to the statistics carefully gathered and
collated by the large insurance companies in recent years, is a
serious bar to great expectancy of life. In a large series of cases it
was found that not a single individual recorded as being more than
twenty per cent. over the normal weight that he should have for
height, died of old age. Furthermore no one of over-weight attained
the age of eighty years, though 44 under-weights passed this age, and
two of them even reached the age of ninety. Death from nearly every
known cause is more frequent among the over-weights than in the normal
population, except in the single instance of tuberculosis.

What was thus demonstrated from statistics, carefully gathered in
modern times, has been a commonplace in medicine since the earliest
days. Hippocrates summed up Greek experience in the aphorism "persons
who are naturally very fat are apt to die earlier than those who are
slender." Practically all the commentators since his time have agreed
with him. In early years thinness may be quite as dangerous.

If there were no other reason but the greater frequency of diabetes
among the obese, this of itself would be sufficient to act as a strong
deterrent motive. It may well be used as such, especially in families
where a tendency to diabetes has been manifest. Diabetes figures as a
cause of death in life insurance statistics five times more frequently
among those who are over-weight than in the general population. Those
who are under-weight suffer from the disease in fatal form less than
one-half as frequently as the average. Hence, obesity and diabetes are
evidently closely related. As we have suggested, the disturbance of
metabolism due to the failure to use sugar properly in the system and
to its consequent elimination, corresponds in some, as yet not well
understood, way to the other metabolic disturbance by which
unnecessary fat is accumulated in the system. It is probable that the
over-eating of starchy foods and fats which leads to obesity, causes
in some people a breakdown of metabolism in the matter of the proper
disposal of sugar, and this initiates diabetes which becomes a
pathological condition, after a time quite beyond control.


Sleep and Exercise.--After the reduction of diet, the most important
feature of any successful treatment of obesity must consist of an
increase in the amount of exercise. Both of these can be accomplished
only through the patient's will, and by frequently repeated
suggestion, and auto-suggestion, of the necessity for constant
surveillance in both these matters. Any form of exercise that is
pursued faithfully is beneficial. Exercise in the open air, because it
encourages oxidation, is preferable to gymnastic exercises, but the
care of a trained instructor, the influence of example, the habit of
taking it at regular hours, make gymnastic exercise of value in this
condition. A regular walk every day is invaluable if it can be
secured. Women can be tempted to walk even three or four miles,
if the habit is gradually formed, and if they realize the necessity
for it. It is important that too much sleep should not be indulged in.
One of the difficulties with pet animals is that they sleep so much
more in domesticity than in the state of nature. Sleep must be
absolutely regulated for the obese. The old monastic rule "seven hours
for a man, eight hours for a woman and nine hours for a hog" must be
emphasized.


Heredity.--There always remains in these cases the influence of
heredity. Many people are sure that because they come from families
with the tendency to obesity, it is impossible for them to overcome
this assumed heredity, and that the only thing for them is to bear the
affliction with equanimity. They usually do this while indulging their
taste for the luxuries of the table rather freely. This question of
heredity, however, has come in recent years to occupy a very different
position in the minds of biologists from that which it held a
generation ago. We know now that the evidence for acquired characters
being transmitted is so trivial as to be quite negligible.

The children of stout parents are likely to acquire their parents'
habits as to the consumption of food, in such quantity and quality as
will almost inevitably put fat on them. It is this habit much more
than any hereditary element, which is the underlying cause of the
obesity. There may be some influence of heredity, but it is much less
than has been thought, and even where it exists, it is not so
inevitable as has been considered. There are cases in every
physician's experience where the children of stout parents who, for
some reason, have been brought to habits of spare eating, have been
thin all their lives. On the other hand, anyone who has seen the
change that has come over the sons of spare, lanky farmers, in whom
both father and mother were of the thin type, yet who in the midst of
the luxury of city life have taken on weight, will be convinced that
personal habits mean much more than any influence of heredity in the
production of obesity.

Where there is normal occupation of mind and body with strict
regulation of the hours of sleep, and simple though abundant food,
there is little tendency for people to become obese, even though there
may seem to be hereditary tendencies. In a considerable experience
with religious communities I have often noted that the member of a
family who enters a religious order often goes but slightly above
normal weight, even though other members of the family may become
distinctly fat. This is not because of rigid self-denial in the matter
of food, that is to such an extent as to take less food than is
necessary, for most members of the religious communities work too hard
for this to be possible, but because they live the regular active life
and have the simple food of the community. This is true in spite of
the fact that their indoor life would seem to predispose them to the
accumulation of fat. After fifty most of them put on weight because
this is the physiological accompaniment of that period of life, but it
is not this form of fat accumulation that the physician is called upon
to treat as a rule, but that in people between the ages of twenty and
forty.

If the prevention of over-weight is taken up in time, if habits are
broken before they become tyrannous, if proper self-control is
cultivated early in life, there are very few people that need fear the
oncoming of obesity. There are some pathologically obese families in
which this will not be true, but they are as rare as diabetic
families. The most important element in any treatment is the
rousing of the patient's mind and his will to take up seriously the
task of unlearning habits of overeating and not allowing sluggishness
of life to gain control. This can be done best, not by removing all
sorts of articles for which there is special taste from the diet, but
by a general reduction in the quantity of food eaten, by the
introduction of food material that does not put on weight yet
satisfies the craving, by the replacing of many of the starchy
vegetables by greens of various kinds, by replacing many of the
desserts by gelatine products and cheese, and by additions to the
exercise. But there must be no extremes in the reduction of food or
the taking up of exercise. Patients should not be permitted to lose
five pounds a week--at most two or three pounds--and they should be
made to understand that it is a life work and the formation of lasting
habits that they have before them. They should be made to understand,
also, after a time the satisfaction that comes from a more active life
will give them even more pleasure than the satisfaction of their
appetite did before.


Principles of Treatment.--Many systems of treatment of obesity have
been invented. All of them are supported by cured cases. Some of them
are founded on a reduction in the amount of fluids, some on a
reduction of the amount of vegetables eaten, in some cases going to
the extreme of an almost exclusively meat diet. Most of them modify
the diet very extensively. It is doubtful, however, whether any of
these systems, when successful, have owed their success so much to the
physical effect as to the suggestive influence exercised on the
patient's mind, that he must at the same time limit his eating and
increase his exercise. In the matter of fluids particularly, some of
the systems are absolutely contradictory of one another, yet success
follows their application. There is one serious difficulty in the
application of these systems. After a time the patient becomes very
tired of the monotony of diet suggested, and growing discouraged,
relapse into old habits. If suggestion can be used with as much force
without such extreme modifications of diet, the results are as good,
and are always more lasting. The important factor is a reduction in
the amount eaten, without necessarily denying any but the very rich
foods. In this way patients can very soon be induced to take half
portions of what they have been previously eating and thus secure a
prompt reduction in weight.

It is important that the bowels of obese patients be kept freely open.
Tendencies to constipation seem to disturb metabolism in the direction
of fat deposition, and even fatty degeneration. Many of the cures at
watering places include the taking of laxative salts, or waters of
various kinds, and undoubtedly this is helpful at the beginning. But
the continuance of such treatment may seriously disturb peristalsis so
that it is important to have intervals of rest for the bowels, during
which, while there is a regular daily evacuation, there are no
tendencies to diarrhea. The suggestive influence of the taking of
salts has meant much for a great many so-called obesity cures. They
should be employed carefully, but must not be abused.

For fat already accumulated, only exercise will serve as a sure
remedy. For fat within the abdomen, the various leg exercises which
may be gone through in bed, and the trunk movements, especially those
of sitting up from a lying position, when frequently repeated, will
soon serve to dissipate accumulated fat. They will also encourage the
taking of outdoor exercises, as well as relieve the patient from
many muscular discomforts, difficulties of breathing and heart
palpitation, which were not only annoying before, but discouraged the
taking of exercise.





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