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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