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Nothing to Eat but Food
LEADING
failed to go on losing weight after discharge from hospital. It is surprising that these workers found " hypometabolism " in many or most of their overweight patients; this was based on tests of iodine metabolism and a delay in relaxation of the ankle-jerk (implying hypothyroidism), but they did not comment on the basal metabolic rate, which is usually normal in obesity’! Nor do they appear to have measured any effect on weight that might have arisen from changes in the physical activity of the patients.
THE LANCET LONDON
14
MARCH
593
ARTICLES
1964
GORDON et al. were also impressed by the rapid and striking fluctuations in weight that may be observed in obesity, particularly the water retention that accompanies a relatively high intake of carbohydrate, and the diuresis and loss of weight that follow when a high-fat diet is substituted, or indeed when the intake of carbohydrate is restricted. PASSMORE and SWINDELLS4 recently analysed the gains in weight of a group of healthy adults who ate quantities of carbohydrate much in excess of their normal energy requirements. They found that some retained more than a litre of water in 24 hours, with an appropriate gain in weight, and they also stored sufficient sodium to maintain isotonicity, assuming that the water accumulated in the extracellular space. Another report from Edinburghdescribes the changes that followed the overfeeding of two obese young women who were already almost 50% overweight. In the course of 9 days of overfeeding, mainly with carbohydrate, to a total calorie surfeit of 7300 and 10,500 calories each, these two patients gained 2-86 and 2-58 kg. respectively. In a subsequent period of 5 days they received only a token diet providing about 300 calories daily, and with total calorie deficits of 12,000 and 14,000 calories, they lost 6-22 and 5-63 kg. .
but Food THE difficulties that obese patients have in keeping down their weight are all too well known.! For the majority, the balance of energy intake and output can be manipulated only by modifying the diet. The simple but distant target for the patient is so to adjust the habit of eating that having reached a normal weight this equilibrium can be maintained. An imposed dietary discipline -in hospital, for example-is always successful while it lasts, but subsequent efforts at self discipline often fail. A new system of weight reduction has now been described by GORDON and his colleagues.To begin the regimen, they advocate an absolute fast for 48 hours,
Nothing to Eat
followed, paradoxically, by six meals daily, providing
a
total of 1320 calories and including twice as much protein (100 g.) as carbohydrate, and a relatively large intake of fat (80 g.), of which 15-20% is unsaturated. A more controversial feature is the use of triiodothyronine in doses of as much as 250 tg. daily, but varying with the patient’s tolerance of the drug; the dose is aimed at just below the amount that produces signs of hyperthyroidism. GORDON et al. recognise that this step might be hazardous and should certainly be avoided in patients with ischxmic heart-disease. Moderate salt restriction and diuretics are included in the regimen. In formulating this system, the authors were impressed by the analogy with rats, illustrated by the work of HOLLIFIELD and PARSON 3 and others. These workers showed that when rats were allowed to feed only once daily for two hours, as opposed to having free and constant access to food, the animals put on weight steadily until they weighed much more than their controls. Biochemical studies showed that the rate of formation of fat was greatly increased in this way, and was rapidly reversed if a period of fasting was interposed between the system of feeding two hours daily and the reversion to free access to food-the nibbling regimen. GORDON et al. showed that 14C-glucose is oxidised less rapidly by obese patients. Presumably they store the glucose as fat. Again, as in the rats studied by HOLLIFIELD and PARSON,3, brief period of fasting reversed this trend. It is still early for more than a very general statement about the efficacy of this treatment. The patients specifically denied hunger at any time and very few "
1. 2. 3
"
Strang, J. M., in Diseases of Metabolism (edited by G. G. Duncan). London, 1959. Gordon, E. S., Goldberg, M., Chosy, G. J. J. Amer. med. Ass. 1963, 186, 50. Hollifield, G., Parson, W. J. clin. Invest. 1962, 41, 245, 250.
PASSMORE et al. contrast these
findings with an earlier
study 6based on overfeeding thin young men, and conclude that, whereas the two obese women required an excess of approximately 6000 and 10,000 calories in order to gain 2-5 kg. in weight, the thin young men each required about 20,000 calories to achieve the same gain. A possible explanation is that the tissue laid down by the obese contained a high proportion of water, while that deposited by the thin men contained much less. In the short term, at any rate, there seems to be some support for the claim so often made by the obese-namely, that they will gain weight on a diet which their more slender relatives can eat with impunity. DOLE,8 quoted as a supporter of this view, is said to have found that after weight reduction the total energy expenditure of the erstwhile obese is only half or two-thirds that of comparable thin persons. From serial estimations of the respiratory quotient, the Edinburgh workers suggest that their findings would be best accounted for if the excess carbohydrate was first stored as glycogen; conversion to fat might then begin when " the glycogen stores were full ". This hypothesis 4. Passmore, R., 5. Passmore, R., 6. Passmore, R., 1955, 9, 20. 7. 8.
Swindells, Y. E. Brit. J. Nutr. 1963, 17, 331. Strong, J. A., Swindells, Y. E., el Din, N. ibid. p. 373. Meiklejohn, A. P., Dewar, A. D., Thow, R. K. ibid.
Passmore, R., Meiklejohn, A. P., Dewar, A. D., Thow, R. K. ibid. p. 27. Dole, V. P. Quoted by Shank, R. E. Nutr. Rev. 1961, 19, 289.
594
be extended further to cover the relatively large but labile reserves of water which some of the obese appear to accumulate when fed with carbohydrate, and to lose when using dietary or endogenous fat as a source of energy. RusSELL9 has described the effect of artificial reducing diets on the loss of weight and on water and sodium balance in a group of three obese patients studied while their physical activities were restricted. The intake of calories and sodium and the amount of water they drank were kept constant throughout, while the quantities of carbohydrate, protein, and fat that they ate were varied at intervals of 7 days. As others have found, when the proportion of calories derived from carbohydrate was about 70%, weight-loss was lowest, and it became greater when the carbohydrate in the diet was reduced. Under the stringent conditions of this study, it was possible to show that the true water balance and the sodium balance were closely correlated, and their osmotic relationship suggests that the changes in water balance were attributable to fluctuations in the volume of extracellular
might
fluid. From Philadelphia, DUNCAN and his colleagues 10 have recently described clinical studies on 107 obese patients who were treated by periods of complete fasting, usually lasting from 4 to 14 days. Water and other drinks of no food value were given as desired, plus a preparation containing several vitamins. After the initial fast, these patients were recommended diets providing 1500-2300 calories daily, and a fast on one day in each week. Although weight-losses during the period of fasting averaged between 2 and 2-7 lb., only 17% of the patients continued to lose weight after the initial period of fasting -not a very promising response. DUNCAN et al. believe that hyperketonamia accounted for the loss of appetite noted after the first day of the fast: this is somewhat surprising in view of the accepted " resistance " of the obese to the development of ketosis." In a similar investigation DRENICK et al.12 extended the period of starvation to as much as 117 days in one of their 11 patients. While the weight reductions were impressive, the side-effects would preclude the use of this treatment except under the closest observation in hospital. For example, 5 patients had quite severe postural hypotension, sufficient to stop the treatment in 3. Acute gout developed in 2 patients, and what appears to have been a reversible form of hypoplastic anaemia in another. In the absence of any consistently successful method of controlling obesity outside hospital, the testing of hypotheses that might lead to reliable methods of treatment is welcome. Meanwhile, even minor additions to our understanding of metabolic derangements in obesity may help by providing points of departure for new and perhaps effective methods of managing this intractable condition. Russell, G. F. M. Clin. Sci. 1962, 22, 269. Duncan, G. G., Jenson, W. K., Christofori, F. C., Schless, G. L. Amer.J. med. Sci. 1963, 245, 515. 11. Kekwick, A., Pawan, G. L. S., Chalmers, T. M. Lancet, 1959, ii, 9. 10.
1157
12.
Drenick,
E. J., Swenseid, M. med. Ass. 1964, 187, 100.
E., Blahd, W. H., Tuttle, S. G. J.
Amer.
Venereal Disease and Young People ANXIETY about the increase in venereal disease ane reports of habitual promiscuity among young people
resulting in more venereal disease and more illegitimate pregnancies, led the council of the British Medica Association to appoint a committee to investigate the matter. The committee included representatives of the medical, teaching, and nursing professions, the Churches and the social services, and oral and written evidence collected from social and church workers, doctors, teachers, and others in close contact with young people, The investigation covered the period between May; 1961, and January, 1964, and the committee’s report,’ published last week, summarises the evidence and states conclusions and recommendations. Successive reports of the chief medical officer of the of Health have indicated that the incidence of Ministry " sexually transmitted diseases " in England and Wales increased by 73-5% and that of venereal diseases as legally defined-namely syphilis, gonorrhoea, and soft chancre-by 47’3% during 1951-62. During the same time the population increased by only 6-5%. The published figures for cases of infection refer only to patients attending the clinics and therefore indicate only part of the problem. A study2 sponsored by the British Medical Association in 1956 suggested that patients with syphilis treated outside the hospital service might amount to one-quarter of the reported total and those with gonorrhoea and non-gonococcal urethritis to oneseventh. Evidence regarding the prevalence of these diseases among young people is mainly based on successive studies 34 by the British cooperative clinical group of the Medical Society for the Study of Venereal Diseases. In 1961 young people aged 15-19 were responsible for approximately 6% of infections with gonorrhoea in men and 26% in women, the increase over the preceding year in infections at these younger ages being very much greater than in the older age-groups. Figures for 1962 were much the same. There is evidence that immigrants have been responsible for about half the increase in cases of gonorrhoea since 1952, but venereal disease among immigrants is virtually nonexistent outside London and about four other large cities. A London County Council study5 of venereal disease treated in the London area during 1963 showed that, of 13,380 male patients under the age of 25, 52% were born outside the United Kingdom; of 7802 female patients of the same age, 33% were from abroad. Thus, although young immigrants have made an appreciable contribution to the problem, the evidence indicates that theirs was not the sole or even the main responsibility. In England and Wales over 37,000 illegitimate children were born annually between 1955 and 1961, and the proportion of the total live births which they represent rose from 4-6% to 6-6%. The equivalent figures for the was
1. Venereal Diseases and
Young People. A British Medical Association Report. March, 1964. Pp. 160. 5s. 6d. 2. Brit. J. vener. Dis. 1959, 35, 114. 3. ibid. 1963, 39, 1. 4. ibid. p. 149. 5. Report of the County Medical Officer of Health and Principal School Medical Officer, London County Council, 1962; p. 145. 6. Annual Report of the Chief Medical Officer of the Ministry of Health, 1961, part II; p. 127. H.M. Stationery Office.
failed to go on losing weight after discharge from hospital. It is surprising that these workers found " hypometabolism " in many or most of their overweight patients; this was based on tests of iodine metabolism and a delay in relaxation of the ankle-jerk (implying hypothyroidism), but they did not comment on the basal metabolic rate, which is usually normal in obesity’! Nor do they appear to have measured any effect on weight that might have arisen from changes in the physical activity of the patients.
THE LANCET LONDON
14
MARCH
593
ARTICLES
1964
GORDON et al. were also impressed by the rapid and striking fluctuations in weight that may be observed in obesity, particularly the water retention that accompanies a relatively high intake of carbohydrate, and the diuresis and loss of weight that follow when a high-fat diet is substituted, or indeed when the intake of carbohydrate is restricted. PASSMORE and SWINDELLS4 recently analysed the gains in weight of a group of healthy adults who ate quantities of carbohydrate much in excess of their normal energy requirements. They found that some retained more than a litre of water in 24 hours, with an appropriate gain in weight, and they also stored sufficient sodium to maintain isotonicity, assuming that the water accumulated in the extracellular space. Another report from Edinburghdescribes the changes that followed the overfeeding of two obese young women who were already almost 50% overweight. In the course of 9 days of overfeeding, mainly with carbohydrate, to a total calorie surfeit of 7300 and 10,500 calories each, these two patients gained 2-86 and 2-58 kg. respectively. In a subsequent period of 5 days they received only a token diet providing about 300 calories daily, and with total calorie deficits of 12,000 and 14,000 calories, they lost 6-22 and 5-63 kg. .
but Food THE difficulties that obese patients have in keeping down their weight are all too well known.! For the majority, the balance of energy intake and output can be manipulated only by modifying the diet. The simple but distant target for the patient is so to adjust the habit of eating that having reached a normal weight this equilibrium can be maintained. An imposed dietary discipline -in hospital, for example-is always successful while it lasts, but subsequent efforts at self discipline often fail. A new system of weight reduction has now been described by GORDON and his colleagues.To begin the regimen, they advocate an absolute fast for 48 hours,
Nothing to Eat
followed, paradoxically, by six meals daily, providing
a
total of 1320 calories and including twice as much protein (100 g.) as carbohydrate, and a relatively large intake of fat (80 g.), of which 15-20% is unsaturated. A more controversial feature is the use of triiodothyronine in doses of as much as 250 tg. daily, but varying with the patient’s tolerance of the drug; the dose is aimed at just below the amount that produces signs of hyperthyroidism. GORDON et al. recognise that this step might be hazardous and should certainly be avoided in patients with ischxmic heart-disease. Moderate salt restriction and diuretics are included in the regimen. In formulating this system, the authors were impressed by the analogy with rats, illustrated by the work of HOLLIFIELD and PARSON 3 and others. These workers showed that when rats were allowed to feed only once daily for two hours, as opposed to having free and constant access to food, the animals put on weight steadily until they weighed much more than their controls. Biochemical studies showed that the rate of formation of fat was greatly increased in this way, and was rapidly reversed if a period of fasting was interposed between the system of feeding two hours daily and the reversion to free access to food-the nibbling regimen. GORDON et al. showed that 14C-glucose is oxidised less rapidly by obese patients. Presumably they store the glucose as fat. Again, as in the rats studied by HOLLIFIELD and PARSON,3, brief period of fasting reversed this trend. It is still early for more than a very general statement about the efficacy of this treatment. The patients specifically denied hunger at any time and very few "
1. 2. 3
"
Strang, J. M., in Diseases of Metabolism (edited by G. G. Duncan). London, 1959. Gordon, E. S., Goldberg, M., Chosy, G. J. J. Amer. med. Ass. 1963, 186, 50. Hollifield, G., Parson, W. J. clin. Invest. 1962, 41, 245, 250.
PASSMORE et al. contrast these
findings with an earlier
study 6based on overfeeding thin young men, and conclude that, whereas the two obese women required an excess of approximately 6000 and 10,000 calories in order to gain 2-5 kg. in weight, the thin young men each required about 20,000 calories to achieve the same gain. A possible explanation is that the tissue laid down by the obese contained a high proportion of water, while that deposited by the thin men contained much less. In the short term, at any rate, there seems to be some support for the claim so often made by the obese-namely, that they will gain weight on a diet which their more slender relatives can eat with impunity. DOLE,8 quoted as a supporter of this view, is said to have found that after weight reduction the total energy expenditure of the erstwhile obese is only half or two-thirds that of comparable thin persons. From serial estimations of the respiratory quotient, the Edinburgh workers suggest that their findings would be best accounted for if the excess carbohydrate was first stored as glycogen; conversion to fat might then begin when " the glycogen stores were full ". This hypothesis 4. Passmore, R., 5. Passmore, R., 6. Passmore, R., 1955, 9, 20. 7. 8.
Swindells, Y. E. Brit. J. Nutr. 1963, 17, 331. Strong, J. A., Swindells, Y. E., el Din, N. ibid. p. 373. Meiklejohn, A. P., Dewar, A. D., Thow, R. K. ibid.
Passmore, R., Meiklejohn, A. P., Dewar, A. D., Thow, R. K. ibid. p. 27. Dole, V. P. Quoted by Shank, R. E. Nutr. Rev. 1961, 19, 289.
594
be extended further to cover the relatively large but labile reserves of water which some of the obese appear to accumulate when fed with carbohydrate, and to lose when using dietary or endogenous fat as a source of energy. RusSELL9 has described the effect of artificial reducing diets on the loss of weight and on water and sodium balance in a group of three obese patients studied while their physical activities were restricted. The intake of calories and sodium and the amount of water they drank were kept constant throughout, while the quantities of carbohydrate, protein, and fat that they ate were varied at intervals of 7 days. As others have found, when the proportion of calories derived from carbohydrate was about 70%, weight-loss was lowest, and it became greater when the carbohydrate in the diet was reduced. Under the stringent conditions of this study, it was possible to show that the true water balance and the sodium balance were closely correlated, and their osmotic relationship suggests that the changes in water balance were attributable to fluctuations in the volume of extracellular
might
fluid. From Philadelphia, DUNCAN and his colleagues 10 have recently described clinical studies on 107 obese patients who were treated by periods of complete fasting, usually lasting from 4 to 14 days. Water and other drinks of no food value were given as desired, plus a preparation containing several vitamins. After the initial fast, these patients were recommended diets providing 1500-2300 calories daily, and a fast on one day in each week. Although weight-losses during the period of fasting averaged between 2 and 2-7 lb., only 17% of the patients continued to lose weight after the initial period of fasting -not a very promising response. DUNCAN et al. believe that hyperketonamia accounted for the loss of appetite noted after the first day of the fast: this is somewhat surprising in view of the accepted " resistance " of the obese to the development of ketosis." In a similar investigation DRENICK et al.12 extended the period of starvation to as much as 117 days in one of their 11 patients. While the weight reductions were impressive, the side-effects would preclude the use of this treatment except under the closest observation in hospital. For example, 5 patients had quite severe postural hypotension, sufficient to stop the treatment in 3. Acute gout developed in 2 patients, and what appears to have been a reversible form of hypoplastic anaemia in another. In the absence of any consistently successful method of controlling obesity outside hospital, the testing of hypotheses that might lead to reliable methods of treatment is welcome. Meanwhile, even minor additions to our understanding of metabolic derangements in obesity may help by providing points of departure for new and perhaps effective methods of managing this intractable condition. Russell, G. F. M. Clin. Sci. 1962, 22, 269. Duncan, G. G., Jenson, W. K., Christofori, F. C., Schless, G. L. Amer.J. med. Sci. 1963, 245, 515. 11. Kekwick, A., Pawan, G. L. S., Chalmers, T. M. Lancet, 1959, ii, 9. 10.
1157
12.
Drenick,
E. J., Swenseid, M. med. Ass. 1964, 187, 100.
E., Blahd, W. H., Tuttle, S. G. J.
Amer.
Venereal Disease and Young People ANXIETY about the increase in venereal disease ane reports of habitual promiscuity among young people
resulting in more venereal disease and more illegitimate pregnancies, led the council of the British Medica Association to appoint a committee to investigate the matter. The committee included representatives of the medical, teaching, and nursing professions, the Churches and the social services, and oral and written evidence collected from social and church workers, doctors, teachers, and others in close contact with young people, The investigation covered the period between May; 1961, and January, 1964, and the committee’s report,’ published last week, summarises the evidence and states conclusions and recommendations. Successive reports of the chief medical officer of the of Health have indicated that the incidence of Ministry " sexually transmitted diseases " in England and Wales increased by 73-5% and that of venereal diseases as legally defined-namely syphilis, gonorrhoea, and soft chancre-by 47’3% during 1951-62. During the same time the population increased by only 6-5%. The published figures for cases of infection refer only to patients attending the clinics and therefore indicate only part of the problem. A study2 sponsored by the British Medical Association in 1956 suggested that patients with syphilis treated outside the hospital service might amount to one-quarter of the reported total and those with gonorrhoea and non-gonococcal urethritis to oneseventh. Evidence regarding the prevalence of these diseases among young people is mainly based on successive studies 34 by the British cooperative clinical group of the Medical Society for the Study of Venereal Diseases. In 1961 young people aged 15-19 were responsible for approximately 6% of infections with gonorrhoea in men and 26% in women, the increase over the preceding year in infections at these younger ages being very much greater than in the older age-groups. Figures for 1962 were much the same. There is evidence that immigrants have been responsible for about half the increase in cases of gonorrhoea since 1952, but venereal disease among immigrants is virtually nonexistent outside London and about four other large cities. A London County Council study5 of venereal disease treated in the London area during 1963 showed that, of 13,380 male patients under the age of 25, 52% were born outside the United Kingdom; of 7802 female patients of the same age, 33% were from abroad. Thus, although young immigrants have made an appreciable contribution to the problem, the evidence indicates that theirs was not the sole or even the main responsibility. In England and Wales over 37,000 illegitimate children were born annually between 1955 and 1961, and the proportion of the total live births which they represent rose from 4-6% to 6-6%. The equivalent figures for the was
1. Venereal Diseases and
Young People. A British Medical Association Report. March, 1964. Pp. 160. 5s. 6d. 2. Brit. J. vener. Dis. 1959, 35, 114. 3. ibid. 1963, 39, 1. 4. ibid. p. 149. 5. Report of the County Medical Officer of Health and Principal School Medical Officer, London County Council, 1962; p. 145. 6. Annual Report of the Chief Medical Officer of the Ministry of Health, 1961, part II; p. 127. H.M. Stationery Office.