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Obesity
Obesity LAWRENCE S. CAREY, M.D.'"
OBESITY is a challenge to the medical profession, a vast public health problem and a serious threat to the individuals who are overweight. It is a state of overnutrition resulting from a positive energy balance-an excess calorie intake over the energy output-usually occurring over a long period of time. The degree of obesity may be estimated by comparing the patient's weight, based on height, age and sex, with a standard average weight. Other methods have been the measuring of the thickness of the fat layer under the skin and the estimation of the specific gravity by measuring the amount of displaced water by a given individual. All of these methods have their faults and perhaps one can acquire as good an idea as from any other method by simply observing the patient without clothing. A large framed individual with solid flesh might not be overweight as compared to a person who has a thick layer of fat beneath his skin. The importance of obesity becomes more apparent if one considers the influence it has on the development of other serious conditions and on life expectancy.! That we fail to prevent this malady becomes evident when we realize that one of every five adults in the United States weighs more than he should; and about 5 million weigh 20 per cent above their ideal weights. 2 A Gallup poll has estimated that 36,000,000 adults in the United States consider themselves overweight. When a patient is 10 pounds overweight between the ages of 45 to 50 years his chances of death are increased by 8 per cent; when 30 pounds overweight, the increase in death rate is 28 per cent; and a 50 pound excess over the normal weight gives a death rate of 56 per cent above that normally expected. Deaths from cardiovascular disease have been estimated by Dublin and Marks3 to be 62 per cent more common when complicated by obesity. Diabetes is much more common in obese patients than those of normal weight; and when the degree of overweight exceeds 25 per cent, the mortality in these patients is eight times that of normal expectancy. It has been shown recently by Masters4 that a very clear rela• Physician to Pennsylvania Hospital and the Benjamin Franklin Clinic; Assistant Professor of Medicine, Jefferson Medical CoUege, Philadelphia, and Director of Medical Services at Delaware County Hospital. 1701
Lawrence S. Carey
1702
tionship exists between obesity and coronary artery disease in men. In fact, the mortality from any disease is greater in obese persons than in those of normal weight. Through our several mediums of publicity, the general public has come to know something of the seriousness of being overweight, and individuals present themselves to the physician's office for authoritative information as to the truth of publicized statements and also for instruction in methods by which a reduction regimen can safely be carried out. To the physician, the methods of weight control may seem simple, but to the patient they are often complex. Success, therefore, depends upon the care and understanding with which the physician can instruct the patient on the seriousness of being overweight and in the methods by which he can reduce. THE CAUSES OF OBESITY
It may be stated as a basic fact that the primary cause of overweight is the taking of too much food. Many factors may contribute to it. The accompanying diagrams (Figs. 258, 259) will show something of the various factors and their relationship to the taking of excess food.
Excess Food
Intake
Fig. 258. Factors conlributing to the taking of exCe1!8 food.
Habit. The habit of taking excess food occurs in some families in which the preparation of food and its consumption occupy a prominent place in family activities. The physician here needs to point out the faulty habit and to suggest that recreation be obtained in some other manner. Heredity. Although one's parents may have been obese, it does not mean that their offspring must necessarily and inevitably fall heir to the ravages of obesity. The same basic principle that excess food intake is necessary to produce overweight still applies. Endocrine Factors. Endocrine factors are not prominent as a cause
Obesity
1703
of obesity, but various deficiencies of endocrine secretion do influence the position in which fat deposits are set down in the body. Frequently the underlying factor in obesity accompanying endocrine disorders is the fact that the patient is inactive. The relationship between nutritional needs and appetite sometimes may be disturbed by endocrine disorders such as hyperinsulinism and hypothalamic dysfunction. If the hypothalamic area is injured in animals and they are allowed to eat all they want, then obesity results. Patients who suffer hypothalamic injury incident to such diseases as encephalitis develop obesity because they restrict their activities without restricting their appetites. Children frequently grow fat not because of lazy glands but because of diminished activity, often following some illness which restricts them. When these children get away from the coddling of parents and are stirred to normal activity they usually turn out to be normal children. Hypothyroidism of itself is not a cause of obesity. Overweight in patients with this disorder is usually slight and any apparent increase in weight is due to the collection of mucoid material and water, both of which may be dispelled by careful thyroid therapy. Changes in gonadal hormones alter the distribution of fat but do not produce obesity unless the dietary habits are also changed. No alteration of internal secretion has been shown to change metabolism so profoundly that the total fat will increase to the extent of obesity unless the intake of calories is greater than the output. Hyperinsulinism is sometimes blamed; but here again, although the appetite might be increased, the weight will not increase unless the caloric intake exceeds the output. Psychologic factors, such as the taking of excess food to compensate for the lack of attention of the opposite sex, may produce obesity; or perhaps the taking of excess food compensates and produces a sense of satiety in the face of disappointments in other directions. Lack of exercise, as becomes necessary in certain diseases and with advancing years, may sometimes be an important factor in the production of obesity. Custom has made food in almost all nations and localities a symbol of social activity. Whenever people gather at parties or other functions, food takes a prominent place in the entertainment for the evening, thus contributing to obesity. The physiologic mechanisms which increase appetite have been the subjects (Fig. 259) of a great deal of research in the last few years. Previously mentioned are lesions of the ventromedial nuclei in the hypothalamus. 5 In experimental animals it has been shown that lesions of this area produce excessive hunger. For many years it was thought that hunger was produced by emptiness of the stomach and induced by contractions of the stomach walls. This cause for increased appetite is not supported by the evidence. 6 Denervation of the stomach walls does not change one's excessive appetite. Neither can hypoglycemia always be
Lawrence S. Carey
1704
correlated with feelings of hunger and excessive appetite. There has been no correlation found between the degree of hunger and blood sugar levels, i.e., the excessive appetite of diabetes is inexplainable on a hypoglycemia basis. The rate of the rise of skin temperature during eating has been shown to be slower in stout people than in slender people. 7 It is believed that a rapid rise of temperature of the skin with the process of eating is associated with the onset of a feeling of satiety. The difference between the blood glucose levels in the arteries and in the veins of certain areas in the brain is also believed to have a relationship to the production of excessive hunger. The decreased utilization of glucose in the supplied tissue apparently is a factor in this mechanism. The dropping of the blood level of delta glucose below 15 mg. per 100 cc. has been thought to have a bearing on increased appetite.
I OBESITY
I
Increased Appetite
I Endocrine !Hyperinsuli nism
IHypothalamic I~rterio-venous
qllX:ose. differen~
~Iow rise in Ski~1
temp witlJ food
~elta qlucos eblo1! level below 15mg~
!
Specific dYrKlmJ~ Clction of food Psychosomati cJ Factors
Fig. 259. Physiologic mechanisms which increase appetite.
Isotope researchers have shown that fat is not an inert tissue. 8 There apparently are some individuals who give some evidence of increased lipogenesis, but about ten times as much carbohydrate is used in the production of fat as is used in the production of glycogen. Pennington has suggested that there is a breakdown in the carbohydrate utilization, probably at the pyruvic acid stage,9 and has postulated that a high protein diet may favor the utilization of fat tissues stored in the body. TREATMENT
The desirability of a reduction of weight in obese persons was made very evident in a study by Dublin on a group who were accepted for substandard insurance because of overweight. He showed that a reduction in weight decreased mortality by one-fifth in the men and one-third in women. IO In these individuals also there is reduction in the mortality from chronic diseases of the vascular system and kidneys. These facts have heen apparent on clinical grounds for many years and this statistical
Obesity
1705
evidence further supports the necessity for the reduction in weight of the obese. Treatment must be highly individualized since it may not be wise to reduce some patients rapidly.! Patients recovering from operations, a recent injury or myocardial infarction or from an infection such as hepatitis or tuberculosis may need to be very cautious in their reduction procedures. It is true that one patient may lose weight on a diet of 1800 calories a day, and another may need to reduce his diet to less than 1000 calories to produce the same weight loss. The difference is usually explained by the relative differences in the amount of energy output. Some patients also tend to have a greater tendency to retain salt and water than others. In these patients a temporary restriction of sodium intake is helpful. Also, a physically active patient can usually be given a more liberal diet than would be possible for the patient who is hospitalized or who is ill or handicapped in some way. Dietary Restrictions
The first measure of treatment in an obese persons consists of a reduced caloric intake regardless of other influencing factors. Since fat contains the largest number of calories per gram, it is most important that the fat content of the diet be restricted. It is relatively easy for the body to turn carbohydrate into fat deposits, hence the restriction of carbohydrate is of next importance. The specific dynamic action of protein is said to produce additional energy and to aid in utilization of carbohydrates. It is therefore important that a sizable portion of the diet consist of protein. Generally speaking, there are only three dangers in the restriction of diet. One is that the patient may not receive enough proteins, another is that he may not get enough vitamins, and a third is that he may not get enough mineral salts. A goodly portion of protein with each meal, say 3 ounces with both lunch and dinner and one egg with breakfast, will usually provide an adequate protein intake. The second danger of insufficient vitamin intake may be prevented by the taking of a single capsule of a vitamin concentrate. The third danger can be obviated by the taking of a half pint of skimmed milk once daily. The calcium salts are perhaps the most important in this regard, and the skimmed milk will supply this most abundantly. It is usually wise to make the dietary instruction as simple as ifS possible, otherwise the patient will remain on the restricted diet only for a short time and then regard the whole procedure as being too much trouble. In many patients the restriction of starch desserts, the avoidance of sugar, the avoidance of fats and greases and of candy may be sufficient for a satisfactory reduction of weight. In others, usually older and sedentary persons, the diet must be calculated and its restrictions adhered to a great deal more rigidly. A diet for an adult will frequently
1706
Lawrence S. Carey
be satisfactory at approximately 1000 to 1200 calories per day. In the inactive and elderly individual who has become overweight, it might be necessary to reduce the diet to as low as 700 or 800 calories per day before weight reduction will occur. An illustrative diet may be described as follows: total calories 1000, proteins 100 grams, carbohydrate 100 grams and fat 22 grams. Salt restriction is advised in those patients who have edema, cardiac embarrassment or hypertension and in those who are prone to retain salt and water to excess. After the patient reduces his weight, suitable adjustment in dietary allowance can be made. First, protein is added until the allowance reaches 125 grams. Then the other elements are added until th~ diet which maintains his weight at a suitable level is obtained. In the control of excessive hunger, a small amount of food between meals and at bedtime is often helpful. This betweenmeal allowance may be deducted from the other meals. Evans 12 has suggested a very restricted diet for the rapid reduction of weight. This may be accomplished by limiting the calories to 500 per day for a short time. A sample diet restriction of this sort would contain protein 70 grams, carbohydrates 40 grams and fat, 6 to 10 grams. This diet is well tolerated with the patient at rest and in the hospital. This severe undernutrition often produces a lack of appetite which is a distinct advantage in inducing the patient to remain on a low diet. This low diet should probably be used only in those patients who are hospitalized and in whom there are extreme degrees of obesity. Alternating high and low caloric diets allowing an increased diet for a few days and then reducing the diet rigidly for a few days again may be very helpful in some patients. Hospitalization
In many patients, particularly adults, hospitalization is almost a necessity to successful treatment. The advantages of hospitalization may be listed as follows: 11 1. Close observation including careful supervision of the diet and any special studies that may be desired. 2. A complete break from home environment, its responsibilities and its dietary habits. 3. Proof that a loss of weight at a satisfactory rate is possible despite the patient's former belief to the contrary. 4. Instruction in diet given by a dietitian skilled in this form of training and on repeated occasions is often successful when instruction in a physician's office has failed. 5. Impressions gained by the patient concerning the nature of his disorder and its hazards and unfavorable outlook and concerning the means whereby the ground gained can be maintained are often more vivid and lasting under hospital management than under management outside the hospital. Thus, a hospital period of 7 to
Obesity
1707
14 days serves as a valuable training period. Indeed, hospitalization is often as important to the long life of the patient as it is in the treatment of appendicitis or pneumonia. Exercise
Every obese person cannot take strenuous physical exercise. This statement applies to elderly individuals and to the extremely obese. The tendency of exercise to increase the appetite is usually offset by the fact that the exercise takes the patient away from his source of food. Moreover, it has been found practically that exercise frequently satisfies the patient's desire for entertainment and thereby makes his demand for food less urgent. Exercise can be increased as the patient is reduced in his weight. A regular plan of exercise for daily use can be adopted and followed with considerable benefit. Psychotherapy
Motivation for weight reduction must be cultivated in the patient's mind. If the patient sees no need to reduce, then he will not long remain on a restricted diet in the face of craving for food. Inducements such as improved appearance, the avoidance of degenerative diseases, longer life expectancy, the ability to be more active, and perhaps other personal reasons, may give most patients an incentive for keeping their weight down. These motives must be sought individually and discussed with each patient in detail. A wife may feel that a husband who is not very well nourished is not a credit to her cooking. Some groups feel that overweight is a desirable state and actually means good health. Some persons have such an uninteresting life that food is their greatest pleasure. Neurotic subjects seek relief from their anxiety by eating. Many physicians are of the opinion that such a psychiatric appraisal should be made by the internist and not by a psychiatrist. The education of the patient and reassurance concerning his anxieties may often gain his confidence and keep him restricted to a diet that will secure weight reduction. Group therapy has been very successful, according to a number of reports. Many patients fail in their weight reduction regimen because of hunger pangs which gnaw at them. Usually, these sensations will subside when the patient has reduced his weight and he has become accustomed to living on a reduced diet. Individuals in prison camps during the war who were living on extremely low diets have stated that after a time their hunger discomforts were not severe. Drugs
The use of appetite-reducing drugs such as amphetamine sulfate in doses of 5 mg. before breakfast and before lunch either with or without a sedative may help in reducing the persistent craving of food in an
Lawrence S. Carey
1708
occasional patient. The drug apparently is harmless in these amounts but its effect tends to wear off quickly. The results generally have been disappointing. Moreover, the patient has not learned to restrict his own diet when he has used a drug to do the job for him. The use of thyroid substance is indicated only for patients in whom definite hypothyroidism has been shown to exist. In patients with normal thyroid function it has no effect on weight reduction until the dose has been made so large that toxic symptoms occur. Such excessively large doses are therefore dangerous. Increase of metabolism by these means is not under the same prompt control as such an increase by exercise. Several weeks pass before the effect of toxic doses of thyroid disappear. The strain of increased metabolism may be great on the heart and circulation. Diuretics are of help in some persons who have associated myocardial weakness with water retention. The mercurial diuretics are most effective and digitalis may also be very helpful. These drugs do not, of course, correct the obesity but they aid in securing improvement in those patients who already have complications. Bulk-producing agents such as Metamucil and Mucilose often give the patient a feeling of satisfaction by producing bulk in his stomach and intestinal tract. SUMMARY
Obesity is a widespread problem which is attended with great risk when it is complicated by disease. Many factors play a part in obesity, all of which center about the taking of more food than is necessary for energy expended. Treatment must be individualized and directed toward the various influences which play a part in each patient, and continued for a prolonged period of time. Continued observation on the part of the physician is usually essential for final success. A period of hospitalization may be extremely important in the early management. REFERENCES
1. Dublin and Marks: Overweight Shortens Life. Statistical Bulletin, New York, Metropolitan Life Insurance Company, 10: 32, 1951. 2. Dublin: Relation of Obesity to Longevity. New England J. Med. S48: 971-974, 1953. 3. Dublin and Marks: Mortality of Women According to Build. Assoc. of Life Ins. Med. Directors of Am., Oct. 20,1938. 4. Master, Jaffe and Chesky: Relationship of Obesity to Coronary Disease and Hypertension. J.A.M.A. 159: 17 (Dec. 26) 1953. 5. Delgado, Jose and Anand: Increased Food Intake Induced by Electrical Stimulation of the Lateral Hypothalamus. Am. J. Physiol. 17S: 162, 1953. 6. Scott, Scott and Lockhardt: Observations on the Blood Sugar Level Before, During and After Hunger Periods in Humans. Am. J. PhysioI. US: 243, 1938. 7. Booth and Strang: Changes in Temperature of the Skin Following the Ingestion of Food. Arch. Int. Med. 57: 533, 1936. 8. Schoenheimer and Rittenberg: Deuterium as an Indicator in the Study of Intermediary Metabolism. J. BioI. Chem.119: 505,1936.
Obesity
1709
9. Pennington: An Alternate Approach to the Problem of Obesity. J. Clin. Nutrition 1: lOO, 1953. 10. Dublin: Fat People Who Lose Weight Live Longer. The National Vitamin Foundation, Inc., 1953, p. 106. 11. Duncan: Obesity. Paper read at Fourth Middle East Medical Assembly, April 11, 1954. 12. Evans: Obesity. In: Diseases of Metabolism, 3rd Ed., edited by Duncan. Philadelphia, W. B. Saunders Co., 1952, p. 647. 330 S. 9th Street Philadelphia 7, Pennsylvania
OBESITY is a challenge to the medical profession, a vast public health problem and a serious threat to the individuals who are overweight. It is a state of overnutrition resulting from a positive energy balance-an excess calorie intake over the energy output-usually occurring over a long period of time. The degree of obesity may be estimated by comparing the patient's weight, based on height, age and sex, with a standard average weight. Other methods have been the measuring of the thickness of the fat layer under the skin and the estimation of the specific gravity by measuring the amount of displaced water by a given individual. All of these methods have their faults and perhaps one can acquire as good an idea as from any other method by simply observing the patient without clothing. A large framed individual with solid flesh might not be overweight as compared to a person who has a thick layer of fat beneath his skin. The importance of obesity becomes more apparent if one considers the influence it has on the development of other serious conditions and on life expectancy.! That we fail to prevent this malady becomes evident when we realize that one of every five adults in the United States weighs more than he should; and about 5 million weigh 20 per cent above their ideal weights. 2 A Gallup poll has estimated that 36,000,000 adults in the United States consider themselves overweight. When a patient is 10 pounds overweight between the ages of 45 to 50 years his chances of death are increased by 8 per cent; when 30 pounds overweight, the increase in death rate is 28 per cent; and a 50 pound excess over the normal weight gives a death rate of 56 per cent above that normally expected. Deaths from cardiovascular disease have been estimated by Dublin and Marks3 to be 62 per cent more common when complicated by obesity. Diabetes is much more common in obese patients than those of normal weight; and when the degree of overweight exceeds 25 per cent, the mortality in these patients is eight times that of normal expectancy. It has been shown recently by Masters4 that a very clear rela• Physician to Pennsylvania Hospital and the Benjamin Franklin Clinic; Assistant Professor of Medicine, Jefferson Medical CoUege, Philadelphia, and Director of Medical Services at Delaware County Hospital. 1701
Lawrence S. Carey
1702
tionship exists between obesity and coronary artery disease in men. In fact, the mortality from any disease is greater in obese persons than in those of normal weight. Through our several mediums of publicity, the general public has come to know something of the seriousness of being overweight, and individuals present themselves to the physician's office for authoritative information as to the truth of publicized statements and also for instruction in methods by which a reduction regimen can safely be carried out. To the physician, the methods of weight control may seem simple, but to the patient they are often complex. Success, therefore, depends upon the care and understanding with which the physician can instruct the patient on the seriousness of being overweight and in the methods by which he can reduce. THE CAUSES OF OBESITY
It may be stated as a basic fact that the primary cause of overweight is the taking of too much food. Many factors may contribute to it. The accompanying diagrams (Figs. 258, 259) will show something of the various factors and their relationship to the taking of excess food.
Excess Food
Intake
Fig. 258. Factors conlributing to the taking of exCe1!8 food.
Habit. The habit of taking excess food occurs in some families in which the preparation of food and its consumption occupy a prominent place in family activities. The physician here needs to point out the faulty habit and to suggest that recreation be obtained in some other manner. Heredity. Although one's parents may have been obese, it does not mean that their offspring must necessarily and inevitably fall heir to the ravages of obesity. The same basic principle that excess food intake is necessary to produce overweight still applies. Endocrine Factors. Endocrine factors are not prominent as a cause
Obesity
1703
of obesity, but various deficiencies of endocrine secretion do influence the position in which fat deposits are set down in the body. Frequently the underlying factor in obesity accompanying endocrine disorders is the fact that the patient is inactive. The relationship between nutritional needs and appetite sometimes may be disturbed by endocrine disorders such as hyperinsulinism and hypothalamic dysfunction. If the hypothalamic area is injured in animals and they are allowed to eat all they want, then obesity results. Patients who suffer hypothalamic injury incident to such diseases as encephalitis develop obesity because they restrict their activities without restricting their appetites. Children frequently grow fat not because of lazy glands but because of diminished activity, often following some illness which restricts them. When these children get away from the coddling of parents and are stirred to normal activity they usually turn out to be normal children. Hypothyroidism of itself is not a cause of obesity. Overweight in patients with this disorder is usually slight and any apparent increase in weight is due to the collection of mucoid material and water, both of which may be dispelled by careful thyroid therapy. Changes in gonadal hormones alter the distribution of fat but do not produce obesity unless the dietary habits are also changed. No alteration of internal secretion has been shown to change metabolism so profoundly that the total fat will increase to the extent of obesity unless the intake of calories is greater than the output. Hyperinsulinism is sometimes blamed; but here again, although the appetite might be increased, the weight will not increase unless the caloric intake exceeds the output. Psychologic factors, such as the taking of excess food to compensate for the lack of attention of the opposite sex, may produce obesity; or perhaps the taking of excess food compensates and produces a sense of satiety in the face of disappointments in other directions. Lack of exercise, as becomes necessary in certain diseases and with advancing years, may sometimes be an important factor in the production of obesity. Custom has made food in almost all nations and localities a symbol of social activity. Whenever people gather at parties or other functions, food takes a prominent place in the entertainment for the evening, thus contributing to obesity. The physiologic mechanisms which increase appetite have been the subjects (Fig. 259) of a great deal of research in the last few years. Previously mentioned are lesions of the ventromedial nuclei in the hypothalamus. 5 In experimental animals it has been shown that lesions of this area produce excessive hunger. For many years it was thought that hunger was produced by emptiness of the stomach and induced by contractions of the stomach walls. This cause for increased appetite is not supported by the evidence. 6 Denervation of the stomach walls does not change one's excessive appetite. Neither can hypoglycemia always be
Lawrence S. Carey
1704
correlated with feelings of hunger and excessive appetite. There has been no correlation found between the degree of hunger and blood sugar levels, i.e., the excessive appetite of diabetes is inexplainable on a hypoglycemia basis. The rate of the rise of skin temperature during eating has been shown to be slower in stout people than in slender people. 7 It is believed that a rapid rise of temperature of the skin with the process of eating is associated with the onset of a feeling of satiety. The difference between the blood glucose levels in the arteries and in the veins of certain areas in the brain is also believed to have a relationship to the production of excessive hunger. The decreased utilization of glucose in the supplied tissue apparently is a factor in this mechanism. The dropping of the blood level of delta glucose below 15 mg. per 100 cc. has been thought to have a bearing on increased appetite.
I OBESITY
I
Increased Appetite
I Endocrine !Hyperinsuli nism
IHypothalamic I~rterio-venous
qllX:ose. differen~
~Iow rise in Ski~1
temp witlJ food
~elta qlucos eblo1! level below 15mg~
!
Specific dYrKlmJ~ Clction of food Psychosomati cJ Factors
Fig. 259. Physiologic mechanisms which increase appetite.
Isotope researchers have shown that fat is not an inert tissue. 8 There apparently are some individuals who give some evidence of increased lipogenesis, but about ten times as much carbohydrate is used in the production of fat as is used in the production of glycogen. Pennington has suggested that there is a breakdown in the carbohydrate utilization, probably at the pyruvic acid stage,9 and has postulated that a high protein diet may favor the utilization of fat tissues stored in the body. TREATMENT
The desirability of a reduction of weight in obese persons was made very evident in a study by Dublin on a group who were accepted for substandard insurance because of overweight. He showed that a reduction in weight decreased mortality by one-fifth in the men and one-third in women. IO In these individuals also there is reduction in the mortality from chronic diseases of the vascular system and kidneys. These facts have heen apparent on clinical grounds for many years and this statistical
Obesity
1705
evidence further supports the necessity for the reduction in weight of the obese. Treatment must be highly individualized since it may not be wise to reduce some patients rapidly.! Patients recovering from operations, a recent injury or myocardial infarction or from an infection such as hepatitis or tuberculosis may need to be very cautious in their reduction procedures. It is true that one patient may lose weight on a diet of 1800 calories a day, and another may need to reduce his diet to less than 1000 calories to produce the same weight loss. The difference is usually explained by the relative differences in the amount of energy output. Some patients also tend to have a greater tendency to retain salt and water than others. In these patients a temporary restriction of sodium intake is helpful. Also, a physically active patient can usually be given a more liberal diet than would be possible for the patient who is hospitalized or who is ill or handicapped in some way. Dietary Restrictions
The first measure of treatment in an obese persons consists of a reduced caloric intake regardless of other influencing factors. Since fat contains the largest number of calories per gram, it is most important that the fat content of the diet be restricted. It is relatively easy for the body to turn carbohydrate into fat deposits, hence the restriction of carbohydrate is of next importance. The specific dynamic action of protein is said to produce additional energy and to aid in utilization of carbohydrates. It is therefore important that a sizable portion of the diet consist of protein. Generally speaking, there are only three dangers in the restriction of diet. One is that the patient may not receive enough proteins, another is that he may not get enough vitamins, and a third is that he may not get enough mineral salts. A goodly portion of protein with each meal, say 3 ounces with both lunch and dinner and one egg with breakfast, will usually provide an adequate protein intake. The second danger of insufficient vitamin intake may be prevented by the taking of a single capsule of a vitamin concentrate. The third danger can be obviated by the taking of a half pint of skimmed milk once daily. The calcium salts are perhaps the most important in this regard, and the skimmed milk will supply this most abundantly. It is usually wise to make the dietary instruction as simple as ifS possible, otherwise the patient will remain on the restricted diet only for a short time and then regard the whole procedure as being too much trouble. In many patients the restriction of starch desserts, the avoidance of sugar, the avoidance of fats and greases and of candy may be sufficient for a satisfactory reduction of weight. In others, usually older and sedentary persons, the diet must be calculated and its restrictions adhered to a great deal more rigidly. A diet for an adult will frequently
1706
Lawrence S. Carey
be satisfactory at approximately 1000 to 1200 calories per day. In the inactive and elderly individual who has become overweight, it might be necessary to reduce the diet to as low as 700 or 800 calories per day before weight reduction will occur. An illustrative diet may be described as follows: total calories 1000, proteins 100 grams, carbohydrate 100 grams and fat 22 grams. Salt restriction is advised in those patients who have edema, cardiac embarrassment or hypertension and in those who are prone to retain salt and water to excess. After the patient reduces his weight, suitable adjustment in dietary allowance can be made. First, protein is added until the allowance reaches 125 grams. Then the other elements are added until th~ diet which maintains his weight at a suitable level is obtained. In the control of excessive hunger, a small amount of food between meals and at bedtime is often helpful. This betweenmeal allowance may be deducted from the other meals. Evans 12 has suggested a very restricted diet for the rapid reduction of weight. This may be accomplished by limiting the calories to 500 per day for a short time. A sample diet restriction of this sort would contain protein 70 grams, carbohydrates 40 grams and fat, 6 to 10 grams. This diet is well tolerated with the patient at rest and in the hospital. This severe undernutrition often produces a lack of appetite which is a distinct advantage in inducing the patient to remain on a low diet. This low diet should probably be used only in those patients who are hospitalized and in whom there are extreme degrees of obesity. Alternating high and low caloric diets allowing an increased diet for a few days and then reducing the diet rigidly for a few days again may be very helpful in some patients. Hospitalization
In many patients, particularly adults, hospitalization is almost a necessity to successful treatment. The advantages of hospitalization may be listed as follows: 11 1. Close observation including careful supervision of the diet and any special studies that may be desired. 2. A complete break from home environment, its responsibilities and its dietary habits. 3. Proof that a loss of weight at a satisfactory rate is possible despite the patient's former belief to the contrary. 4. Instruction in diet given by a dietitian skilled in this form of training and on repeated occasions is often successful when instruction in a physician's office has failed. 5. Impressions gained by the patient concerning the nature of his disorder and its hazards and unfavorable outlook and concerning the means whereby the ground gained can be maintained are often more vivid and lasting under hospital management than under management outside the hospital. Thus, a hospital period of 7 to
Obesity
1707
14 days serves as a valuable training period. Indeed, hospitalization is often as important to the long life of the patient as it is in the treatment of appendicitis or pneumonia. Exercise
Every obese person cannot take strenuous physical exercise. This statement applies to elderly individuals and to the extremely obese. The tendency of exercise to increase the appetite is usually offset by the fact that the exercise takes the patient away from his source of food. Moreover, it has been found practically that exercise frequently satisfies the patient's desire for entertainment and thereby makes his demand for food less urgent. Exercise can be increased as the patient is reduced in his weight. A regular plan of exercise for daily use can be adopted and followed with considerable benefit. Psychotherapy
Motivation for weight reduction must be cultivated in the patient's mind. If the patient sees no need to reduce, then he will not long remain on a restricted diet in the face of craving for food. Inducements such as improved appearance, the avoidance of degenerative diseases, longer life expectancy, the ability to be more active, and perhaps other personal reasons, may give most patients an incentive for keeping their weight down. These motives must be sought individually and discussed with each patient in detail. A wife may feel that a husband who is not very well nourished is not a credit to her cooking. Some groups feel that overweight is a desirable state and actually means good health. Some persons have such an uninteresting life that food is their greatest pleasure. Neurotic subjects seek relief from their anxiety by eating. Many physicians are of the opinion that such a psychiatric appraisal should be made by the internist and not by a psychiatrist. The education of the patient and reassurance concerning his anxieties may often gain his confidence and keep him restricted to a diet that will secure weight reduction. Group therapy has been very successful, according to a number of reports. Many patients fail in their weight reduction regimen because of hunger pangs which gnaw at them. Usually, these sensations will subside when the patient has reduced his weight and he has become accustomed to living on a reduced diet. Individuals in prison camps during the war who were living on extremely low diets have stated that after a time their hunger discomforts were not severe. Drugs
The use of appetite-reducing drugs such as amphetamine sulfate in doses of 5 mg. before breakfast and before lunch either with or without a sedative may help in reducing the persistent craving of food in an
Lawrence S. Carey
1708
occasional patient. The drug apparently is harmless in these amounts but its effect tends to wear off quickly. The results generally have been disappointing. Moreover, the patient has not learned to restrict his own diet when he has used a drug to do the job for him. The use of thyroid substance is indicated only for patients in whom definite hypothyroidism has been shown to exist. In patients with normal thyroid function it has no effect on weight reduction until the dose has been made so large that toxic symptoms occur. Such excessively large doses are therefore dangerous. Increase of metabolism by these means is not under the same prompt control as such an increase by exercise. Several weeks pass before the effect of toxic doses of thyroid disappear. The strain of increased metabolism may be great on the heart and circulation. Diuretics are of help in some persons who have associated myocardial weakness with water retention. The mercurial diuretics are most effective and digitalis may also be very helpful. These drugs do not, of course, correct the obesity but they aid in securing improvement in those patients who already have complications. Bulk-producing agents such as Metamucil and Mucilose often give the patient a feeling of satisfaction by producing bulk in his stomach and intestinal tract. SUMMARY
Obesity is a widespread problem which is attended with great risk when it is complicated by disease. Many factors play a part in obesity, all of which center about the taking of more food than is necessary for energy expended. Treatment must be individualized and directed toward the various influences which play a part in each patient, and continued for a prolonged period of time. Continued observation on the part of the physician is usually essential for final success. A period of hospitalization may be extremely important in the early management. REFERENCES
1. Dublin and Marks: Overweight Shortens Life. Statistical Bulletin, New York, Metropolitan Life Insurance Company, 10: 32, 1951. 2. Dublin: Relation of Obesity to Longevity. New England J. Med. S48: 971-974, 1953. 3. Dublin and Marks: Mortality of Women According to Build. Assoc. of Life Ins. Med. Directors of Am., Oct. 20,1938. 4. Master, Jaffe and Chesky: Relationship of Obesity to Coronary Disease and Hypertension. J.A.M.A. 159: 17 (Dec. 26) 1953. 5. Delgado, Jose and Anand: Increased Food Intake Induced by Electrical Stimulation of the Lateral Hypothalamus. Am. J. Physiol. 17S: 162, 1953. 6. Scott, Scott and Lockhardt: Observations on the Blood Sugar Level Before, During and After Hunger Periods in Humans. Am. J. PhysioI. US: 243, 1938. 7. Booth and Strang: Changes in Temperature of the Skin Following the Ingestion of Food. Arch. Int. Med. 57: 533, 1936. 8. Schoenheimer and Rittenberg: Deuterium as an Indicator in the Study of Intermediary Metabolism. J. BioI. Chem.119: 505,1936.
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9. Pennington: An Alternate Approach to the Problem of Obesity. J. Clin. Nutrition 1: lOO, 1953. 10. Dublin: Fat People Who Lose Weight Live Longer. The National Vitamin Foundation, Inc., 1953, p. 106. 11. Duncan: Obesity. Paper read at Fourth Middle East Medical Assembly, April 11, 1954. 12. Evans: Obesity. In: Diseases of Metabolism, 3rd Ed., edited by Duncan. Philadelphia, W. B. Saunders Co., 1952, p. 647. 330 S. 9th Street Philadelphia 7, Pennsylvania