Obesity.
Synonyms:—Adiposity; lipomatosis universalis.
Definition:—A deposit of fat in the tissues or in the structures of the organs of the body in such quantities as to produce discomfort and inconvenience, or to impair the functional operations of the organs.
It is impossible to lay down hard and fast lines by which we may always distinguish between a healthy and an unhealthy state of fat in a corpulent individual. A man may weigh 300 pounds and be in no way inconvenienced by it, while another at 225 may find his actions impeded and his health impaired by it.
Etiology:—A tendency to "leanness" or to "fleshiness" exists in different families, and is hereditary. Every member of a family may from infancy be fat and rotund, and yet always in perfect health. One member of such a family may by excessive eating or drinking so increase his weight from an increase of fat as to induce ill health, and perhaps progressive debility. On the other hand, a single child in a family, all of ordinary or average weight, may take on fat rapidly at birth, and become excessively fat and unwieldy in early life, and decline in health after puberty until death occurs before middle life. Those who are naturally "fleshy" may be light eaters, or they may practice habits of dieting, and yet retain their full weight, or even gain in weight.
The most common cause is physical inactivity and overeating, or the excessive drinking of malt liquors and wines. Those drinkers who partake exclusively of brandy and whiskey are not inclined to become obese, while the beer-drinking nations or people are disposed to fat. Those given to luxury and a sedentary life, those of a lymphatic or phlegmatic temperament, are prone to obesity. On the other hand, these habits of life may be induced by obesity.
The condition occurs at all times of life up to sixty years of age, is less common between twenty and forty, and common during the change of life in women and at the same period of life in men. The tendency to obesity is greater in women than in men.
This disorder follows typhoid fever occasionally, or other serious disease, as arute rheumatism or gout. It occurs with diabetes and after certain surgical operations, as the removal of the ovaries and testicles.
Symptomatology:—Among the first symptoms induced by an excess of fat are those of weariness upon slight effort with loss of breath. This latter condition may follow weakness of the heart's action, or it may be caused by the restricted movement of the chest walls. The fact that the using of the limbs or the moving of the body of a patient so greatly increased in weight requires greatly increased muscular effort is often overlooked. The face becomes flushed upon any exertion and the patient gets out of breath quickly because the increase of muscular strength is seldom if ever proportionate to the increase of weight. Another cause of oppressed breathing is the fact that there is a greatly increased capillary circulation constructed, as the fat is deposited, to supply all the tissues, and thus a greatly increased amount of work is required of the heart without a corresponding increase of the power of the heart. The pulse with these patients is at first full, round and sluggish; later it is small and compressible, and there is frequent palpitation, which may follow even the least exertion, or which may occur after eating. The patient is disinclined to stand, some of them refusing to walk; they are dull, drowsy and usually sleep more than patients in normal condition, although there is an occasional patient who is troubled with insomnia, is restless and passes uncomfortable nights.
There is an occasional plethoric patient in which the pulse beats are full and strong but slow; ultimately brachycardia is constant. There may be a persistent subnormal temperature. When fatty degeneration of the heart occurs with these patients, the pulse becomes small, rapid, intermittent or irregular, and the arterial tension is reduced.
Some of these patients have an inordinate appetite, with an excellent digestion. Refusing to control the appetite, they indulge in starches, sugars and fat-producing foods, which greatly increase the already extreme fat. On the other hand, there are fat patients who retain their fat, or even increase in weight, upon a very small quantity of food, sometimes eating only a small meal twice a day and this a very simple one. Others suffer from constipation, and where care is not exercised the feces accumulate in the bowels, because of inactivity and imperfect peristalsis, and this is a fruitful source of autointoxication. The most of these patients sweat freely and profusely.
Fatty deposits may occur around the other organs, or there may be fatty overgrowth or fatty infiltration with enlargement of the liver or kidneys also. The urine is usually free in quantity, but of low specific gravity, as these patients are usually troubled with greatly increased thirst and drink a corresponding amount of water.
Obese patients are subject to hernia, and from heart weakness are also liable to have passive pulmonary congestion, asthma or bronchitis. They may also be attacked with glycosuria or albuminuria. Arteriosclerosis is not uncommon, and as a result cerebral hemorrhage and apoplexy may occur.
Treatment:—Two essential factors which must be considered in the treatment of these cases are diet and exercise. These conditions are applicable in preventing the development of fat in those who anticipate it, especially those who are young. Those in whom evidences of fatty degeneration of the heart or other vital organs are apparent must be guarded in physical exercise. In patients of otherwise good health, food should be selected which, while it sustains the muscular power, provides no additional fat-forming substance, and physical exercise should be taken systematically and in increasing quantities in proportion to the developing strength, if possible, in the open air. This not only includes regular employment, but mild athletics and gymnastics, with other out of door sports.
It is a common habit among lady patients who are plump and rotund naturally to fear that they will ultimately become too fleshy, and to adopt a course of diet or of living which brings on other disorders. Others take, of their own accord, arsenic or other injurious remedies to prevent the development of flesh, or to decrease that which is really a normal amount. The physician should caution these patients that a reduction of the normal fat may result in uterine displacement or floating kidney, or in gastroptosis. Much education is needed by all of these patients, which it is the duty of the physician to impart.
While this is true in general, young patients who are unduly obese should be encouraged in outdoor sports and in physical exercise, and should be taught self-control in eating and in drinking, as the drinking of too much water promotes the increase of fat in all cases. Regular habits of abstemiousness in eating must be acquired. It is possible that patients will become accustomed to a narrow diet and take pleasure in it. No effort should be made with these patients to reduce the fat, but simply to prevent an increase of the deposit. This rule applies also to those in advanced life. At this time any effort at reduction of fat may be detrimental by inducing serious changes in nutrition or in metabolism.
Measures calculated to actually reduce the quantity of fat are more safely conducted between the ages of twenty and forty than at any other period, and even at that time no effort should be made if there is chronic disease of the heart or of the kidneys. The patient must thoroughly understand that a sudden or rapid reduction is impracticable and unsafe; that only gradual reduction, with close attention to the general health at the same time, is permissible, and that those measures, especially physical exercise, which contribute to the desired result, must never be excessive, but must be continued with patience and perseverance in a judicious manner over a long period. Furthermore, it is necessary to continue the course, in part at least, after the results are satisfactorily obtained, until this course of living and the conditions resulting from it in the system become fixed and established and become the habit of life of the individual. Otherwise, upon returning to ordinary conditions, not only will the weight lost be regained, but there may be a tendency to a further undue increase of weight.
Because of the fact that alcohol must be oxidized in the system, this prevents the proper oxidation of food, and makes it imperative that alcohol in any form should be excluded. In planning the diet many writers advise an arbitrary course for all. The diet list of Ebstein, or Oertel of Munich, or of Banting, are laid down as those upon which all patients may subsist. I am convinced that we cannot lay down hard and fast lines in diet any more than we can in medical treatment.
It is safe to say that those substances which are directly convertible into fat, or which carry fat cells directly into the blood, such as starches, sugar and rich foods, are to be discarded in the selection. This includes wheat flour made in any form, potatoes, corn, beans and peas. On the other hand, bulky vegetables, if the digestion will permit, may be advised where starch is not the prominent constituent, and string-beans, cabbage, lettuce, celery, cauliflower, spinach and tomatoes may be eaten, with lean beef and eggs. For breakfast a patient may take a piece of well-toasted bread, a sliced orange or banana, or a small piece of lean meat. If coffee or tea is taken, it should be in limited quantity and without seasoning. At noon the patient may eat quite freely of boiled fish, may take graham bread, stale, and preferably toasted, and may eat of the vegetables named quite freely. Any of the fruits in season, except perhaps grapes alone, may be taken as dessert. At night the patient may have a bowl of soup, or of consomme, or some form of vegetable puree carefully prepared; steak, roast beef or fish may be taken in reasonable quantity, and vegetables also may be taken at this meal, with fruit, and, unless it causes insomnia or nervous excitability, coffee may be drunk at this time.
If these patients are subsisting upon so small a quantity of food as to feel the inconvenience of the restricted diet, or, as some complain, are constantly hungry, it is a good plan to take a light meal in the middle of the afternoon, such as a glass of milk or a cup of tea, with oatmeal, crackers or zwieback, and some celery or lettuce.
It will be necessary to adjust a rigid course to every patient, but the food should be thoroughly masticated and always taken short of full gratification. The quantity of water taken must be sufficient for the vital processes in the system, but if the thirst is excessive, should be limited.
In taking exercise a regular employment out of doors, adjusted to the ability and condition of the patient, is in every way preferable to exercise which is taken simply for the sake of the exercise. While the latter is beneficial, it is apt to be irregular, and often fails of accomplishing the desired result. Golf or ball playing is almost sure to be overdone. Athletic or gymnastic exercises are seldom correctly adjusted, horseback riding, walking or rowing are subject to the whim of the patient and to the condition of the weather. However, any of these may be formally or rigidly indulged in until satisfactory results are obtained.
The use of medicines in preventing the deposit of fat or in reducing obesity has not been satisfactory. There is a class of patients which have received benefit without injury from the concentrated juice of the poke berry—phytolacca decandra. I have prescribed this in patients who suffered from serious stomach and intestinal disorders, or with some cerebral disorders, and have succeeded not only in reducing the fat somewhat, but I have relieved the other condition, and have stopped the increase of fat. I believe the influence of the remedy will promote a normal action of the other glandular organs, while it retards the digestion and appropriation of fats. It also promotes oxidation. I have advised the use of bladder wrack—fucus vesiculosus—in obesity (This will work if there is hypothyroid due to an iodine deficiency. -Henriette), and have obtained favorable reports, but have not had opportunity to observe its action myself.
In 1878 Wilhite stated that the remedy is not a reducer of fat in healthy patients, but where the deposit was the result of a vitiated condition, or where the patient was cold and torpid with clammy skin, with large, flabby rolls of fat, with a relaxed and pendulous abdomen, or with a tendency to extreme inactivity, the remedy would act quite promptly in overcoming these morbid tendencies and in imparting tone to the vascular system and to the sympathetic nervous system—that it would act best upon patients of the lymphatic temperament. The use of the thyroid extract in overcoming obesity has gained considerable ground in the last few years (This will work where there is hypothyroid. -Henriette). The dose must be adjusted carefully to each patient, and it must be borne in mind that it not only reduces fat, but increases nitrogenous waste at the expense of the nitrogenous tissues; therefore nitrogenous food must be given freely while the remedy is being administered. It may be begun in doses of two grains twice a day, and slowly increased, watching for its influence upon the heart, and upon the circulatory apparatus. It may be increased to five or six grains three times daily. Heart remedies may be needed, with strychnin or other tonics while this agent is being taken, and the patient should be cautioned against overexercise.
