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 [{293}] 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 [{294}] 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.