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 [{295}] 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 [{296}] 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 [{297}] 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.
CHAPTER IX
WEIGHT AND GOOD FEELING
Probably the most important single condition for the maintenance of good health and good feeling is the carrying of weight normal for the height and age of the individual, or slightly in excess of normal. Popular expressions contain many proofs of this. The proverb "laugh and grow fat" is undoubtedly due to the recognition by all the world that stout people are nearly always laughers, and as a consequence, perhaps placing the effect for the cause, laughing has been regarded as a factor in putting on flesh. [Footnote 27] There is no doubt that the exercise for the diaphragm afforded by hearty laughing, with the stimulation of the intra-abdominal circulation consequent upon vigorous diaphragmatic movements, is an important element in producing a healthy state of the important organs of the human economy contained within the abdominal cavity. Dr. Abrams in his book, "The Blues, Causes and Cure," attributes this disturbing condition of depression so familiar to those who have much to do with nervous patients, to a disordered blood and nerve circulation in the splanchnic area, and calls it scientifically, splanchnic neurasthenia. This undoubtedly sums up one important element in the causation of a great many depressive conditions. Most of them are banished by frequent hearty laughter which, with its exercise of the diaphragm, tends to stimulate splanchnic blood vessels and nerves.