Reducing weight comfortably; the dietetic treatment of obesity

Preface

On the day on which I write these hnes I have commenced my two thousandth obesity treatment. I have satisfactorily completed sixteen or seventeen hundred such treatments, or, in other words, I have in each case dismissed my patient at the end of the treatment, having effected the reduction in weight which at the beginning of the treatment I pronounced desirable.

Almost without exception the patients undergo the treatment at home. They pursue their usual tasks, undisturbed even though these are such as to make unusual demands upon the intellect and the '^nerves/' As proof of this I may cite the fact that many physicians have followed my directions for months with complete success and without any interruption of their difficult and trying professional duties.

My results will bear comparison with those recorded in the literature of the sub-

PREFACE

ject ; in various directions will even surpass them.

Let me say in advance that I am undertaking neither a historic presentation of the subject nor a criticism of other methods of treatment. I propose to limit myself to a description of the methods by which I have succeeded in reducing the weight of people living under the most different conditions — men, women, and children, sick and well — by the amount deemed advisable: in some cases only two or three kilogrammes, in others as much as forty kilogrammes.

The method which I now use, although improved in details, as the result of constantly-increasing experience, is essentially the same as that which I have employed since 1903.

Chapter 1 9-16

The ergostat. Graduated muscular exercise. Muscular exercise is not a promising and not a productive method of reduction of weight. Consumption of fat in walking on level ground and in mountain climbing. Short and intermittent treatments unsatisfactory. My first and second successful cases.

Chapter II 17-27

The biological significance of fat. Fattening and the consumption of fat. Fat as an "iron" store of nutriment for times of famine and sickness. The cushion of fat as a protection against the cold. An excessive fatty content should never be permanently retained. The "oscillating" body weight. The ideal condition is a constant weight. Gradual or rapid decrease in weight. Influence of pregnancy on the weight. Influence of marriage in the case of men. Reduction a physiological process like fattening. Reduction not dangerous for healthy men and for the majority of invalids.

Chapter III 28-34

Obesity treatments in cardiac cases. They are not merely permissible, but urgently indicated. The work accomplished by the heart depends among other things upon the body weight. Dyspnoea of obese cardiac cases.

Chapter IV 35-54

The different kinds of obesity treatments and methods. Unfounded fear of " under-nourishment." Obesity treatment and under-nourishment almost identical conceptions. Increase of consumption without recording the food eaten generally ineffectual. Double significance of the word "satiation." Very many men eat too much. Only a part of this number is fattened, i.e., puts on an excess of fat. Disposition. Influence of the organs with internal secretion. Thyroid gland preparations as reducing agents. Carthartics.

CONTENTS

Chapter V 55-69

Further impracticable methods of reduction. The sweat-bath. The sweat-bath may be combined with the dietetic treatment in oedema. Training of jockeys according to my method. Indispensability of the sweat-bath as a means of reducing the weight for a few hours to the attainable minimum. Massage useless as a means of reduction, useful in many complications. Attempt to reduce certain localities by massage during the dietetic treatment. Iodine. Faradization of the muscles, injection of colloid metal.

Chapter VI 70-78

The principles of the empirical-dietetic method. Rate of decrease in weight. Recording the weight every week.

Chapter VII 79-85

Food-requirement, caloric value of single foods, and the coefficient of assimilation, are variable quantities. The treatment injures neither the bodily nor the mental efficiency.

Chapter VIII 86-102

The first treatments. Influence of the daily minimum weight by the maximum weight. The regimen of the analogous case. Correcting the first prescription on the basis of the results of the first and second week of treatment. The first week generally brings much greater results than the following ones. The daily maximum and minimum weights. The minimum trace runs almost parallel to the maximum trace.

Chapter XVI 153-164

Concerning satiation. Complaints about the sensation of hunger are only recorded in the first two or three days of the treatment. Satiation by fats or by fatty dishes not the normal satiation. "Ballast" food. Potatoes. Preparation of vegetables. Mushrooms. Nuts. Farinaceous foods; light and bulky. Nutritive value and capacity to satiate. The feeling of hunger appears at the hour of the accustomed meal, but disappears even if nothing is eaten. "Adjustment" of the stomach to quantities of food. Education to moderation by the treatment. The quantities of food which are sufficient to satiate. Good chewing, slow eating, promote satiation. Beef soup.

Chapter XVII 165-173

Prescribing and carrying out a diet. Everything which is consumed, even the "ballast" food, is measured out according to weight. Sugar and saccharin. Foods are weighed, prepared for the table. The body weight is recorded every week. Influence of the varying water content and of menstruation on the body weight. The "sins of treatment." No cure without scales.

Chapter XVIII 174-188

Concerning the age of the patients, who can undergo obesity treatments. Lower limits: in girls, 12 to 13 years, in boys, 15 to 16 years. Large breasts of young girls. An upper limit cannot be drawn. Treatment of an octogenarian. 7

CONTENTS

Chapter XIX 189-210

The blood-pressure in obese people and the influence upon it of the treatment. Frequency of cerebral hemorrhages and sudden death from heart disease in obese people. Without exception the high blood-pressure is reduced by the dietetic treatment.

Chapter XX 211-231

Migraine and dietetic treatments. The typical, non-menstrual migraine is generally favorably influenced by the dietetic treatment.

Chapter XXI 232-240

Influence of the dietetic treatment upon heart-burn and eructation. Both disturbances disappear almost without exception during the treatment. Even people who are not obese can generally be freed from heart-burn and eructations by rational nutrition regulated by the food scales.

Chapter XXV 272-275

The normal diet. It is ascertained empirically. A small increase in weight, which should not be progressive, appears in the first days of the normal diet. Supplementary treatments. A day of treatment in the week in order to keep the weight at the same level.

Chapter XXVI 276-291

Height and weight of body. Table.

Appendix 292-312

Fattening treatments.

Conclusion 313

REDUCING WEIGHT COMFORTABLY

THE DIETETIC TREATMENT OF OBESITY

Chapter I

The therapy of obesity has occupied me for a long time. As many of my readers may know, in 1887 I invented and described the ergostat, a machine which has served primarily to combat corpulence. My efforts met with much approval at that time, and the ergostat quickly won a wide-spread popularity. Much of what I then proposed is of interest even to-day, although, as will be shown later, the practical deductions which I drew from the facts differed almost completely from those which I then accepted as correct.

The ergostat was to offer city residents who can neither split wood nor thresh grain nor take mountain trips every day the possibility of a graduated muscular exercise, which would be sufficiently " concentrated " and of the sort which every one could easily carry out.

A braked- wheel is turned by means of a crank. The shifting of a movable weight regulates the difficulty of the work ; that is to say, it graduates the number of kilogrammetres (units of work) accomplished at each revolution. An indicator registers the number of revolutions. The exact amount of work assigned can be accomplished by the ergostat. The physician can prescribe for his patient the amount of work which he thinks suitable.

The ergostat is employed in physiological laboratories and clinics, when it is a question of studying the influence of a certain amount of muscular work upon tissue change, respiration, circulation, etc. I know a gentleman who for over a score of years has turned the ergostat with wonderful perseverance every day on which he could perform no other physical exercise, and who attributes his good health and his normal figure in no small measure to his habit. But this man is a rare exception.

Experience has taught me, and certainly all who have been occupied with the subject, that the opinion expressed by Bunge concerning the exclusive fitness of muscular exercise for the reduction of superfluous fat is not correct. I would even go so far as to express the opinion that among the different means of effecting a reduction of obesity muscular exercise is the least promising. Not that there is anything hazy in the physiological principles regulating the increase of tissue-change by means of exercise! On the contrary, nothing is more certain than this part of the theory of tissue-change and of nutrition. The obstacle is to be found in the nature of our patients.

I have often succeeded in converting a glutton to moderation and in weaning alcohol-drinkers and tobacco-smokers from their habits. Yet my arts of persuasion have never succeeded in curing a lazy man of his inactivity, nor in stimulating him to take up regular physical exercise in any form whatever. To be sure, this is successful for a few weeks in a health resort where walks lasting many hours must be taken by all the patients, and where nothing else, or at least nothing more important, can be found to do. As soon as the invalid is 11 home again, however, he relapses into the old inactivity beyond recall.

The man without experience is very apt to over-estimate (quantitatively) the influence of muscular exercise upon tissue-change. Very frequently I hear complaints about the injustice of the fate which puts fat on its victim although he takes a daily walk or is kept much on his feet by his calling.

One gramme of fat when transformed into work produces almost 4000 kilogrammetres, and would hence be sufficent to do the work which is necessary to lift a man weighing 80 Kg. 50 metres high. Now the motor which represents the muscular apparatus of man works with a mechanical efficiency of about 30 per cent. Therefore about three grammes of fat are required in the work mentioned. According to Rubner, a man weighing 70 Kg. in walking one hour on level ground over a distance of 3500 metres, consumes 12.8 Gm. of fat more than when at rest; in climbing 150 metres (high) over a distance of 3500 metres, 20.2 Gm. of fat more. These figures plainly teach us that by ambulatory exercise alone eight hours of walking on a level or five hours of mountain climbing would be required for the removal of 100 Gm. of fat or about 140 Gm. of fatty tissue in a day.

There are many permissible ways of removing superfluous fat. None of them makes so great demand on the will power and endurance of the patient as the ones which require the exclusive use of increased muscular work to attain their end.

This consideration caused me to try the other means, too. First, I did what is customary in such cases: I recommended my patients to visit a health resort or a sanatorium in which obesity treatments are given. There, if all went well, they lost in the course of three to five weeks, under the combined effect of all " methods of treatment," two to five kilogrammes. There were even some whose decrease in weight could only be expressed in fractions of a kilogramme, and those who showed no decrease at all, although they alleged that they had followed " everything " faithfully. Even the " successful " cases had given rise to a familiar and disappointing observation. Hardly had they left the Hmits of the health resort when the weight of the body, which had been forced down by deprivations and tortures, began to rise again. Within a few weeks the old level was reached. If the disposition to put on fat had not changed, then, very likely, the weight became greater than before, and the indication to seek the health resort again became more urgent with each successive year. Who does not know of people who with unrelenting determination have visited a health resort every year for decades in order to lose weight, and in spite of that have accumulated enormous burdens of fat? Some years ago I saw a gentleman who had already celebrated a jubilee of his visit and who then weighed 192 Kg.

Nothing is further from my mind than to reproach the physicians practising in the health resorts or to criticize the treatments usual in the health resorts. I only wish to agree with those who do not consider it proper to treat a sickness of an obstinate nature and inclined to relapses by an intermittent treatment which is limited to a few weeks every year and which is even then relatively insufficient. For there can be no doubt that not enough has been done when a man weighing 50 Kg. above the normal weight is only temporarily relieved of five or six kilogrammes.

As so often in life, a single case of necessity led me to give up the old model and to set out in new paths.

A distinguished young actress whose role demanded dancing and singing, at times even singing while dancing, was afflicted with the unhappy disposition to obesity.

One day — it was in 1902 — she implored my aid. She said that she was no longer able to practise her calling, and had already tried every means of becoming lighter and more active. Without success ! An interruption of her professional duties was impossible for reasons not necessary to mention. Hie Rhodus, hie salta!

I myself was at that time a suitable subject for an obesity treatment. Therefore I experimented for some weeks on myself and found that my expectations proved right : that the treatment advanced while I perceived no deprivations and remained in excellent health. Then I plucked up courage to call upon the artist to become No. 2 of my experimental subjects. With characteristic enthusiasm she agreed, and stood it bravely for weeks and months. Then we were delighted to see how kilogramme after kilogramme vanished and how the earlier activity returned again. This established for me the possibility of conducting a treatment of obesity up to the desired result without disturbing the patient even for a single day in an occupation taxing alike physical and mental powers.

Chapter II

In the organic world we find wide-spread a wonderful arrangement. In times of surplus nutrition stations are created which help out in times of need. In the plant kingdom these stores consist chiefly of carbohydrates (starch and sugar) and of fat; in the animal kingdom, almost exclusively of fat.

Like many of our domestic animals, man is also easily fattened; that is, a surplus of nutriment which has been consumed is accumulated in the form of drops of fat in a tissue of its own — the fatty tissue under the skin — but also in other places, as in the diaphragm, the pericardium, and the liver.

It is no longer doubted that the three chief groups which compose our nutriment — carbohydrates, fats, and albuminous bodies — are able to bring about the formation of fat. The experience of those who fatten animals teaches this just as convincingly as do numerous tissue-change experiments in the case of men and animals.

2 17

But the physiological significance of the fat deposited in the fatty tissue we learn from wild animals. They put on fat in summer and consume their fat in winter. Many hibernating species who go for months without nourishment can provide meanwhile by the oxidation of their fat for the necessities of tissue-change, which, it is true, are somewhat reduced. We fatten our domestic animals — swine and geese in order to gain for ourselves valuable fat, or (beef, sheep, chicken) in order to make their muscles, w^hich are infiltrated with fat, more palatable and of greater volume.

A certain degree of fatty element is very advantageous for man himself. A man extremely deficient in fat can not be considered altogether normal. The external appearance is unfavorably influenced by a too small degree of fat, especially in women and children. The skin, particularly that of the face, allows the bones and muscles lying beneath to protrude too much, and is lacking in lustre and elasticity. This is much less to be feared in men. So long as the muscular system is well developed the fat may be reduced to a small quantity.

Beauty of face does not suffer thereby, still less that of body and limbs. A man's countenance should show well-defined lines which are not rounded off and obliterated, and the contour of every muscle, of every bony prominence, and of many sinews should be plainly visible under a thin skin on the body and at the extremities. Excessive poverty in fat itself, however, distorts the face of an otherwise healthy man to that of an old man. We see this in jockeys, who, because of their occupation, must sacrifice the last pound of their fat in training. But a disfiguring influence of reduction is only to he feared when the fatty content of the body sinks below the normal, not, however, in a treatment which is kept within reasonable bounds.

However, the most important function of fat is this: it is an iron store of nutriment, which is consLmied in time of want and which suffices, as we learn from many chance observations and experiments carried out by " hunger artists," to sustain in action all the vital functions and thereby life itself for several weeks. ( The organism can dispense with water only for a few days without collapsing.)

Since the time of railroads and the development of a marine commerce, Europe, as well as all other human settlements which are involved in the dense world trade, has been spared actual famine. Yet in India and China millions of men die of hunger when the crops fail. There is no doubt that fat men survive a famine better than lean ones. As has been mentioned, at least at present there is no question of a famine for us, although even in this country single individuals die of hunger.

However, it occurs altogether too frequently that sickness hinders an individual in taking or assimilating food, entirely or in part. Then circumstances develop which correspond to the real hunger condition. If the illness is accompanied by fever, we are confronted by the fatal combination of an increased demand and a decreased or almost entirely arrested supply of nutriment and fuel. A hungry man who is at the same time in a fever consumes his fat faster than a healthyhunger artist.

Now, each one of us is exposed to this *' hunger danger," and it is just as clear theoretically, as it has been shown through observation, that a man equipped with a normal cushion of fat can survive such " consuming " diseases more easily than an excessively lean one.

Still another function is to be attributed to the cushion of fat. As a poor conductor of heat it protects the body like the clothing in times of cold, and under these circumstances facilitates the regulation of heat and the maintenance of a constant body temperature. The huge layers of fat of the mammals and birds living in the waters of the polar regions have this task to fulfil. Since the water in which these animals live draws much more heat from the body than the air does, and since, moreover, the temperature of this water often reaches down close to the freezing point, a truly enormous demand for nutriment and fuel would be imperative to keep these organisms continually at a temperature which is so very different from that of the surrounding medium/ An example of the loss of this function is to be found at times in cases of radical obesity treatments in winter. If there is a decrease of five or more centimetres in the fatty layer of the body and also a considerable decrease at the extremities, then certain invalids are wont to complain about feeling the cold when the temperature is lov/. It is almost the same condition which occurs when their clothing, or at least a layer of their covering, is removed.

Since man, fortunately, does not live in the waters of the polar sea, and, moreover, since he can protect himself from excessive losses of heat by suitablychosen clothing and by the heating of his dwelling rooms, the presence of a thick layer of fat is of no use to him as a heat insulator. The advantage which it would give in winter would be outweighed by the

^The food requirement of mammals living in cold water is always enormous, in spite of the heat-insulating layers of fat. The walrus, whose weight is about equal to that of the ox, consumes in 24 hours no less than 50 Kg. of fish. I take this statement from C. Hagenbeck's " Guide through Stellingen." The stimulating effect of the cold bath on tissue-change, of which more explicit mention will be made in a later chapter, is in this way most excellently illustrated.

disadvantage which it would cause its wearer here in summer and in hot chmates at all seasons. Rubner has pointed out that heat regulation is rendered much more difficult for obese people in warm, damp air, from which they receive manifold disagreeable consequences.

In organisms which periodically take on fat in time of excess nutriment, the oxidation of this store in time of want of nutriment is a normal, physiological process. We would doubtless disturb the health of these animals were we to keep them permanently fat by removing the lack of food in winter.

It is a well-known fact that domestic animals which are hard to fatten (swine, geese) have, while being fattened, much more delicate health — indeed, must be considered positively sick. We do not try to fatten these and other animals for the purpose of prolonging their life.

As has already been said, man belongs to the organisms who can take on fat with abundant nutriment. Aside from the " iron store " which is to be kept permanently and which we should attempt to restore by a fattening treatment when it fails, a supply of fat beyond this measure should he at most merely temporary, hut never permanent.

It is observed that season workers put on fat and increase in weight at the time of their occupation, and become lean when their work is scarce, chiefly in winter. On the other hand, we see members of those classes of society who eat their fill at every season become fatter in winter at the time of the flood of our social aff*airs, the chief object of which seems to be either to fatten the guests by delicately compounded meals or to destroy their stomachs and sleep. If these men, as often occurs, eat and drink less abundantly and take more exercise (or at least go walking) in simmier, then they can consume their winter fat again. Their weight sinks back to the old measure. This state, the oscillating weight, can be considered permissible so long as it is kept within definite, narrow bounds. However, the ideal condition of a man who does not have to fear famine is the constant weight. It happens far too easily that once or several times the compensating decrease does not occur, and then the effects of the fattening periods total up to threatening values. Much worse are those who fatten themselves without any interruption or alternation 365 days in the common and 366 days in leap year.

To take on 10 Gm. in weight in a day does not matter much. In a year, however, this has become 3.65 Kg., and in 10 years 36.5 Kg. Each one of us know men who have stored up by such consistent economy 70 and more kilogrammes over the permitted measure.

In other cases the patients report to us that the tendency to take on fat has been present for a long time ; that their weight has grown steadily but slowly; then, however, beginning at a certain time, the rate of increase has hastened rapidly. Cases in which the patient gains 20 Kg. and more in a year are not uncommon. In women what brings about the rapid increase is generally pregnancy — this itself or the following lactation; but, to go deeper, the unreasonable method of diet (beer in immense quantities as a drink!) which is demanded at this time by almost ineradicable prejudices. The appearance of the climacteric, as we shall see later, is likewise not seldom accompanied by rapid rise in weight. In men the rapid addition of fat can often be dated from their marriage. A quieter and evener Hf e and more abmidant nutriment with " favorite dishes " are the probable causes of this frequent phenomenon.

Every addition of fat which exceeds the iron store ought to be temporary. Its continuous existence is the cause of disadvantages and even dangers. Ohese people should know and always keep before their eyes the fact that the removal of fat is a normal, physiological process^, the integrant second half of the accumulation of energy, which has been arranged so suitably by Nature. The stored-up, superfluous fat must be consumed again, and not always increased, if the organism is not to collapse and choke under the burden (taken also in the literal sense).

When the lean times, for which the fat is designed, do not come of themselves, they must be artificially produced. When, however, the fat is once removed, we should aim to keep the body weight continually at the same height. Neither the climate nor the other conditions of life under which by far the greater part of civilized mankind lives makes it desirable, or even permissible, that we put on and take off fat alternatelj^ However, if we have put on fat, we must take into the bargain the removal of fat.

Like all other physiological processes, the oxidation of superfluous fat is connected neither with dangers nor disadvantages to the organism. Assertions and apprehensions to the contrary are without foundation. This holds not only for the man whom we characterize as healthy, — that is, one who exhibits no disturbances of the important functions recognized by himself or the physician; this holds also, with few exceptions, for the invalid ; above all, for the cardiac case.

Chapter III

In this, as in many other points, my experience coincides with that of Von Noorden, who not merely declares it permissible to reduce the flesh of cardiac cases, but who has found, on the contrary, that no greater and more important service can be shown to an obese sufferer from heart-disease than to relieve him of his burden of fat. The stout cardiac case suffers much more from his great weight than does the healthy man.

The work to be accomplished by the heart is determined by many factors. One of the most important of these is providing the muscular system with blood. The blood requirement is entirely different, according as the muscular system rests, so far as this is possible (the respiratory muscles and the cardiac muscle never rest), or as it accomplishes work. In the latter case the demand is considerably greater, and, what is more, grows with the amount of work which the muscles perform. We often see cardiac cases who feel tolerably well so long as they are lying in bed or sitting quietly; that is, so long as the muscular system of their bodies continues in almost complete inactivity. As soon as they attempt to make the movements necessary in walking, phenomena of cardiac insufficiency appear, phenomena which indicate that the heart is no longer equal to its task. Walking has increased the demands on the heart. In other and, fortunately, more frequent cases these patients can even cover long level stretches without being conscious of their ailment. Cardiac insufficiency, however, appears when they begin to mount stairs or elevations. In doing this, besides accomplishing the work which the horizontal forward movement necessitates, they must also raise the weight of their bodies. The heart is no longer equal to this greater task.

Moreover, the working capacity of the healthy heart may not be exceeded with impunity. A very considerable part of the professional athletes finally become victims of cardiac diseases.

The amount of work which the heart does stands in direct relation to the body weight. The greater the body weight, the greater the burden which the body muscles are obhged to hft and to move. The more the muscles are taxed, the more work the heart has to do in order to keep pace with the great demands of the increased blood supply. Relatively a much greater amount of blood flows through the working muscle than through the muscle at rest. When many and large muscles are brought into action, the path of the blood is enormously extended, and the heart must set in motion a much greater quantity of blood in the unit of time than when the muscular system is at rest.

If labor is not excessive, and for those who have been trained for the particular kind of work, the blood-pressure, as my own observations have taught me, remains unchanged. The amount of work done b}^ the heart must accordingly increase in proportion to the rise of circulator}^ activity. Every additional kilogramme which is loaded upon the muscular system is felt by the heart. Regard for the heart determines the load which the soldier bears. He is made to carry as great a burden of weapons, ammunition, etc., as his heart (i.e., the average heart of a young man) can stand without danger. However, when he is about to be called upon to endure long marches or other unusual exertions, he is made to lay aside everything in his equipment which is not absolutely indispensable.