Treatment of Obesity

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1 Treatment with Diet and Exercise

In America there are fewer cures for obesity undertaken than abroad ... because ... there are fewer obese people here.

This statement was made in 1917, but time and the tides have now produced an epidemic of obesity in America (204).

The clinical approach to treatment of obesity long antedates the Scientific Era. From the time of Hippocrates (205) and Galen (206) in the prescientific era, diet and exercise were an integral part of the therapeutic regimen for obese patients. Hippocrates, the ''Father of Medicine,'' suggested in the 5th century BC:

Obese people and those desiring to lose weight should perform hard work before food. Meals should be taken after exertion and while still panting from fatique and with no other refreshment before meals except only wine, diluted and slightly cold. their meals should be prepared with a sesame or seasoning and other similar substances and be of a fatty nature as people get thus, satiated with little food. They should, moreover, eat only once a day and take no baths and sleep on a hard bed and walk naked as long as possible (205).

Galen, nearly 2000 years ago, outlined his approach to treatment of the obese as follows:

I have made any sufficiently stout patient moderately thin in a short time, by compelling him to do rapid running, then wiping off his perspiration with very soft or very rough muslin and then massaging him maximally with diaphoretic unctions, which the younger doctors customarily call restoratives, and after such massage leading him to the bath after which I give him nourishment immediately but bade him rest for a while or do nothing to which he was accustomed, then lead him to a second bath and then gave him abundant food of little nourishment so as to fill him up but distribute little of it to the entire body (206)

From this Greco-Roman beginning dietary treatment can be traced to the Arabic tradition in medicine. In the first book of his Cannon, Avicenna describes how to reduce the overweight individual:

The regimen which will reduce obesity. (1) Produce a rapid descent of the food from the stomach and intestines, in order to prevent completion of absorption by the mesentery. (2) Take food which is bulky but feebly nutritious. (3) Take the bath before food often. (4) Hard exercise... (207)

When the Western medical tradition moved to Europe in the 11th to 13th centuries, so did the concepts of hygiene, diet, and exercise. These were embodied in the "institutes of medicine,'' a major component of medical education for centuries. One of the most widely used guides was the Regimen Sanitatis (208) developed in the school at Salerno, Italy, in the 12th century, which did not specifically provide advice for obesity. Chaucer, the 14th-century poet, did reiterate the advice flowing from Hippocrates when he said;''Agonys glotonye, the remedie is abstinence.'' (Against gluttony the remedy is abstinence.)

Dietary treatment in the 18th century was summarized by Tweedie:

In attempting its cure, when the habit is threatened with any morbid effects, from the plethora existing either in the head or lungs, this must be removed by a bleeding or two; and as corpulent people do not bear blood-letting well, purging is most to be depended upon for the removal of the plethora (209).

He also says, ''The diet should be sparing. They should abstain from spirits, wines and malt liquors, drinking in their stead, either spring water, toast and water or else water agreeably acidulated by any pure vegetable acids.'' Finally he increases exercise gradually.

The 18th-century Italian layman Cornaro (210) became a champion of dietary moderation after he successfully conquered his own obesity. At the beginning of his book he says: ''O wretched, miserable Italy! Does not though plain see, that gluttony deprives [us] of more soul years, than either war, or the plague itself could have done?'' Cornaro's doctor's advice was to eat or drink nothing that was not wholesome and that only in small quantities.

Comments on obesity have occasionally come from the field of gastronomy, the classic work by Brillat-Savarin in 1826 being the best known. This masterpiece has been published in many attractive and beautifully illustrated editions (211). He attributes obesity to several causes:

1. The first is the natural temperament of the individual.

2. The second principal cause of obesity lies in the starches and flours which man uses as the base for his daily nourishment.

3. A double cause of obesity results from too much sleep combined with too little exercise.

4. The final cause of obesity is excess, whether in eating or drinking.

From this, Brillat-Savarin moves to treatment. He says: ''Any cure of obesity must begin with the three following and absolute precepts: discretion in eating, moderation in sleeping, and exercise on foot or on horseback.'' Having said this much he goes on to say: '' Such are the first commandments which science makes to us: nevertheless I place little faith in them. . .'' He then goes on to recommend a diet low in grains and starches.

In spite of the long history of dietary recommendations for treatment of obesity, it wasn't until 1863 that the first ''popular'' diet book appeared. This was a small, 21-page pamphlet published privately by William Banting entitled '' A Letter on Corpulence Addressed to the Public'' (212). The demand was so great that a second, hardcover edition was published within a year. In this pamphlet, he recounted his successful weight loss experience using a diet prescribed by his ear surgeon, William Harvey (213). The immediate success of this pamphlet led to reprinting worldwide and a popularization of the term ''Bantingism'' as a reference to dieting.

Banting's Cure (very severe)

Breakfast, 8 AM: 150-180 g (5-6 oz) meat or broiled fish (not a fat variety of either); a small biscuit or 30 g (1 oz) dry toast; a large cup of tea or coffee without cream, milk, or sugar. Dinner, l PM: Meat or fish as at breakfast, or any kind of game or poultry, same amount; any vegetable except those that grow underground, such as potatoes, parsnips, carrots, or beets; dry toast, 30 g (1 oz); cooked fruit without sugar; good claret, 300 cc (10 oz). Madeira or sherry.

Tea, 5 PM: Cooked fruit, 60-90 g (2-3 oz); one or two pieces of zwieback; tea, 270 cc (9 oz)

without milk, cream, or sugar. Supper, 8 PM: Meat or fish, as at dinner, 90-120 cc (3-4 oz); claret or sherry, water, 210 cc (7 oz). Fluids restricted to 1050 cc (35 oz) per day.

From these humble beginnings, diet books by professionals, self-styled professionals, and lay people have continued to appear, particularly as the concerns about obesity as a health and cosmetic problem have increased (35).

I have summarized two diets from the early 20th century to show the approaches that were used at that time (203).

Von Noorden's Diet

Von Noorden, one of the leading scholars of obesity at the beginning of the 20th century, based his dietary approach on an estimate of an individual's caloric requirement. Basal calorie needs were estimated from ideal weight. For this he assumed that a 70-kg individual would require 37 kcal/kg, or 2590 calories. If the individual weighed an extra 30 kg, they would need 1110 extra calories to feed this extra 30 kg. Von Noorden's first-degree reduction diet reduced energy to 80% of the basal needs, or for the 70kg individual to 2000 kcal/day. His second-degree reduction diet reduced intake to 60% or 1500 kcal/

day for the individual requiring 2500 kcal/day. His third-degree reduction, which was only infrequently used, lowered calories to 40% or 1000 kcal/day. His dietary approach also reduced fat to 30 g/day. His protein allowance was 120-180g/day with carbohydrate in the neighborhood of 100 g/ day. His menu plan, adapted from Carter et al. (203), is summarized below:

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