Obesity, popularly considered to be an over-accumulation of fat, is sometimes thought to exist only when there is the large development of abdomen which is more properly designated corpulency. In its strictly scientific sense it represents excessive over-weight, that is, above twenty per cent. more of weight than is normal for the height of the particular individual. (See table of weight for height in chapter Weight and Good Feeling.) The Latin derivation of the word gives also its etiology. Ob-ese means having eaten too much. It is a question of failure of due proportion between the taking of nutrition and the oxidation processes within the body. More food being taken than is needed, there is an accumulation of it in the form of fat, and this is deposited by natural preference in certain places, such as the abdomen, the breasts and in the panniculus adiposus beneath the skin. The fats and starches are most readily converted into this fat, but under certain circumstances proteid material may be turned into fat, and then a true pathological condition develops resembling diabetes in certain ways.

The metabolism of fat is rather simple, but this may be disturbed by bad habits. When such large quantities of sugar-making materials are taken that they are beyond the power of the normal metabolism to dispose of, they are excreted in the urine with the production of what is known as physiological {291} glycosuria. In the same way, the eating of a superabundance of fat-forming food leads to the deposition of fat in the tissues where, when in excess, it is just as much wasted as if it were excreted. Physiological glycosuria is, however, usually considered to be dangerous, inasmuch as its frequent occurrence may disturb the normal metabolism of sugar, and lead to diabetes. In the same way, the over-consumption of fat-forming materials may disturb the fatty metabolism, and lead even to the changing of proteid materials into fat. This represents a real disease requiring careful management, while ordinary obesity needs only the exercise of the patient's will to secure such proportion between the amount of food taken, and the amount of exercise and fresh air, as will not only prevent accumulation of fat but will lead to the reduction of any accumulation that may, through neglect of this care, already have taken place.

Over-eating.—The putting on of weight depends on the individual's craving for food, and his satisfaction of his appetite. While it is not ordinarily looked at from this standpoint, this craving for food and the habit of satisfying it which is developed, is not very different from the craving for stimulants and the habit that forms with regard to them. People insist that they can not eat less—that their appetite simply requires them to eat. We have all heard this story over and over again from the man who craves alcoholic stimulation. Usually the obese can be persuaded more easily than the inebriate to break off their habit, but they relapse into it even more easily than he does. It is comparatively easy to limit the appetite, or rather to forego the satisfaction of eating abundantly, for a week or two weeks or even a month, but the effort finally becomes appalling and the consequence is a relapse. If the patient really wants to lose weight, in nine cases out of ten it is a comparatively simple matter. The trouble is that they want to lose in weight without giving up the satisfaction of eating.

Under Exercise.—The second factor in obesity—lack of sufficient exercise, is even more important than the habit of over-eating. This is illustrated very well by the cases of certain animals who, without any tendency to fat accumulation by nature, but rather the contrary, acquire fat to a marked degree, owing to the habits that are forced on them by their relations to human beings. A typical example is the pet dog. Dogs living their natural active lives, have little tendency to put on superfluous flesh. Kept in the house in cities, they practically always put on weight until, after some years, many of them are quite incapable of moving except in an awkward waddle, often comically symbolizing their mistresses in this respect. Besides the inactivity, the dog is subject to the influence of the other cause of obesity, the over-eating of fat producing material. Another typical example, and one that provides evidence of the pathological tendency to fat accumulation, is found in the Strasburg geese from whom the fatty goose livers for pates de foie gras are obtained. Geese are placed in a warm underground room, in a mass of cement that gradually hardens round their feet keeping them almost completely inactive, and then they are fed abundantly with fat-forming materials. The absence of light and air, and the immobility, leads to the production of the fatty changes, eventually producing the enlarged fatty livers, which delight the gourmet's palate.

What is true of the dog and the goose is exemplified in the lives of all other {292} animals. The fattening process is well understood by butchers—keep the animal inactive and supply an abundance of fattening food. The inactivity is even more important than the food.

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.

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.