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Pounds & Inches
A NEW APPROACH TO
OBESITY
BY: Dr. A.T.W. SIMEONS
SALVATOR MUNDI INTERNATIONAL HOSPITAL
00152 - ROME
VIALE MURA GIANICOLENSI, 77
FOREWORD
- introduction by Dr. Simeons
This book discusses a new interpretation of
the nature of obesity, and while it does not advocate yet
another fancy slimming diet it does describe a method of
treatment which has grown out of theoretical considerations
based on clinical observation.
What I have to say is, in essence, the views
distilled out of forty years of grappling with the fundamental
problems of obesity, its causes, its symptoms, and its very
nature. In these many years of specialized work, thousands of
cases have passed through my hands and were carefully studied.
Every new theory, every new method, every promising lead was
considered, experimentally screened and critically evaluated as
soon as it became known. But invariably the results were
disappointing and lacking in uniformity.
I felt that we were merely nibbling at the
fringe of a great problem, as, indeed, do most serious students
of overweight. We have grown pretty sure that the tendency to
accumulate abnormal fat is a very definite metabolic disorder,
much as is, for instance, diabetes. Yet the localization and the
nature of this disorder remained a mystery. Every new approach
seemed to lead into a blind alley, and though patients were told
that they are fat because they eat too much, we believed that
this is neither the whole truth nor the last word in the matter.
Refusing to be side-tracked by an all too
facile interpretation of obesity, I have always held that
overeating is the result of the disorder, not its cause, and
that we can make little headway until we can build for ourselves
some sort of theoretical structure with which to explain the
condition. Whether such a structure represents the truth is not
important at this moment. What it must do is to give us an
intellectually satisfying interpretation of what is happening in
the obese body. It must also be able to withstand the onslaught
of all hitherto known clinical facts and furnish a hard
background against which the results of treatment can be
accurately assessed.
To me this requirement seems basic, and it
has always been the center of my interest. In dealing with obese
patients it became a habit to register and order every clinical
experience as if it were an odd looking piece of a jig-saw
puzzle. And then, as in a jig saw puzzle, little clusters of
fragments began to form, though they seemed to fit in nowhere.
As the years passed these clusters grew bigger and started to
amalgamate until, about sixteen years ago, a complete picture
became dimly discernible. This picture was, and still is, dotted
with gaps for which I cannot find the pieces, but I do now feel
that a theoretical structure is visible as a whole.
With mounting experience, more and more facts
seemed to fit snugly into the new framework, and then, when a
treatment based on such speculations showed consistently
satisfactory results, I was sure that some practical advance had
been made, regardless of whether the theoretical interpretation
of these results is correct or not.
The clinical results of the new treatment
have been published in scientific journal and these reports have
been generally well received by the profession, but the very
nature of a scientific article does not permit the full
presentation of new theoretical concepts nor is there room to
discuss the finer points of technique and the reasons for
observing them.
During the 16 years that have elapsed since I
first published my findings, I have had many hundreds of
inquiries from research institutes, doctors and patients.
Hitherto I could only refer those interested to my scientific
papers, though I realized that these did not contain sufficient
information to enable doctors to conduct the new treatment
satisfactorily. Those who tried were obliged to gain their own
experience through the many trials and errors which I have long
since overcome.
Doctors from all over the world have come to
Italy to study the method, first hand in my clinic in the
Salvator Mutidi International Hospital in Rome. For some of them
the time they could spare has been too short to get a full grasp
of the technique, and in any case the number of those whom I
have been able to meet personally is small compared with the
many requests for further detailed information which keep coming
in. I have tried to keep up with these demands by
correspondence, but the volume of this work has become
unmanageable and that is one excuse for writing this book.
In dealing with a disorder in which the
patient must take an active part in the treatment, it is, I
believe, essential that he or she have an understanding of what
is being done and why. Only then can there be intelligent
cooperation between physician and patient. In order to avoid
writing two books, one for the physician and another for the
patient - a prospect which would probably have resulted in no
book at all - I have tried to meet the requirements of both in a
single book. This is a rather difficult enterprise in which I
may not have succeeded. The expert will grumble about
long-windedness while the lay-reader may occasionally have to
look up an unfamiliar word in the glossary provided for him.
To make the text more readable I shall be
unashamedly authoritative and avoid all the hedging and
tentativeness with which it is customarily to express new
scientific concepts grown out of clinical experience and not as
yet confirmed by clear-cut laboratory experiments. Thus, when I
make what reads like a factual statement, the professional
reader may have to translate into: clinical experience seems to
suggest that such and such an observation might be tentatively
explained by such and such a working hypothesis, requiring a
vast amount of further research before the hypothesis can be
considered a valid theory. If we can from the outset establish
this as a mutually accepted convention, I hope to avoid being
accused of speculative exuberance.
Obesity a Disorder
As a basis for our discussion we postulate
that obesity in all its many forms is due to an abnormal
functioning of some part of the body and that every ounce of
abnormally accumulated fat is always the result of the same
disorder of certain regulatory chanisms. Persons suffering from
this particular disorder will get fat regardless of whether they
eat excessively, normally or less than normal. A person who is
free of the disorder will never get fat, even if he frequently
overeats.
Those in whom the disorder is severe will
accumulate fat very rapidly, those in whom it is moderate will
gradually increase in weight and those in whom it is mild may be
able to keep their excess weight stationary for long periods.
In all these cases a loss of weight brought about by dieting,
treatments with thyroid, appetite-reducing drugs, laxatives,
violent exercise, massage, or baths is only temporary and will
be rapidly regained as soon as the reducing regimen is relaxed.
The reason is simply that none of these measures corrects the
basic disorder.
While there are great variations in the
severity of obesity, we shall consider all the different forms
in both sexes and at all ages as always being due to the same
disorder. Variations in form would then be partly a matter of
degree, partly an inherited bodily constitution and partly the
result of a secondary involvement of endocrine glands such as
the pituitary, the thyroid, the adrenals or the sex glands. On
the other hand, we postulate that no deficiency of any of these
glands can ever directly produce the common disorder known as
obesity.
If this reasoning is correct, it follows that
a treatment aimed at curing the disorder must be equally
effective in both sexes, at all ages and in all forms of
obesity. Unless this is so, we are entitled to harbor grave
doubts as to whether a given treatment corrects the underlying
disorder. Moreover, any claim that the disorder has been
corrected must be substantiated by the ability of the patient to
eat normally of any food he pleases without regaining abnormal
fat after treatment. Only if these conditions are fulfilled can
we legitimately speak of curing obesity rather than of reducing
weight.
Our problem thus presents itself as an
enquiry into the localization and the nature of the disorder
which leads to obesity. The history of this enquiry is a long
series of high hopes and bitter disappointments.
The History of Obesity
There was a time, not so long ago, when
obesity was considered a sign of health and prosperity in man
and of beauty, amorousness and fecundity in women. This attitude
probably dates back to Neolithic times, about 8000 years ago;
when for the first time in the history of culture, man began to
own property, domestic animals, arable land, houses, pottery and
metal tools. Before that, with the possible exception of some
races such as the Hottentots, obesity was almost non-existent,
as it still is in all wild animals and most primitive races.
Today obesity is extremely common among all
civilized races, because a disposition to the disorder can be
inherited. Wherever abnormal fat was regarded as an asset,
sexual selection tended to propagate the trait. It is only in
very recent times that manifest obesity has lost some of its
allure, though the cult of the outsize bust - always a sign of
latent obesity - shows that the trend still lingers on.
The Significance of Regular Meals
In the early Neolithic times another change
took place which may well account for the fact that today nearly
all inherited dispositions sooner or later develop into manifest
obesity. This change was the institution of regular meals. In
pre-Neolithic times, man ate only when he was hungry and on1y as
much as he required too still the pangs of hunger. Moreover,
much of his food was raw and all of it was unrefined. He roasted
his meat, but he did not boil it, as he had no pots, and what
little he may have grubbed from the Earth and picked from the
trees, he ate as he went along.
The whole structure of man's omnivorous
digestive tract is, like that of an ape, rat or pig, adjusted to
the continual nibbling of tidbits. It is not suited to
occasional gorging as is, for instance, the intestine of the
carnivorous cat family. Thus the institution of regular meals,
particularly of food rendered rapidly, placed a great burden on
modern man's ability to cope with large quantities of food
suddenly pouring into his system from the intestinal tract.
The institution of regular meals meant that
man had to eat more than his body required at the moment of
eating so as to tide him over until the next meal. Food rendered
easily digestible suddenly flooded his body with nourishment of
which he was in no need at the moment. Somehow, somewhere this
surplus had to be stored.
Three Kinds of Fat
In the human body we can distinguish three
kinds of fat. The first is the structural fat which fills the
gaps between various organs, a sort of packing material.
Structural fat also performs such important functions as bedding
the kidneys in soft elastic tissue, protecting the coronary
arteries and keeping the skin smooth and taut. It also provides
the springy cushion of hard fat under the bones of the feet,
without which we would be unable to walk.
The second type of fat is a normal reserve of
fuel upon which the body can freely draw when the nutritional
income from the intestinal tract is insufficient to meet the
demand. Such normal reserves are localized all over the body.
Fat is a substance which packs the highest caloric value into
the smallest space so that normal reserves of fuel for muscular
activity and the maintenance of body temperature can be most
economically stored in this form. Both these types of fat,
structural and reserve, are normal, and even if the body stocks
them to capacity this can never be called obesity.
But there is a third type of fat which is
entirely abnormal. It is the accumulation of such fat, and of
such fat only, from which the overweight patient suffers. This
abnormal fat is also a potential reserve of fuel, but unlike the
normal reserves it is not available to the body in a nutritional
emergency. It is, so to speak, locked away in a fixed deposit
and is not kept in a current account, as are the normal
reserves.
When an obese patient tries to reduce by
starving himself, he will first lose his normal fat reserves.
When these are exhausted he begins to burn up structural fat,
and only as a last resort will the body yield its abnormal
reserves, though by that time the patient usually feels so weak
and hungry that the diet is abandoned. It is just for this
reason that obese patients complain that when they diet they
lose the wrong fat. They feel famished and tired and their face
becomes drawn and haggard, but their belly, hips, thighs and
upper arms show little improvement. The fat they have come to
detest stays on and the fat they need to cover their bones gets
less and less. Their skin wrinkles and they look old and
miserable. And that is one of the most frustrating and
depressing experiences a human being can have.
Injustice to the Obese
When then obese patients are accused of
cheating, gluttony, lack of will power, greed and sexual
complexes, the strong become indignant and decide that modern
medicine is a fraud and its representatives fools, while the
weak just give up the struggle in despair. In either case the
result is the same: a further gain in weight, resignation to an
abominable fate and the resolution at least to live tolerably
the short span allotted to them - a fig for doctors and
insurance companies.
Obese patients only feel physically well as
long as they are stationary or gaining weight. They may feel
guilty, owing to the lethargy and indolence always associated
with obesity. They may feel ashamed of what they have been led
to believe is a lack of control. They may feel horrified by the
appearance of their nude body and the tightness of their
clothes. But they have a primitive feeling of animal content
which turns to misery and suffering as soon as they make a
resolute attempt to reduce. For this there are sound reasons.
In the first place, more caloric energy is
required to keep a large body at a certain temperature than to
heat a small body. Secondly the muscular effort of moving a
heavy body is greater than in the case of a light body. The
muscular effort consumes calories which must be provided by
food. Thus, all other factors being equal, a fat person requires
more food than a lean one. One might therefore reason that if a
fat person eats only the additional food his body requires he
should be able to keep his weight stationary. Yet every
physician who has studied obese patients under rigorously
controlled conditions knows that this is not true. Many obese
patients actually gain weight on a diet which is calorically
deficient for their basic needs. There must thus be some other
mechanism at work.
Glandular Theories
At one time it was thought that this
mechanism might be concerned with the sex glands. Such a
connection was suggested by the fact that many juvenile obese
patients show an under-development of the sex organs. The
middle-age spread in men and the tendency of many women to put
on weight in the menopause seemed to indicate a causal
connection between diminishing sex function and overweight. Yet,
when highly active sex hormones became available, it was found
that their administration had no effect whatsoever on obesity.
The sex glands could therefore not be the seat of the disorder.
The Thyroid Gland
When it was discovered that the thyroid gland
controls the rate at which body-fuel is consumed, it was thought
that by administering thyroid gland to obese patients their
abnormal fat deposits could be burned up more rapidly. This too
proved to be entirely disappointing, because as we now know,
these abnormal deposits take no part in the body's
energy-turnover - they are inaccessibly locked away. Thyroid
medication merely forces the body to consume its normal fat
reserves, which are already depleted in obese patients, and then
to break down structurally essential fat without touching the
abnormal deposits. In this way a patient may be brought to the
brink of starvation in spite of having a hundred pounds of fat
to spare. Thus any weight loss brought about by thyroid
medication is always at the expense of fat of which the body is
in dire need.
While the majority of obese patients have a
perfectly normal thyroid gland and some even have an overactive
thyroid, one also occasionally sees a case with a real thyroid
deficiency. In such cases, treatment with thyroid brings about a
small loss of weight, but this is not due to the loss of any
abnormal fat. It is entirely the result of the elimination of a
mucoid substance, called myxedema, which the body accumulates
when there is a marked primary thyroid deficiency. Moreover,
patients suffering only from a severe lack of thyroid hormone
never become obese in the true sense. Possibly also the
observation that normal persons - though not the obese - lose
weight rapidly when their thyroid becomes overactive may have
contributed to the false notion that thyroid deficiency and
obesity are connected. Much misunderstanding about the supposed
role of the thyroid gland in obesity is still met with, and it
is now really high time that thyroid preparations be once and
for all struck off the list of remedies for obesity. This is
particularly so because giving thyroid gland to an obese patient
whose thyroid is either normal or overactive, besides being
useless, is decidedly dangerous.
The Pituitary Gland
The next gland to be falsely incriminated was
the anterior lobe of the pituitary. This most important gland
lies well protected in a bony capsule at the base of the skull.
It has a vast number of functions in the body, among which is
the regulation of all the other important endocrine glands. The
fact that various signs of anterior pituitary deficiency are
often associated with obesity raised the hope that the seat of
the disorder might be in this gland. But although a large number
of pituitary hormones have been isolated and many extracts of
the gland prepared, not a single one or any combination of such
factors proved to be of any value in the treatment of obesity.
Quite recently, however, a fat-mobilizing factor has been found
in pituitary glands, but it is still too early to say whether
this factor is destined to play a role in the treatment of
obesity.
The Adrenals
Recently, a long series of brilliant
discoveries concerning the working of the adrenal or suprarenal
glands, small bodies which sit atop the kidneys, have created
tremendous interest. This interest also turned to the problem of
obesity when it was discovered that a condition which in some
respects resembles a severe case of obesity - the so called
Cushing's Syndrome - was caused by a glandular new-growth of the
adrenals or by their excessive stimulation with ACTH, which is
the pituitary hormone governing the activity of the outer rind
or cortex of the adrenals.
When we learned that an abnormal stimulation
of the adrenal cortex could produce signs that resemble true
obesity, this knowledge furnished no practical means of treating
obesity by decreasing the activity of the adrenal cortex. There
is no evidence to suggest that in obesity there is any excess of
adrenocortical activity; in fact, all the evidence points to the
contrary. There seems to be rather a lack of adrenocortical
function and a decrease in the secretion of ACTH from the
anterior pituitary lobe.
So here again our search for the mechanism
which produces obesity led us into a blind alley. Recently, many
students of obesity have reverted to the nihilistic attitude
that obesity is caused simply by overeating and that it can only
be cured by under eating.
The Diencephalon or Hypothalamus
For those of us who refused to be discouraged
there remained one slight hope. Buried deep down in the massive
human brain there is a part which we have in common with all
vertebrate animals the so-called diencephalon. It is a very
primitive part of the brain and has in man been almost smothered
by the huge masses of nervous tissue with which we think, reason
and voluntarily move our body. The diencephalon is the part from
which the central nervous system controls all the automatic
animal functions of the body, such as breathing, the heart beat,
digestion, sleep, sex, the urinary system, the autonomous or
vegetative nervous system and via the pituitary the whole
interplay of the endocrine glands.
It was therefore not unreasonable to suppose
that the complex operation of storing and issuing fuel to the
body might also be controlled by the diencephalon. It has long
been known that the content of sugar - another form of fuel - in
the blood depends on a certain nervous center in the
diencephalon. When this center is destroyed in laboratory
animals,
they develop a condition rather similar to
human stable diabetes. It has also long been known that the
destruction of another diencephalic center produces a voracious
appetite and a rapid gain in weight in animals which never get
fat spontaneously.
The Fat- bank
Assuming that in man such a center
controlling the movement of fat does exist, its function would
have to be much like that of a bank. When the body assimilates
from the intestinal tract more fuel than it needs at the moment,
this surplus is deposited in what may be compared with a current
account. Out of this account it can always be withdrawn as
required. All normal fat reserves are in such a current account,
and it is probable that a diencephalic center manages the
deposits and withdrawals.
When now, for reasons which will be discussed
later, the deposits grow rapidly while small withdrawals become
more frequent, a point may be reached which goes beyond the
diencephalon's banking capacity. Just as a banker might suggest
to a wealthy client that instead of accumulating a large and
unmanageable current account he should invest his surplus
capital, the body appears to establish a fixed deposit into
which all surplus funds go but from which they can no longer be
withdrawn by the procedure used in a current account. In this
way the diericephalic "fat-bank" frees itself from all work
which goes beyond its normal banking capacity. The onset of
obesity dates from the moment the diencephalon adopts this
labor-saving ruse. Once a fixed deposit has been established the
normal fat reserves are held at a minimum, while every available
surplus is locked away in the fixed deposit and is therefore
taken out of normal circulation.
Three Basic Causes of Obesity
(1) The Inherited Factor
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