Obesity which complicates surgery

Obesity which complicates surgeryThe one condition which complicates all sys­tems of disease treatment more than any other is obesity. Not only does this abnormal state complicate disease states and their surgical treatment, it also predisposes to almost all diseases. More­over, obesity is actually a disease in itself.

Obesity may be defined as a disease state of psychological origin wherein there are abnormal quantities of fat tissue throughout the body.

To preface the discussion of obesity, the obvious fact must be mentioned that there are only two routes through which substances nor­mally enter the body; namely, the gases inhaled into the lungs and those substances ingested through the mouth. It is a well-known fact that any inhaled gases or vapors cannot be stored as bodily components. It is therefore the route of oral ingestion which must be considered whenever any body component is present in ex­cessive amounts. Obesity, then, is an abnormal­ity of oral intake. Under no conditions can this fact be denied. In the past numerous abnormal physical conditions have been suggested as un­derlying causes of this seriously unhealthy state, such as “gland disease,” “heredity,” and “over­digestion.” But, in the final analysis, each in­criminated condition resolves itself as a greater oral intake than the body presently needs. In a word, there is no route that the excess fat, or any other body constituent, can come from, other than by ingestion—eating and drinking.

The body has certain needs. These are oxy­gen, salts, water, vitamins, minerals, proteins, carbohydrates, and fats. To sustain life and function properly, adequate amounts of each of these must be provided. The specific uses and fates of each of these vital substances after en­tering the body are major fields of study, and the problems of excessive intake necessitate sepa­rate considerations. So only briefly can mention of each be made here.

In order for any action to take place in the body, a chemical reaction first occurs, involving oxygen, water, and glucose. Specific salts, vita­mins, and minerals may enter into certain of these reactions. Other salts, vitamins, minerals, and proteins are important elements in the growth and repair of body tissues. But of prime concern in the subject of obesity is the sub­stance glucose, the material which is the actual fuel which burns in the acting tissues to provide the energy for the actions. This substance is de­rived in the body only from the carbohydrates, proteins, and fats. These are the energy-supply- ing groups of foods.

Oxygen cannot be stored in the body, so nor­mally is never taken in in excess amounts; a con­stant intake is necessary. Water, salts, vitamins, and minerals can be stored in only limited amounts, and excessive ingestion of any of these results in their immediate excretion through the urine or bowels. The residue of foods eaten which is not composed of any of these necessary body substances is not absorbed from the in­testinal tract, but rather passes through to be eliminated as feces. But with carbohydrates, pro­teins, and fats, the physiology is different. These foods are totally absorbed from the intestinal tract, and never are excessive amounts excreted or otherwise eliminated from the body. Their storage, as hereinafter described, is unlimited.

Since the carbohydrates, proteins, and fats are known to supply the energy needs of the body, the specific amount of energy supplied by each of these foods has been accurately determined. Any carbohydrate food provides the same amount of energy as any other carbohydrate food per unit of weight. Similarly, all protein and all fat foods furnish the same amount of energy as any other food of their respective group. The unit of measure used to designate energy consumption in the body and energy capacity of food is the calorie.

A calorie is a specific and definite amount of energy. One caloric, regardless of its source, is capable of doing the same amount of work as any other calorie. An ounce of protein pro­vides approximately the same number of calories as does an ounce of carbohydrates. But an ounce of fat supplies more than twice the number of calories as do these other two food groups.

Actually, few foods eaten today are comprised strictly of one food group, but rather are mix­tures of carbohydrates, proteins, and fats, in various proportions. The digestive processes separate and absorb each component individu­ally. Food analysts have calculated the over-all caloric values of the commoner foods, and desig­nate the total calories in them according to usual serving measures.

It must be pointed out that the absorption from the intestinal tract is 100 per cent efficient, except in extremely rare situations. In certain instances of prolonged dysenteric disease with profuse diarrhea, when the food is rushed through the digestive system before digestion and absorption can be completed, and in cases of anatomical defects of the digestive tract where the food passage is shunted or short-cir­cuited through the tract, absorption of all the food elements may be impaired. But such situa­tions are very infrequent. Normally, every calorie that is eaten is absorbed through the intestinal wall into the body as a calorie of fuel, and is capable of providing a calorie of energy. And also of import in the problem of obesity is the fact that the absorption of food calorics, like any other functioning system, can be no more than 100 per cent efficient. No more calories can be absorbed than are eaten. The body cannot manufacture calories, nor can it abstract more than one calorie of energy from each calorie. One calorie eaten means one calorie absorbed for one calorie of energy.

The energy requirements of the body are quite variable. Not only do the needs for energy vary from individual to individual, but also in the same person from time to time. The caloric re­quirements depend on both the overt activity of the individual and the rate of the fundamental maintenance processes in the body. A man who docs heavy manual labor has greater energy requirements than one who is engaged in a sedentary occupation. And in anyone, of course, there is more fuel burned with activity than during the resting hours. The energy the body spends in carrying on the basal metabolic activ­ity can be determined quite accurately (see basal metabolic rate). These sustaining processes are controlled in part by hormones secreted from the thyroid and other glands. Energy consumption is greatly influenced by the state of emotions. During apprehension and anxiety the amount of fuel burned is increased seemingly out of proportion to the increase in physical activity. During periods of worry and other prolonged emotional upsets, this so-called “nervous energy” may reach great proportions. To summarize, it may be said that the energy requirements of the body are dependent on the physical activity, basal metabolic rate, state of emotions, age, sex, and weight of the individual.

Carbohydrates, proteins, and fats, which are the only energy-supplying food groups, each have a primary function. Carbohydrate is the main source of glucose, the actual tissue fuel; protein is utilized primarily for building and repair of tissues, and fat is stored for later energy in case the carbohydrate supply is de­pleted. But, for the most part, these functions are interchangeable. If the carbohydrate intake is not sufficient for conversion to glucose in the quantities needed for immediate fuel, proteins and fats are converted. A small amount of glucose is stored in the liver as glycogen and keeps the blood stream supplied at the normal level of glucose from meal to meal, but when the carbohydrate intake does not furnish enough for this, the proteins and fat become the source of fuel. When amounts of proteins and carbo­hydrates are ingested in excess of their primary function, they are changed to fats and stored. This of course is a basic fact in the study of obesity. Never are excess amounts of any of the energy foods eliminated from the body. All excess calories are put in the form of fat and stored. (Alcohol, although not classed as a food by some, is a source of calories. Some alcoholic beverages contain other substances as well and furnish a tremendous number of calorics.)

It must be pointed out that an excess intake of calories does not make an individual feel more energetic or ambitious. It is the activity of the body which dictates the amount of food converted to available energy, rather than vice versa. Only a certain level of energy fuel is ever reached in the blood stream and tissues.

The correct balance between calories burned in the body and the amount ingested is normally regulated by appetite. When the amount of ready energy in the blood stream becomes low or the stomach is empty, a desire for food is experienced. This is the appetite. But it is influ­enced by several other forces which are more psychological than physiological. Recently an area in the brain designated as the “appestat” has been thought to have some influence on the appetite, but it still appears that the psychologi­cal factors play a greater role in influencing the appetite. The mental and emotional forces at play with the appetite are many; some are simply explained and some are complicated. The eating habits a person develops have a most important influence. Likes and dislikes for certain foods arc formed early in life. Too often the foods of greatest liking are the sweets and other foods high in calories. Some persons habitually eat excessively large meals to “gorge” themselves once or more often each day. Others eat several times between meals or at bedtime. A few persons can be said to eat but one meal a day—it starts upon rising and finishes at bedtime!

Changes in work habits with no change in the eating patterns can mean excessive caloric intake. A person who changes from an occupa­tion of heavy manual labor to a sedentary one often retains the same eating habits and gains weight. An increase in weight is common after occupational retirement, because eating habits have not been adjusted to the lessened caloric needs. The economical housewife who cats food leftovers, rather than discard them, may be headed for obesity. Social events and snack periods throughout the day often initiate inordi­nate eating habits.

Upsets in the normal balance between caloric intake and caloric expenditure may appear at times of emotional stress. The mechanisms of the emotional influences on appetite are many; some involve complicated analysis, and others are quite apparent; some are immediate emo­tional compensatory measures, and others are long-standing indirect readjustment patterns. Some persons at times of emotional disappoint­ments seek temporary diversion through de­light in new foods. The person whose childhood emotional problems were diverted by receiving candy or other goodies to appease crying may subconsciously have rationalized that oral cram­ming is the answer to all emotional conflicts. Similarly, rewards in the form of food for ex­ceptional behavior in childhood may be carried over into adulthood, so weight gains are seen at times of accomplishment as well. Life would in­deed be monotonous without our emotions, but the emotional influence which may disturb health must be guarded. Boredom, anxiety, disappoint­ment, maladjustment, joy, and contentment are only a few emotional states which may upset the delicacy of the appetite’s usual physiological control of caloric intake and expenditure.

The prevention and treatment of obesity, like any other abnormal condition, must be directed at the underlying cause. Since obesity is of psy­chological origin, the mind is the primary factor in its control. More specifically, the will power is the fundamental therapeutic agent. No person can satisfactorily reduce if he does not really want to reduce. The desire to attain and retain normal proportions must be matched by the will power. There are no short-cuts. It has been mentioned that all excess calories taken into the body are converted to fat and stored. Reduction of weight must be directed at taking in fewer calorics than the body burns as fuel, so that the stored fat will be recalled to furnish the extra calories not supplied in the diet. Obesity is strictly a dietary problem secondary to the men­tal powers. In its formation excessive amounts of calorics have been ingested; in its control, the excess calories must be expended, and then balance established.

Control of the diet for reduction purposes may be very precise or quite informal. In either case it should be initiated by a physician or a dietitian. In the precise method the exact diet of the indi­vidual is specified. Detailed instructions for each item of each meal are provided. The selection, the preparation, and the amounts of each food are designated. In the informal method the indi­vidual learns the principles of reduction and the relative caloric values of foods. He then is left “on his own” to select limited amounts of the foods low in calorie content. The latter method is more convenient, of course, and preferred by those persons who are of strong determination. In either case, it must be estimated day by day that the energy expenditure exceeds the caloric intake. In some instances it is fitting to begin on the precise scheme, and, when the principles have been realized, assume an informal plan.

Persons undertaking a weight reduction course must realize that the body has certain essential needs which have not been stored in the body. A daily supply of these is important in all per­sons, but especially in those on a restrictive diet. Water can be taken freely as dictated by thirst. There need be no restriction of ordinary table salt for reduction purposes. Providing the neces­sary daily requirements of the vitamins, minerals, and proteins is most important, but this is easily accomplished by incorporating the re­quired foods in the reduction diet. This actually makes a sound and convenient cornerstone on which to devise the entire dietary plan.

The required basic foods are discussed in the next section, and should be included in every diet. Essentially, every person should include daily in his diet two glasses of milk, one egg, a slice of bread or cereal, one serving of meat or fish, one pat of butter, one green and one yellow vegetable, a citrus fruit, and one other fruit. What comprises the remainder of the diet in healthy individuals makes little difference. These foods will provide all the required vitamins and minerals. But to safeguard this, often supple­mental synthetic vitamins are prescribed during any restrictive diet.

Normally, a person’s weight fluctuates a few pounds from day to day or even from hour to hour. This is due to the amount of residue in the digestive tract and the amount of water retained in the tissues. Salts in the tissues control the osmotic forces between membranes and retain the correct amount of water necessary for their correct dilutions. Thus, the weight changes in accord with the amount of salt as well as the amount of water the tissues need. But these con­stitute only minor alterations in weight and have no effect whatsoever on the fat stores.

Limiting the water and salt intake with intent to treat obesity is fallacious, and may invoke harmful upsets to the fluid system of the body. The intake of water and salt should be dictated by thirst and taste in the healthy individual, as the kidneys will excrete any excess.

Changes in fat stores in the body are quite gradual. It takes an excess of approximately 4,000 calories to add one pound of fat to the body, and similarly takes the same deficiency of about 4,000 calories in the diet to rid the body of a pound of fat. An average working man uses about 3,000 calories per day. If such a man were to eat but 2,000 calories per day, he would use 1,000 calories from stored fat each day. So it would take four days to rid the body of one pound of fat.

During the time of fat reduction, the actual weight may not show the decrease but may even increase, due to the normal body weight changes through salt and water physiology.

In certain diseases involving salt and water physiology, the physician is concerned with the daily weight changes, but in obesity daily changes are not significant, for the only real concern is in the fat stores. Some physicians advise monthly or even less occasional weight measurements in obesity therapy, for patients become very dis­couraged with the less dramatic daily weighings.

As previously mentioned, weight reduction schemes should be initiated by a physician or a dietitian in order that they may be effective and yet not harmful. There is danger from too rapid depletion of fat stores. Ordinarily two to four pounds’ calculated reduction per week is ideal.

Too frequently, after a successful course of reduction therapy, the person gradually resumes his previous eating habits with calories in excess of the needs. Gradually the fat stores again build up. For this reason a maintenance diet should be instituted when the weight has been reduced to the ideal level. This of course does not take nearly the effort that the actual reduction pro­gram demands. By this time the individual is well aware of the high calorie foods. He must take limited servings of these, and must avoid all between-meal snacks and give up or limit such things as carbonated beverages and alcohol.

After reduction the body does not work nearly so hard for ordinary activity as it did when the person was obese, so the energy requirements are less. The resumption of previous eating habits would mean a rapid gain in weight. The person must keep the caloric values of food foremost in his mind at all times, for it is a pity indeed to allow all the efforts of reduction to go to waste through failure to maintain the results.

It would appear that burning of fat stores could be accomplished by increasing the amount of energy expended. This is true provided that the caloric intake remains the same. To this end, exercise has been advocated as a weight reduc­tion measure. But it must be remembered that using up the fat deposits in the body is con­tingent on a lesser number of calories taken in than those used for energy. Exercise uses calories but also increases the appetite, usually to a greater proportion than the caloric utilization. And actually the number of calories used in the exercise is of insignificant amounts. It has been estimated that the energy required to walk a mile could be supplied by one slice of bread. So, too often, efforts to reduce by exercise alone are to little avail. There is possible harm in vigorous exercise, too, as added strain is placed on the already overtaxed cardiovascular (heart-vessel) system.

Certain drugs have been proposed as adjuncts to weight reduction by dieting. These are based on the principles of stimulating the body’s basic metabolic processes and obtunding the appetite. In the obese person these processes are already hard at work in efforts just to maintain the body, so further stimulation may be quite harmful. The heart of the obese is working under great strain, and the effects of stimulating drugs on this organ alone is usually contraindication to their use. Furthermore, when such medications are prescribed, some individuals try to rely entirely on them rather than adhering to their dietary restrictions. Needless to say, these drugs should not be used over long periods of time. But, in a few select cases, they may be prescribed during the initial phases of a dietary plan. However, it must be impressed on the person’s mind that such drugs are only an adjunct; they cannot replace dieting. When a dietary program and these drugs have been successful in ridding the body of its excess fat, there is a greater tendency to regain weight after the drugs have been dis­continued. In this circumstance establishment of sound maintenance eating habits is most impor­tant.

Many other adjuncts and substitutes have been advocated as reduction measures. Various forms of physical therapy are presently in vogue for control and treatment of this seriously abnormal condition of obesity. These are all highly over­rated or entirely erroneous. The popular steam bath is employed on the principle that the heat applied to the tissues will speed up their metabolic processes and thereby burn more calories. There may appear to be a weight loss after the bath, but this is only from evaporation of water from the tissues, which is soon replaced through thirst. The fat loss by such heat methods is infinitesimal. Various cold baths, needle showers, and special douches often give a sense of well-being through increased muscle tone (tautness) and psycho­logical response, but they will remove no fat.

There is widespread desire in both men and women to get rid of fat in local areas, such as about the waist and the hips and “double chins.” This has flooded the market with numerous “spot reducing” devices, such as pressure straps, sup­porting harnesses, vibrators, heat lights, and mas­saging appliances. None of these is of any value in reducing local deposits of fat. There is no method to make fat disappear from one region of the body without proportionate reduction in other regions.

Probably there are more misconceptions about obesity than any other medical problem. The medical facts of a few of these fallacious ideas can be mentioned here. The old idea that a ravenous appetite is always a sign of good health is now known to be unsound. That fat people arc healthier than slender persons is entirely false. The tendency of obesity to run in families is due more to the acquired familial eating habits than it is to hereditary factors. Salt and water are not fat-producing foods, and loss of these substances through perspiration by exercise or overheating does not mobilize the body’s fat stores. Over­weight persons are not necessarily stronger or more resistant to disease than those of normal stature. Obesity is not a disease of the body’s glands. Fat does not “insulate” the body to keep the obese person warm in cold weather, but rather it is the person who must keep the excess fat warm.

The health hazards of obesity are many. The fact that overweight individuals are not insurable or have to pay larger premiums is sufficient evi­dence of the role this condition plays in lon­gevity. Their life expectancy is not so great as that of normal weight individuals, for statistics definitely prove that the obese die at a younger age. In the study of the cause of any disease, mention is always made of the causes which pre­dispose to the disease. In almost every instance obesity is listed as one of the main predisposing causes; in short, the obese are more prone to develop almost every disease than a normal weight person. Especially important is the obese person’s predisposition to heart disease. Every­thing that the obese individual does entails more work and the heart must function in accord with the body’s work. The person who is 60 pounds overweight actually performs as much added work climbing a flight of stairs as would the normal-weight person to carry a bushel of po­tatoes up the stairs. The obese person performs such added work with every movement he makes in proportion to his excess fat stores, and the heart has to deliver to the acting tissues all the oxygen and other nutriments needed for the work. Moreover, the heart has the additional fat tissues to keep supplied. It has been accurately estimated that there are five sixths of a mile of blood vessels developed in each pound of fat deposited in the body. Thus, a person 60 pounds overweight has 50 miles of extra blood vessels through which the heart must pump blood. And it has been suggested that fat deposits about the heart itself may crowd this organ to impair its normal beating action. It is little wonder, there­fore, that heart disease is far more prevalent in obese people. Diabetes is another serious dis­ease which occurs far more commonly in obese people.

Not only are almost all diseases more apt to occur in the obese, but also their management is always more complicated. The diagnostic pro­cedures are not so reliable, and indicated thera­peutic measures not so easily carried out. Phys­ical examination is hampered by the thick layers of fat all over the body, and even x-ray pictures are not so clear. Medications used in treatment are diffused throughout more tissues so greater effective dosages are required, and yet the body has no greater capabilities of detoxifying or eliminating the larger dosages. Physical treat­ments, x-ray therapy, ambulation, and personal hygiene are much more difficult in the obese.

It may be said without reservation that obesity is the greatest single complicating condition in the surgical field. Today more operations which would benefit the health and comfort of the patient have to be denied because of obesity than because of heart disease or any other cause.

Like medical illnesses, almost all surgical ail­ments are more prevalent among the obese, and in this condition are encountered the greater proportion of operative complications. Gall­bladder disease, as an example, occurs several times more frequently in overweight persons. Respiratory, cardiac, and blood clot complica­tions are more common during convalescence. Diagnosis, preoperative preparation, and post­operative care are more formidable in the obese, and rehabilitation is often far more difficult. Needless to say, the operation itself is of greater magnitude. The anatomy is less distinct; greater areas of tissue are damaged; more ligatures and sutures are needed; and more anesthetic is re­quired over a longer length of time.

Any alarm caused by this discussion in point­ing out the health hazards of obesity cannot be claimed by the author as unintentional. The markedly obese person treads on thin ice regard­ing his state of health, and he should know it. It should be the intent of any member of the medical profession to prevent disease as well as to cure it. If you are obese, these facts are about you. Concede the power of your psycho­logical forces, and develop the resourcefulness of your will power to control your eating habits.

Obesity probably represents the greatest medi­cal cultural lag of the day, for, though its cause, consequence, and treatment are well recognized, yet it becomes more prevalent. From the health standpoint, overeating is no doubt the greatest personal vice of people in this country today. To this habit may be attributed a greater loss of life and greater crippling than to smoking, drinking, overwork, and poor hygiene combined.

The health hazards of obesity have been seen, and so it is not just a matter of being more at­tractive to others.

As a final point, it should be stated that no pa­tient seems to have more gratitude than the one who has been obese and has reduced to a normal weight. He has exercised his self-discipline to make himself handsomer and healthier. He has rehabilitated himself to be less disabled and less predisposed to illness. And he knows he has done it for himself.

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