(From The British Medical Journal.).
THE accumulation of excess fat, in that it always tends to reduce physical efficiency and not uncommonly to imperil life, should be regarded far more gravely than is generally the case. Now although there are a considerable number of different causes of undue rotundity, yet in practice the majority of cases result from excessive food intake, and deserve, therefore, our chief attention.
Thus most people over the age of 40 are too fat, although at first glance they might be passed as normal. Fat creeps insidiously into the abdominal wall and the enclosed viscera, producing the middle-age spread as its first sign. At this stage treatment is a simple matter and unassociated with any danger. It may consist of either exercises or reduced food intake, or preferably both.
Most exercises advised for fat people are almost useless, and in many cases very wasteful of physical effort for the result achieved. Thus the contortions made familiar to us from our young days by the gymnasium instructor often produce powerful biceps, a deep chest, and strong abdominal recti. They have out of account entirely the importance of the oblique muscles of the abdomen and the quadratus lumborum.
It is the weakening of these muscles, however, which is responsible for the loss of waist line, pendulous belly, and constipation of those possessed of a redundant paunch. Another objection to current bathroom exercises is that they can be practised only in strict privacy, for their employment in the street would inevitably lead to an observation cell.
What, then, are the exercises which we should advise ? In the first place, they must involve all the main muscles of the abdominal wall and pelvic floor. Secondly, it should be possible to carry out some of them, at any rate, during working hours without attracting undue attention. In my opinion those described by Hornibrook in The Culture of the Abdomen are far and away the best.
This book is better prescription for abdomen obesity, and for that matter for constipation, than any drug or combination of drugs. The principle is this: the abdominal muscles can be contracted and relaxed at will without causing gross movements of the trunk. The viscera, however, are thus kept in healthy turbulence, and fat deposits over and in the muscles steadily disappear. The action is much the same as that which produces contraction of the quadriceps femoris without accompanying extension of the knee-joint.
First, the patient should be taught to pull his abdominal wall in and out while standing and while sitting. This activates the recti chiefly, but also to some extent the obliques. Secondly, he should learn to exercise the obliques and quadratus lumborum by standing and drawing the hips and lower ribs together, first on one side then on the other. This is more difficult to learn and at first involves more movement, but in time the action can be mastered so that the lateral and posterior abdominal muscles are alternately contracted and relaxed but little motion of the trunk.
Again, they can be carried out eventually in a sitting posture. The patient should be taught to appreciate what is happening by placing his finger-tips over the muscles to be exercised. By this means he will grasp the scheme much more quickly and carry it out more efficiently. Thirdly, the pelvic floor should be exercised by alternately drawing up and relaxing the anus.
As a sharp contraction of the relevant muscles takes place in both sexes at the end of defaecation and of micturition it can be explained in this way without difficulty. The reason for these exercises is that the pelvic floor is usually weakened in the obese and tends to the production of incontinence of urine in the female, constipation, rectal prolapse, and piles.
Lastly, the back must not be forgotten. All fat people eventually develop a bad stance, and a healthy abdominal wall cannot be achieved if its main point of attachment is weak and warped. Insistence should thus be placed on the importance of carrying the head and body erect as a positive means to the desired goal. Now although many other excellent exercises have been devised, yet only those described above can easily be carried out from time to time during the day.
The muscular contractions can be performed while the patient is travelling, white waiting for a bus, sitting at a desk, and even at the dinner table, without exciting comment. The great secret of successful exercises is that they should be capable of being performed at frequent intervals until they become a habit. This is obviously of far greater value than a quarter of an hours intense boredom of “bedroom jerks”.
Effective as the abdominal contractions are they in no way exhaust the patient, and can thus be carried out by the fattest person, who would be rendered gravely ill by attempting any of the more common violent exercises. When should these exercises be advised? Clearly, to all fat people.
But particularly one should use ones opportunity as a doctor to catch the disease at its inception. The complacency with which the middle-aged accept increasing girth is deplorable, and only their doctor can warn them of the danger without the risk of incurring their displeasure.
For those also afflicted with fat arms and neck the same principle of static muscular contractions can be applied. It is noteworthy that fat will not accumulate over a muscle which is frequently used. Observe, for instance, the well-shaped legs of the fattest glutton who has not yet settled down to the almost perpetual recumbency of an over-replete boa-constrictor. The great muscle of eating– namely, the masseter– is a remarkable exception to this rule.
WHAT TO EAT.
Whereas most people have themselves to blame for the fat which encumbers them, one must admit a large element of bad luck (if such a term may be pardoned) in many. This refers, of course, to an inherited predisposition to fatness. Such people may eat small meals and yet put on weight. Others of lean stock may be possessed of the grossest appetites and yet escape unscathed.
The explanation of this is not clear. It may be a matter of complete absorption of foodstuffs in the one and incomplete absorption, possibly occasioned by rapid transit, in the other. Yet again, glandular deficiency may play a part, However, though the problem is interesting, it does not appreciably affect the nature of the treatment. In these persons a strict dietetic regime is essential, as also in the obviously gluttonous.
It is popularly supposed that drinking with food increases the tendency to put on fat. There is an element of truth in this. Apart from the rare cases of obesity due to water retention, in which the total fluid intake must be restricted, it is unnecessary to limit the amount of water taken by fat people.
The reason why drinking with meals may aggravate obesity is that by washing down the food it encouraged further excess. On a standard dietary such as that mentioned no difference is observed as the result of taking fluid before or with food.
DANGERS OF TREATMENT.
With the measures outlined above there are no dangers of vitamin deficiency, acidosis, or thyroid poisoning. There remains one fear, however, and that is for the heart. A rapid reduction in weight in the very fat patient of 50 or more may induce myocardial failure.
Should signs of heart weakness appear, a tablespoonful of glucose should be given twice daily for three days, the diet raised to full normal, and the patient kept in bed for a week. Dieting may then be recommenced, but on a modified scale. Such eventualities are very rare, and indeed the plethoric, panting, corpulent, caricature is far more likely to regain liveliness and slender lines from dieting than to suffer from a cardiac catastrophe.