OBESITY - A DISEASE CAUSED BY MALADJUSTMENT - CIBOMANIA
1 - STOPPING OF PHYSICAL ACTIVITY
Those who stop or greatly reduce their physical activities usually do not reduce their intake of calories proportionately. Those who prepare their food continue to provide the usual portions and those to whom it is served have no difficulty in consuming them; in reality they would be surprised if they were unable to use up the same amount of food they had eaten every day for many years. In reality, without being aware of it, for the first time they are introducing a larger amount of food than they need for their present metabolic needs. When after a few months or years they realize they have put on weight, their nutritional equilibrium has been compromised forever.
This triggering factor is undoubtedly the most frequent one and for the most part involves males owing to the more intense physical activity they normally perform. It does not come into play when physical activity is reduced gradually to allow proper dietary adaptation. Prevention consists of avoiding the abrupt interruption of activity and in immediately reducing intake to adapt to the new energy requirements. The beginning of a new gratifying activity may be helpful. Thus the services of a health practitioner are necessary not only at the beginning and during physical activity, but also when this is stopped.
2 - MATERNITY
This is the most frequent triggering factor among adult women. Inappropriate nutrition can be applied during pregnancy and/or breast-feeding. If we exclude the feeding techniques applied in livestock raising, it is exclusively reserved to women who are often the target of attention and bad advice from relatives, friends, husbands and so on. What is a very common physiological event in nature very often for women becomes an occasion for worry and anxiety, with inevitable repercussions on the nutritional plane (see Emotional Stress below). Sometimes it becomes a good excuse for cutting down on physical activity: even labour laws concerning maternity can become incentives for a sedentary life.
Some damaging prejudices still persist, both concerning pregnancy (craving, eating for two and so on) and breast-feeding (drink beer, eat a lot to keep up the flow of milk and so on): not wanting to appear irresponsible to members of the family, women are easily led to follow this advice.
Continuing to work even in the final stages of pregnancy (when the job is not very tiring and there are no particular contraindications), taking longer walks in time off (when the job is sedentary), following the advice of the obstetrician, keeping to a varied and balanced diet and paying attention exclusively to the natural need for food, considering maternity not as a precious gift to loved ones but simply a special physiological condition needed and essential for procreation can help women to spend this period serenely, without feeling the need for the unjustified and self-defeating gratification of those around them.
It may be useful instead to explain that in the first months of pregnancy (after eliminating smoking, alcohol, salty foods, raw meats and sausages) that it is not a good idea to change previous eating habits when they are good ones, since normally, at the end of the second month the increase in weight should be very slight (about 0.5 kg (1 lb) and at the end of the third month must be no more than 1.5 kg (3.3 lbs). From that point on, following the body's natural increased need for calories, it will not be difficult to keep to the 9 to 12 kg (20 to 26 lbs) required at the end of the pregnancy through a moderate increase in the assumption of fruit, milk and vegetables, especially in the form of snacks. In the presence of overweight, metabolic disorders or other nutritional problems, periodic checkups by a dietician are a good idea both during pregnancy and breast-feeding.
3 - TREATMENTS
Overweight often represents a side-effect of medical or surgical treatments. Among the former we frequently find neuro-psychiatric drugs (antidepressants, sedatives), sanatorium treatments (isoniazid), hormonal treatments (cortisone, anabolic steroids, contraceptives and so on), tonics (vitamins, aminoacids, anti-anaemic drugs, antihistamines and so on).
Proper control over food intake and body weight, accompanied by proper dietary information, can prevent the onset of obesity.
4 - TOO MUCH PARENTAL WORRYING
During a visit a mother reports: "He never had any appetite... you can't imagine how hard it was to get him to eat."
This cause involves most patients who believe they have always been fat. Children of normal weight, as is true for all living beings (except for animals raised for human consumption) instinctively eat as much as is required by their metabolisms. If what they consume is insufficient, they will call for more; if it is too much they will leave the excess on the plate. In the latter case, the child is strongly prodded to eat the entire portion ("eat up and you'll grow up… it's good for you… it'll make you strong… here comes the airplane full of…"). Although very reluctantly, the child will often make the effort to please his parents (uncles, aunts, grandparents) and so with the passing of time, consuming more than he needs, he gains weight and becomes permanently maladjusted as far as food is concerned.
Normally speaking, if a child is healthy (no fever, no cough, plays regularly and so on) and does not eat snacks or sweets or drink soft drinks before meals, there is no discrepancy between appetite and metabolic requirements. Unfortunately, in many cases the child’s slender constitution is easily mistaken for skinniness and this causes parental apprehension. In reality, adipose tissue is well represented and a paediatrician or the family doctor has no trouble in checking this: there should be a thickness of 7 to 11 mm, as is normal in children, of the posterior brachial cutaneous plica (Pett L.B. and Olgivie G.F., cited by Travia - Manuale di Scienza dell'Alimentazione – 1st edition, page 80).
On 8 April 2005 we wrote to Professor Sirchia, then the Italian Minister of Health, to express our appreciation of the measures he had adopted to fight smoking, but we also warned him of the risks involved in using the same methods in the field of nutrition. The letter began: "Hon. Professor Sirchia, Minister of Health, don't cut in half the portions in restaurants - cut in half the prices!". After briefly describing the differences between smoking and nutritional problems, we suggested what in our opinion would be a truly useful solution: to activate primary prevention by informing people concerning the triggering factors leading to obesity. After sealing the letter and putting a stamp on it, while browsing through the local newspaper, l'Unione Sarda, we came across a letter written by a mother to the newspaper's paediatrician. She wrote: "I am really worried: my six-year-old daughter refuses to eat, at least the way I want her to. She eats when she likes and what she likes (very little) and doesn't listen to my advice. Naturally I took her to two general practitioners of the public health service and then to two private paediatricians. They all found her healthy, but I don't think this lack of appetite is normal. I've tried everything: flattery, threats, promises, screams, crying, scenes. For years now I've been fighting a war with few moments of truce. I'm nearing a nervous breakdown. But if I give up I'm afraid I would be behaving irresponsibly." The emblematic newspaper heading was "The food war is won with a smile." We opened the envelope and put in a copy of the mother's letter and the response of the paediatrician, with the following post script. "......the child has stood up to the threats and promises, but will certainly surrender to the smile and the game of the "airplane that arrives full of...".
5 - CHANGES IN LIFESTYLE
In this group of triggering factors we find marriage, employment, retirement, a long holiday, moving, the end of a period of dieting and any other event that causes an abrupt change in eating habits which is capable of inducing an increase in calorie intake unjustified by metabolic needs.
Marriage, in which both husband and wife may assume new eating habits borrowed from the partner, may cause a change in the former calorie intake. The case of women who report having begun drinking wine during meals to keep their husbands company or that of men who report a greater consumption of fatty and elaborate dishes compared to those prepared by their mothers are frequent. Moreover, in both, life in common may limit the freedom of movement (sports, walks) or dietary autonomy (when one is not hungry and the other is, it is more difficult to skip a meal). Finally, between husband and wife there is often a certain emulation that may facilitate food consumption beyond real metabolic needs, such as when one eats only to keep the other company; this normally goes to the disadvantage of the wife, since her energy expenditure (resting and total) is less than that of the husband. An understanding of these concepts helps to eliminate or keep to a minimum the risks involved in married life.
Employment in sedentary activities leads to a decrease in energy expenditure in those who previously did manual labour or practiced sports (see no. 1). Furthermore, especially after beginning one’s first job, which means having more money than before, with brief breaks during the working day may create new occasions for snacks (cappuccinos and pastries) which more often than not do not replace normal meals but are in addition to them.
Retirement, when not accompanied by other productive work or adequate recreation, may cause decreases in energy consumption (more time in front of the TV or in bed) and make eating more gratifying.
Holidays, when sufficiently long or, in the case of children a period of time spent in a camp in the mountains or at the sea with grandparents or close relatives, are other occasions that may be the beginning of the fattening process. The new taste experiences, the separation from daily occupations, the pleasant attention given by those around (relatives, friends, waiters) may go together to increase food consumption (local dishes, sweets, ice cream, drinks) and, unfortunately, these new habits are not always left in the holiday resort on returning home.
Moving from one place to another can trigger obesity, both owing to the possible reduction in energy consumption caused by less exercise than usual (sports, walks) and to compensatory gratifications favoured by the discomfort deriving from longing for the previous familiar environment (places, relatives, friends, social gatherings) and from the difficulty of settling down in a new place. We recall the case of a foreign girl who moved to Sardinia in the 1960s following her marriage to a fellow countryman who was stationed at a NATO base on the island. The difficulty of adjusting, also caused by not speaking the language, homesickness and loneliness (her husband came home only in the evening) led to her gaining about 20 kg (44 lbs) in less than a year. She, who up to that time had never had weight problems, blamed her condition on the climate!
Dietary restrictions, when lasting over a more or less long period, followed by a return to a normal diet, which also means an increase in food quality, can easily pull the trigger: some trace the beginning of their obesity to the end of the war and rationing, others to the overcoming of a state of need caused by special personal or family conditions.
6 - EMOTIONAL STRESS
Anxiety, worrying and disappointments represent, as said before, a factor that aggravates nutritional maladjustment and therefore constitute a serious obstacle to following a diet. In reality, stress activates a defensive mechanism of the conscious ego which, in substitutive and compensatory ways, leads to an increase in food intake, which takes people’s minds off the source of the anxiety, which is exactly what occurs in smokers who in moments of tension double their consumption of cigarettes.
7 - BOTTLE-FEEDING
Among the patients who in our case histories reported always being fat, in reality only 15% of them weighed more than the average (see no. 8, Macrosomia), 28% had been bottle-fed, and for them the beginning of overweight took place in the first years of life; the others had been the victims of exaggerated care by parents (unpublished research in 1997).
8 - MACROSOMIA
This triggering factor comes into play during pregnancy under the effect of a metabolic alteration. The production of too much insulin with the consequent hypoglycaemic effect and the subsequent increase in metabolic demand is the best-known example of this. In our experience, more than 70% of those having this cause have a family history of diabetes.
9 - GIVING UP SMOKING
This represents one of the triggering factors that comes into play latest in life and only when the habit is deeply rooted and there is a certain degree of addiction. It does not come into play when the person is still in the first stages, keeping in mind that they may last some months but also some years when smoking is limited to a cigarette now and then.
10 - MENOPAUSE
In women this is the most frequent late cause. While we do not exclude a possible alteration in the appetite and even a possible reduction in metabolism linked to the change in the hormonal situation, we believe that the explanation is to be found above all in problems of a psychological nature, often with an origin in depression, which accompany menopause and act by triggering the substitutive mechanism of food.
When the mother and father are obese it is easy to conclude, even without recourse to genetics, that their children will be overweight from the very first years of their lives. In reality, the parents’ poor eating habits will necessarily represent a model for them, in the same way that language and moral behaviour are learnt. As said previously, if the mother and father speak with a lisp, all the children raised in the house will have the same pronunciation anomaly. Many cases included in triggering factor number 4 (too much worrying by parents) can be classified in this group as well.
12 - EATING AND WEIGHT PROBLEMS
NIn the last few years we have seen an increasing number of persons (usually young women) who report having begun to put on weight following spontaneous dieting both for the purpose of losing weight, whether they considered themselves too heavy rightly or wrongly, or owing to pseudoscientific or pseudo-religious convictions (vegetarianism, raw-food dieting).
13 - AN UNKNOWN TRIGGERING FACTOR
In a fair number of cases it is impossible to establish the triggering factor with any certainty. Many people report being overweight all their lives and probably, at least in some cases, they were the victims of mistaken attention in infancy (too much parental worrying), a circumstance that usually comes out only after carefully questioning the parents. In other cases it may be found more appropriately in the familial background. But even when it is impossible to identify the mechanism that led to overweight, it is important for the patient to know that the triggering factor, even when it remains mysterious, is still at the origin of the condition and played a determining role in the gaining of weight and the consequent loss of instinctive control over food consumption.
Among the triggering factors, we purposely did not include organic afflictions (endocrine dysfunctions, tumours and so on) since in these conditions the excess of adipose tissue (and not simply of weight, which may be the result of other causes) represents only a symptom (secondary obesity), although it is in all cases the result of an increase in calorie intake over and above the required amount. Fortunately, these are fairly rare cases in which excess weight assumes a marginal role with respect to the disease that causes it.
n conclusion, we propose the following summary: