OBESITY - A DISEASE CAUSED BY MALADJUSTMENT - CIBOMANIA


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TRIGGERING FACTORS

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).
Any kind of surgical treatment may be a triggering factor in gaining weight. But this is most frequent following hysterectomies, tonsillectomies, cholecystectomies (Giovannini C. et al. - Alim. Nutr. Metabol. 1: 97-100, 1980) and thyroidectomies; most likely this is not directly linked to the operation itself, but to the period of convalescence that follows. The pleasant sensation of having recovered, the disappearance of the preoperative symptoms and the progressive overcoming of the postoperative disturbances, the gradual recovery of the appetite following the obligatory pre- and postoperative fasting and finally the gratifying attention of health providers, family and friends all come together to favour normal food consumption and facilitate the application of a rich diet necessary to make up for the loss of weight. When this increased food intake continues over a sufficiently long period of time, the triggering mechanism come into play.

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).
Even school lunchrooms may be a risk factor if the family administers unneeded food integrators.

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...".
We sent the letter registered on 11 April. Naturally we received no reply.

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.
Unfortunately, today we still find research performed on persons of normal weight, mostly students, who are put on strict low-calorie diets for periods of even up to several weeks and who at the end of the study were found to have begun to put on weight! (Obesità 1992 - Congress in Verona 12-15 April 1992: Keys A. et al., cited by Bosello O. "Fluttuazione del peso corporeo e rischio cardiovascolare" - Quon, 1 January, 1994)
This triggering mechanism, together with the ceasing of physical activity, the change in lifestyle and economic gratifications perfectly justify the obesity of the Pima Indians (the prime argument of geneticists) without the need to cite far-fetched genetic theories. In fact, in such conditions any person, community or population necessarily puts on weight!

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.
In any case, psychic disturbances, when particularly intense and long-lasting, besides worsening the cibomania already present, may become a primary triggering factor. Initially, there may be a loss of appetite and even total refusal of food but then, after a few days or weeks, the instinct of survival once again prevails over the tendency towards self-destruction; in some cases there is a gradual return to normal eating behaviour while in others the defensive hyperorexic mechanism is triggered; although while it deviates attention from the painful event by lessening the suffering, it also favours the onset of the weight problem. The death of a loved one, the breaking off of an engagement, misunderstandings between husband and wife, financial emergencies and existential problems are among the most frequent causes of emotional stress.
In exceptional cases, when the refusal of food persists, we have the onset of anorexia nervosa.
A precise understanding of how this triggering mechanism works, together with adequate psychological support, can help in reacting in a more positive way by facilitating the reawakening of other compensatory and diverting interests that are not bad for the health, such as joining a club, doing volunteer work, working at a hobby, physical activity, reading, conversing, doing art work and other alternatives that keep people from wallowing in their problems.

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).
Evidently, bottle-feeding is to be added to the list of triggering factors. It is certainly logical to assume that breast-feeding, since it is regulated both by the mother and the child through physiological self-control mechanisms, offers a better guarantee of proper nutrition compared to bottle-feeding, which differs in the composition of the milk, the different and easier way of sucking and finally in the need to judge the amount of milk, which does not always correspond to the real needs of the child. It is easier to take from the bottle and even easier to give from it!
Close observation of the child’s increase in weight and height facilitate the proper judgement of the right amount of milk to give.

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.
A careful examination of the clinical and laboratory conditions of pregnant women, especially where diabetes or other metabolic dysfunctions run in the family, may show up the need for a diet which provides the proper amounts and balances of foods and at the same time assures the proper increase in weight during pregnancy.

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.
It must be emphasized immediately that smoking does not help a person stay slender: smokers can be fat or thin, just like non-smokers. Many obese adults who go to dieticians are smokers and often they were smokers before they began putting on weight (unpublished study). However, when one stops smoking, this may set off the process of gaining weight or aggravate an existing overweight condition.
It may also be that the greater amount of food introduced is due to an improvement in digestion (smoker’s gastritis) but for the most part it is certainly linked to the psychological substitutive mechanism described for emotive stress (no. 6 above). The former smoker, who ended each meal by lighting the ritual cigarette, now unconsciously remains seated at the table, worried about not giving in to the craving for the most important cigarette of the day, the one following a meal. It is as if the meal were missing.
The substitutive function of chocolate and candies consumed in place of the cigarette is even more easily understandable.
A precise knowledge of these concepts can help the patient to keep to his/her usual eating habits, thus eluding the iniquitous substitutive mechanism. If necessary, constant control over weight and, possibly, the timely intervention of the dietician can remove these causes, thus sidestepping the fear of getting fat as an alibi for continuing to smoke.

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.
The coincidence in time of menopause and the average life expectancy of women, which was present up to a few decades ago, could in some way justify the appearance of alterations of humour in this particular physiological phase: menopause then meant not only the end of the genital function, but also the beginning of the end of life. Today, with the increase of about thirty years in the average life expectancy of women, the end of ovulation and menstrual manifestations, now superfluous, can easily be accepted since all the other functions, including sex, remain unchanged for many years to come. Thus menopause should not be the cause of despair nor decrease the joys of life. This idea, which often represents a novelty, is easy to accept and appreciate.
The development of new interests of a recreational, cultural, social and charitable nature can eliminate this triggering factor.

FAMILIAL BACKGROUND

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).
As is known, persons gifted with physiological self-control over food (in Western countries perhaps no more than 30% of adults and 75% of children) have no trouble, just like animals in their natural environments, in maintaining their normal weight since they are properly guided by the signals of hunger and satiety. Considering that the availability of food is no problem, all they have to do is pay attention to the quality of what they eat to avoid a deficiency of required substances or an unbalanced diet (we not only have to eat, we must also nourish ourselves).
We are of the opinion that in their cases, following a strict diet can only be damaging, even when the diet is properly calculated. And what can we say of spontaneous diets, the ones copied from newspapers or suggested by friends and others lacking the necessary expertise? In most cases they are qualitatively unbalanced and quantitatively inadequate diets; fortunately they are usually quickly abandoned with the appearance of health problems or the pangs of hunger. But when the diet is continued it is easy to acquire new eating habits and an excess or insufficiency of weight (Bosello O. "Il paradosso della dieta" - Atti II Congr. Naz. ANSISA 1993, page 13). After repeated phases of weight loss, immediately followed by more than the recovery of the weight lost (the weight cycling syndrome), there are two options: unconditional surrender to the craving for food or, more rarely, self-induced anorexia. The defensive barriers erected against bulimia do not always guarantee the maintaining of normal weight, or do so only for short periods.

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:

    1. cibomania + increase in adipose weight = obesity
    2. Pathological dieting + thinness = anorexia nervosa
    3. Pathological hyperorexic behaviour, accompanied by extreme defensive measures, with or without changes in body weight = bulimia
    4. A well-controlled cibomania with no important changes in body weight = clinical cure of obesity or its stabilization.

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