OBESITY - A DISEASE CAUSED BY MALADJUSTMENT - CIBOMANIA


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THERAPY

PRIMARY PREVENTION

As with all conditions of illness, the best treatment is primary prevention, and this is especially true in cases of maladjustment. In our case prevention is based on the extensive knowledge at all levels of the mechanisms that lead to the onset of the illness and, in particular, of the triggering factors mentioned in the chapter devoted to these.
Subsequent treatments can bring patients back to their proper weight, but in no case can they restore metabolic equilibrium, which has been lost forever: the weight reached during the treatment can be maintained only through constant and painstaking control over food intake (cibomania, or foodwatching). In our experience the only exception is to be found in children who follow a diet at a preadolescent age.

SECONDARY PREVENTION

ALL PATIENTS WHO ARE SUITABLY MOTIVATED AND IN POSSESSION OF NORMAL INTELLIGENCE AND WILLPOWER CAN RETURN TO A DESIRED OR ACCEPTABLE WEIGHT AND CAN KEEP IT IN THE LONG RUN BY FOLLOWING A GOOD DIET TOGETHER WITH ADEQUATE EDUCATIONAL AND BEHAVIOURAL SUPPORT.

Since even the most carefully planned diet will fail if patients lack the proper mind-set in following it. To ensure the success of the therapy the highest priority must be given to finding the MOTIVATIONS that led them to seek help.
APPEARANCE as a motivation is often given spontaneously by women, but it is present in all cases, even when patients feign complete indifference to this aspect of the problem: at the end of treatment all patients express their satisfaction at having returned to their right weight.
Males put on weight prevalently in the trunk, especially in the upper middle part of the abdomen; in females the regions affected are prevalently the trochanters and the lower central region of the abdomen. This distribution of fat in females may be particularly accentuated both owing to hereditary and familial, constitutional and neuroendocrine tendencies, as well as by the effect of tight clothing which hinders venous and lymphatic circulation. In such conditions, a slight overweight of just a few kilos is sufficient to create an unsightly effect. As we said previously, even in such cases of fairly limited overweight they are to be treated as a health problem and physicians, if competent, must apply their skills. The aesthetic defect in fact limits freedom of movement, the choice of clothes, the unruffled participation in social events (at the seaside, in sports activities, beauty contests and so on). Only when it cannot be corrected (lack of fatty tissue in other parts of the body) is it necessary to limit treatment to correcting the 'non-acceptance of one's body.
The fact that this is the reason why some patients decide to consult a physician represents in reality a good sign; without this, we would have to treat complicated cases of obesity. The best time to step in with secondary prevention is when the problem is to deal with a modest overweight condition which at the beginning is simply a question of appearance but which, if not properly treated, may lead to a case of true obesity or, even worse, of pathological maladjustment in eating habits.

HEALTH is another frequently mentioned motivation, sometimes by itself, but more often together with that of appearance. Dyslipidemia, diabetes, high blood pressure, heart diseases, bone and joint disturbances, stomach upset and chronic bronchitis represent, in decreasing order, the conditions that most frequently accompany the need for dieting. Directly originated by overweight, or aggravated by it, after their onset they too will have to be kept under control at all times, just as the problem of being overweight itself. This once again confirms the importance of primary prevention or secondary prevention as early as possible.
Since the result of treatment depends for the most part on the motivations supporting it, the dietician must strengthen those already in place as well as introducing new ones. Even when the health motivation appears to be sufficiently strong to ensure keeping to the diet (those who have had heart attacks, those awaiting surgery and so on), it is still important to remind the patient of the favourable effects of treatment on physical efficiency, clothing and movement, in other words, on the quality of life.

Our experience has demonstrated that in all patients a new, original motivation is stimulating and of great psychological help:

LOSING WEIGHT MEANS FEWER HUNGER PANGS IN THE FUTURE

This motivation, more than that of health and appearance, represents the strongest incentive in changing eating habits and introducing a new lifestyle. It stimulates patients to participate with greater conviction during the losing of weight and makes maintaining the result easier.
Whoever has, or has had, problems of overweight has no difficulty in accepting the truth and importance of this new motivation. With the progressive increase in weight, people not only realize that their health and appearance are affected, but also find it increasingly difficult to stop the fattening process. The continuous adaptation of the digestive tract and adaptation to the increasing volume of the body, the increase in sweating, having to move in a different way, the progressive exclusion of other interests not connected with food as well as the negative repercussions of a psychological nature all combine to aggravate the state of cibomania: it is the dog chasing its tail.
On the contrary, a gradual improvement in eating behaviour brought on by the diet and the new knowledge concerning the true nature of the illness and the reawakening of other interests in cultural and sports events and work favoured by the return to normal weight will make the attitude towards food easier and more gratifying.

SETTING UP THE DIET

The CUSTOMIZING of dietary rules represents a special and essential part of proper treatment. They can be decided only after a scrupulous investigation into patients' health records, their eating and exercise habits and a careful objective examination which, besides revealing past conditions of health and clinical examinations, also determines the state of blood formation and pressure, any signs of nutritional deficiencies (skin, mucous membranes) or other circumstances in any way connected with eating and, finally, supplies all the anthropometric data necessary in calculating metabolism (weight, height, evaluation of the panniculus adiposus and circumference). The weak point of the dietary investigation is certainly represented by evaluation of real energy expenditure since this datum, in itself fairly complex, is not based on verifiable objective data but on what patients report, often with no great accuracy.
Customizing the diet means first and foremost respecting patients' eating habits when they are correct and provide the proper and balanced assumption of the main elements, and avoiding the prescription of foods with which the patient is not acquainted or which are difficult to find. Even in the presence of specific dietary prescriptions, it is necessary to avoid drastically revolutionizing patients' eating habits so that the diet is not seen as an imposition, even a temporary one, while awaiting the return to freedom in the shortest possible time: otherwise it is better not even to begin the treatment.

The distribution of meals during the day is another totally individual habit and one that is not easy to change. Of course we must not consider a serious obstacle in the way of the treatment the fact that in not a few cases it is impossible to persuade patients to accept a rational distribution of meals into four (for example, breakfast 20%, lunch 35%, mid-afternoon snack 15% and supper 30%). But the distribution of meals varies from country to country depending on local traditions, working hours, climatic differences and other factors. Generally speaking, in Anglo Saxon countries the important meals are breakfast and supper, with lunch being little more than a snack. Sometimes it is even difficult to introduce breakfast when the person has not eaten breakfast for many years or it is no more than one or two coffees with or without sugar. Here again, there are cultural differences: it's difficult to imagine an Anglo Saxon skipping breakfast!
As concerns this, it is to be pointed out that the obese are not particularly afflicted by cibomania in the morning since the disturbance comes into play at the end of meals owing to lateness in the arrival of the sense of satiety. Even after a fairly abundant supper, patients often leave the table still hungry and only after the long and laborious processes of digestion and assimilation, with the consequent biochemical modifications at the blood and cerebral levels during the night do they find themselves on awakening free from the sensation of cibomania. However, keeping in mind during the diet that the risk of a fall in blood sugar or low blood pressure is far greater in the long period of fasting between the evening meal (which is no longer what it used to be) and lunch on the day after, it is fairly often possible to get patients to eat a light breakfast.

The total or partial lack of fruit and vegetables represents a fairly widespread bad eating habit. Sometimes when putting on weight people eat so much bread with first and main servings that they no longer have room for fruit and vegetables: but there is usually enough for the dessert!
The aversion to cooked or raw vegetables is particularly present in the very young. It must be explained to them that these foods, since they require a certain effort to digest, favour the sense of satiety; they are also rich in fibre and thus help to avoid constipation, which is a frequent side effect in low calorie diets (on eating less, the intestine becomes lazy). Finally, they provide large amounts of vitamins, mineral salts and oligoelements (antioxidants) and thus represent a powerful preventive weapon against the most serious diseases and keep the organism healthy and the appearance pleasant.
This message is usually favourably accepted by the youngest who, however, are more easily attracted by a variety of vegetables with two or three different colours obtained by chopping up and mixing different vegetables. The organism benefits from these changes in diet and thus easily adapts to them.

The erroneous ideas about eating that must be corrected are:
- avoid bread and pasta "which are fattening"
- avoid drinking water at mealtimes "so as not to assimilate";
- eat as much fruit as you like "since it's not fattening";
- follow dissociated diets (primitive people ate what they found and only that);
- be a strict vegetarianism, eat a raw-food diet and so on.

To make it easier to stick to the diet, here are some useful suggestions:
- the morning, weigh and put aside the bread, fruit and vegetables to eat during the day;
- eat meals slowly, enjoying the food without being afraid of putting on weight: the feeling of cibomania will greatly benefit from this;
- at the end of the meal, leave the table immediately, brush the teeth and do some work or a recreational activity that you have planned before the meal.

The setting up of the diet, even with personal software available, is time-consuming and must be done as soon as possible after examining patients so that all details and impressions not written down at the time concerning their participation, their expectations about the duration of the treatment, the reasons for any past failures in dieting, the prevalence of fat in certain areas and not others, the psychological conditions, any other treatments being followed, favourite foods and so on are not overlooked. All these elements are of great importance in evaluating cases at the time of deciding on how many calories to reduce and the choice and division of the foodstuffs.

CUTTING DOWN ON CALORIES is surely the most important and difficult stage in planning a diet, keeping in mind that one hundred calories more or less are not to be overlooked in making the treatment successful. Any low-calorie diet, if followed scrupulously, will lead to a loss of weight, but only those that are suitable from the standpoint of calories, well-balanced as concerns nutrients, sufficiently free in the choice of foods and how they are divided into meals and, within proper limits, respectful of patients' eating habits, will be followed with a spirit of tolerance and with the greatest educational effect, up to the reaching of the goal set at the beginning, even when many months or years are necessary, depending on how much weight is to be lost.
What is most important is not the number of pounds lost in a given period of time, but the final result of the treatment. To lose weight and then put it back on again in a short time is certainly worse than not having followed a diet. Such an experience is a boomerang psychologically (disillusionment, loss of faith in oneself, behavioural disturbances become chronic) and physically (loss of consistency of the subcutis, the seriousness of the metabolic overload which is particularly important in the fattening stage).
The proper number of calories and the composition of the diet as well as the active and, to a certain extent, vexatious participation of patients surely represent the most important elements in reaching the goal set and the long-term maintenance of the results.
Only a careful and painstaking computerized processing of all the data collected will produce the proper calorie intake and composition of the diet.
It is thus surprising to see the nonchalance with which researchers or leading specialists in internal diseases sometimes decide to reduce calories, for example simply by prescribing 1200 Kcal for women and 1500 for men without taking into account the individual's energy consumption, height, weight, constitution, age or specific individual needs. Perhaps this explains why in national and international congresses the yo-yo effect and the progressive increase in dietary maladjustments are constantly mentioned and the hypothesis is advanced that dieting as a cure for obesity is not only useless but even dangerous.
Just any diet cannot but be risky; the only useful one is the proper one: one thing is to prescribe, something else again is to prescribe the right thing! In our experience the number of calories in a diet may vary from 1100 to 2300 Kcal; in exceptional cases it may be less than 1100 and rarely above 2300. In other regions, where on the average people are taller than Sardinians, an even higher number of calories may be required.

In our over forty years of experience, since we have never felt the need to apply other methods, we have always calculated BASAL METABOLISM by means of the following formula:
BM = 71.84 * ISW^ .425 * H^ .725 / 10000 * 24 * (Kcal/m2/h)
By adding 12 Kcal per kilo of excess weight, we have the theoretical basal metabolism compared to real weight.

Apart from BM, among the elements that make up TOTAL METABOLISM (TM), the specific dynamic action (SDA) of foods or food thermogenesis and physical activity, as well as MOTOR BEHAVIOUR, which explains differences in energy expenditure in individuals who are similar in other parameters, must be taken into consideration: it consists of the different physical or motor attitudes assumed when seated or standing with no other physical activity. There are those who remain seated without moving, with the arms at the sides or with elbows on the table supporting the head, the hands under the chin, and there are those who have difficulty in remaining seated for a long time or who cross the legs with the foot in constant movement or who rock from side to side on the chair. During the examination this aspect of energy consumption must be estimated and then included in the calculations.
The motor investigation must be performed scrupulously, considering a typical working day starting from the time patients wake up to when they go to bed, establishing exactly how many hours are spent standing and sitting, with or without other physical activity, and how many hours are spent in bed (including afternoon naps). The complexity of the investigation derives mostly from the fact that each time it is necessary to consider different activities, such as housework, exercising, walks and so on, activities that usually vary from day to day or are performed only from time to time. Nor can we neglect the intensity and the way in which the activities are performed. As can be seen, the calculation of energy expenditure is objectively the weak point in a dietary survey but, considering its importance, it deserves the greatest attention and is worth all the time it takes to arrive at the most reliable solution possible.

To calculate TM:
- from BM we subtract: hours of sleep (HSl) * K * .07 (in the hours of sleep the metabolism slows down by approximately 7%);
- we add hours seated: (Hse) * K * SI, where SI is an index that varies from .30 to .45, depending on motor behaviour;
- we add hours standing: (HSt) * K * StI, where StI varies from .45 to .60 depending on motor behaviour;
- we add hours of activity: (HA) * K * AI, where AI represents the metabolic index of the activity performed or the weighted average of different indices if, as is often the case, more than one activity is performed.
Thus we have the following formula for TM:
TM = BM - HSl * K * .07 + HSe * K * SI + HSt * K * StI + HA * K * AI

The number of calories to be eliminated must be based on the many different aspects of the re-educational treatment and, most important of all, on the acceptability of the diet. It is important not to calculate calories only in an absolute sense, but also, and most of all, in terms of a percentage of overall calorie intake. In fact, the acceptability of the diet does not depend on the calories subtracted, but on the percentage they represent in comparison to total metabolism (not to basal metabolism, as is found in some commercial programs!). For example, if a decrease of 800 Kcal can be considered modest, or at least acceptable, in the case of a total metabolism of 3200 Kcal (25%), it would be quite drastic and hardly acceptable in the long run if applied to the case of a metabolism of 1600 Kcal (50%). Theoretically, and with all other things being equal, such a decrease could be tolerated if in the latter case the decrease were only 400 Kcal.
In our professional experience the number of calories subtracted varies from 10-15% to 25-35%, but in the great majority of cases it is between 25 and 32%. This is indeed the best solution in planning an acceptable diet, one that combines health and appearance, the re-educational effect and finally sufficient gratification deriving from the slimming process.
In children and the elderly for obvious reasons it is preferable never to go exceed a calorie reduction of 25% and, in preadolescence and at puberty a decrease of even less (8-20%) is preferable since the mere arrest of the weight-gaining process is to be considered positive while awaiting the increase in height to re-create the proper body equilibrium.

In cases of psychological disturbances, especially depression, it is a good idea to persuade patients to accept the results of a not overly strict diet (15-20%) so as not to risk adding other reasons for stress. However, if patients express a desire to undergo a faster weight loss and are willing to accept a more rigorous diet, it is possible to plan a reduction of even 30%, with periodic controls every 15 to 20 days instead of monthly. Most patients of this kind respond quite well to treatment and receive immediate benefits from the physical and psychological standpoints. In some cases there is actually an actual remission of symptoms, to such an extent that the psychiatrist may reduce or sometimes even suspend pharmacological treatment. In many cases such patients put on weight owing to the administration of sedatives and antidepressants (triggering factor no. 3), while in other cases the psychiatric disturbances were the causes of the weight problem and the subsequent failure of attempts to return to normal weight.

However, there are some particularly difficult situations in which the desire to return to normal weight is not accompanied by even the slightest effort of the will. Generally speaking, these are patients treated at different times with anorexic drugs that act on the central nervous system, especially those of the amphetamine type which, more than other drugs, have a totally negative effect on eating behaviour, besides the inevitable cardiovascular and psychological repercussions. At the end of each cycle there is necessarily a further aggravation of the cibomania condition and a progressive weakening of the will, to the point of its complete disappearance. The correction of bad eating habits, which is essential in maintaining the results of dieting, is ensured, as we have said, only with the arduous participation of the patient. There are no alternatives.
In these cases, the philosophy of carpe diem ('well, now I'm just going to enjoy a snack? maybe on Monday I'll go back to the diet?') will always get the upper hand over planning for the future (a better quality of life, better health, having fewer pangs of hunger). The physician must be content with providing, together with the necessary information on the question of eating, strong psychological support in getting patients to accept their bodies and helping them through a difficult moment. His/her work will be truly praiseworthy if it is successful only in stopping the fattening process.

Another condition in which a modest decrease in calorie intake (10-20%) is required is represented by the tendency for fat to accumulate in certain areas of the body, in women typically at the top of the thigh and at the trochanters. On the other hand, a very strict diet, one that forces the metabolism to require an excessive amount of body fat, will make it less selective as concerns the part of the body from which to take it, and it may even come more from the parts that are better permeated and already contain less fat. The greater the disproportion in the distribution of fat, the less severe the diet must be, and it must also be accompanied by hygienic measures such as a suitable increase in physical activity and elimination of elastic and tight clothing: the results will come and they will often be far better than expected. However, when the folds of fat in the other parts of the body are below normal, it is difficult to obtain appreciable results without running risks to health and appearance. In these cases, besides the hygienic measures the patient can be advised to go to a massotherapist to activate the circulation.

Surgery for the removal of fat from certain areas (lipectomy, liposuction) in our experience can lead to a worsening of these imperfections. In television programmes, plastic surgeons show us photos taken before and after the operation and, in reality, the effect is quite convincing, but very rarely do they show the results after a few years from the operation. In fact, in procedures of this kind, together with the fat, the fat cells that contain it are also removed and therefore the unhindered process of gaining weight (nobody has explained to the patient how to stop this from happening) will soon emphasize the unpleasantly sharp difference between the area treated, which no longer has fat cells, and the adjoining areas. The panniculus adiposus, having to substitute for the surgically removed fat cells, will quickly flourish. The number of patients who present such imperfections (the cauliflower effect or boot at the trochanters, the turtle effect of the abdomen), which probably can no longer be treated, is continually on the increase.
The favourable results of surgical treatment will last as long as patients maintain their proper weight, and this can to some extent be made possible only by following a diet and understanding the reasons why it is necessary.

There are conditions in which it is possible and necessary to prescribe a more severe cutback on calories, but never beyond 35-40% of total energy expenditure.
Cases of patients whose loss of weight was prescribed by physicians (orthopedic surgeons and heart surgeons) in the pre-operative period are not infrequent. Other situations that require a rapid loss of weight are when awaiting a selective medical examination or before interviews for the hiring of personnel for particular jobs, marriage in the near future and so on. Here the persons involved are perfectly willing to follow the treatment; despite this, however, it is advisable in these cases to plan the periodic checkups at intervals of no more than twenty days.
Generally speaking, a sharp reduction in calorie intake is better tolerated in the very obese compared to those who are only slightly overweight, since the latter may suffer from sharp weight decreases, not only from the viewpoint of health (low blood pressure, anaemia, asthenia, insomnia), but also from that of appearance, with unpleasant effects on the face, breast and sometimes even on the body profile, most likely owing to a greater involvement of muscle tissue in the loss of weight.
In all cases it is best to keep in mind that the re-educational effect of the treatment is all the greater the lesser is the restriction in the number of calories; in fact, dietary re-education cannot neglect the completeness of the diet, both quantitatively and qualitatively. For this reason, the theoretical basal metabolism can be taken as the limit not to be overcome except in cases of particular urgency or in those that present a very slight difference between total metabolism and basal metabolism (hospitalized patients, serious motor deficiencies and so on).

THE WAY FOODS ARE EATEN is another characterizing aspect of cibomania. With few exceptions, those affected by cibomania eat their meals quickly and in a disorderly way, as if eating slowing and enjoying the food increased the risk of getting fat (an antagonistic relationship with food). The pleasure of eating decreases and slowly but surely the mouth becomes nothing more than the stomach?s hopper!
Waiting at least thirty seconds before beginning to eat the food on the table may facilitate a return to the physiological times of chewing, tasting, digesting and absorbing which are those of normal persons. Participating in the conversation, enjoying the food and the company and no longer worrying about filling the stomach, putting down knife and fork every so often, keeping in mind and following the diet prescribed for each meal will help to better observe how much is eaten and thus to prepare the nervous centres to send a faster signal of the sense of satiety.

THE DAILY DIVISION OF CALORIES in the three main food classes - proteins, glucides and fats - is also an important part of nutritional re-education. The unlimited availability of foods does not in fact eliminate the risk of malnutrition caused by too much (sugars, proteins, alcoholic beverages, sodium etc.) or not enough (vitamin A, calcium, iron and so on). This is even more important when one is following a diet.
As is known, the following division of calories: 12-15% proteins, 25-30% lipids and 55-60% glucides is universally accepted. This rule is often neglected in diets prescribed by persons who are not competent and who sometimes even totally eliminate one of these in favour of the others. This imbalance, together with a too drastic reduction in calorie intake, besides overlooking the re-educational function necessary in maintaining the results in the long term, also represents the most frequent cause of unpleasant and sometimes quite serious consequences to the health and appearance, depending on the duration and severity of the metabolic imbalance..
However, in our opinion, if there are no particular contraindications, the treatment may benefit from a higher proportion of proteins, even up to 18-20% of overall calorie intake. And in no case is it advisable to go below one gram per kilo of body weight: this avoids the involvement of muscle tissue in catabolic processes. A greater protein intake is also suggested by two more considerations: protein calories are widely spread by food thermogenesis (about 25% against 3-5% of lipids and 5-10% of carbohydrates); proteins in general, and those of meat in particular, favour the onset of the sense of satiety, thus making the diet more acceptable.

Finally, patients must learn to differentiate foods also by their caloric density, distinguishing for example fennel or zucchini from potatoes and peas, watermelons from bananas or figs, a lean minute steak from sausages. The diet must therefore provide the widest possible choice of foods in the different homogeneous groups according to their composition, without eliminating those that patients normally eat so long as they are compatible with healthy eating habits.

(See also CIBOMANIA - Ettore Gasperini Editore - Cagliari 1997)

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