Obesity Versus Overweight

Weight measurements do not necessarily give good estimates of body fatness or obesity. The height-weight tables used to decide whether or not you are overweight merely list the average weights for people of given height, age, and sex who were sold life insurance policies 50 to 60 years ago. The measurements were made "as ordinarily clothed" - in the style of 1895! No judgments about obesity or "frame" size or type were recorded then or later. Modern tables that list weights according to body frame size or skeletal type - "small" or "light", "medium", "large" or "heavy" - are pure guesswork. And no advice is given about measuring "frame size" for the good reason that the life insurance people not only did not measure it themselves; they have never indicated that they have any idea as to how to do it.

These, then, are the only standards by which "overweight" is judged. Do they apply today? Do they apply to you? And what have they to do with actual body fatness, the result of overeating? If you are 3 stones overweight by the tables, you are probably overfat as well - but you do not need to weigh yourself to discover it. You can decide better than the scales simply by looking at yourself, unclothed, and by pinching up your skin here and there. What you pinch in a skin fold is pretty much pure fat, so be guided therefrom! This is an old and reliable method of judging the fatness of animals and was used in estimating the fatness of slaves for thousands of years.

With special calipers the actual thickness of the layer of fat under the skin can be measured. About half of the total fat of the human body is right under the skin where it can be got at, at least in certain parts of the body. A good place to choose for estimation is the skin of the back of the arm about half-way between the elbow and the tip of the shoulder. Another good spot is on the back over the tip of the scapula (shoulder blade), but this is not so easily accessible. Table 3 gives arm skin fold values corresponding roughly to "very thin" and to "very fat". For a man, an arm skin fold much over half an inch thick is too fat; for a woman in the twenties an inch is too much, while for women of 40 to 60 we might, reluctantly, approve of a little more, say up to 11 inches. It should be noted that the distribution of fat differs in individuals and some people with thin arm skin folds are too fat in the middle and lower part of the body.

JUDGING OBESITY Judging relative obesity from the thickness of the skin fold over the back of the upper arm, midway between tips of elbow and shoulder, as measured with calipers under pressure of 10 grammes per square millimetre. Values are in millimetres (1 inch = 25.4 mm ). Note that these measurements are double the thickness of the skin and subcutaneous fat and that the true skin is only about 1 millimetre thick.

Very Thin, Less than:

„	„	30-39	5	If	17	„
„	„	40-49	6	„	19	„
„	„	50-59	6	„	20	„
			8	„	23	„
		„ 30-39	9		30	„
		„ 40-49	9		35	„
2)		„ 50-59.	8	„	33	„

From skin fold and other true fat measurements it is found that the ordinary body weight conceals the extent of your increasing fatness as you grow older. If you still weigh what you did when you were in your teens, do not boast that you are as lean as ever; you have probably exchanged a good deal of muscle for fat unless you have kept in unusually good shape in the intervening years. Sedentary people average more fat per pound of weight than do people who do physical work. Many an office worker of "normal" weight is overly fat.

Changes in the body weight are very revealing. Your body weight may be a poor measure of absolute fatness, but it is an excellent way of following the progress of your reducing programme as well as of finding where you are, relatively, from month to month and year to year.

Causes of Obesity Basically, all obesity is caused by eating more than your energy expenditure warrants. You may get fat because you eat more and more without changing your activity, or because you maintain the same old diet but reduce your activity.

In most cases of the common or garden variety of obesity the history runs to a common pattern. The young man or woman, who perhaps was never inclined to be a bean pole anyway, leaves school, gets married, takes a steady job, stops the exuberant activity of youth, and gradually becomes more and more sedentary and economical of muscular effort. But the change in the diet does not keep pace with the changed energy output. Greater economic freedom means more luxurious meals and a change to more and more fat in the diet. Bread is reduced, meaning a loss of a couple of hundred calories a day, but the meat portion rises so fat calories are substituted for carbohydrate.

Thus from age 25, when the last bit of "growth" (really only the final calcification of a few bones) has stopped, to age 35, there may be a gain of 20 or 25 pounds. By age 45 the weight is up 3 to 3- stones since student days and the problem of obesity is obvious. If this is your story you are an easy case, and a little understanding plus a good deal of determination will put and keep you more or less in line, perhaps 10 or 15 pounds heavier than you ought to be, but not a real problem. The person who was already grossly overweight at age 18 and who got fatter and fatter with the passage of the years is a tougher case but still salvageable.

Everyone must know by now that neither endocrine disorders nor peculiarities in the absorption of food are primarily involved in obesity. Some few unfortunate persons do have endocrine or neurological disorders that make them constantly hungry or insensitive to a filled stomach, but these are rare, repeat, rare indeed.

As for "super-efficient" digestion and absorption, this is a hoary myth. Everyone, or almost everyone, digests and absorbs foods at around 95 per cent completeness and efficiency, and no one does any better. The only direction of abnormality is poor efficiency, a situation that exists in a few people with gastro-intestinal disorders and who are usually full of complaints of diarrhoea, weakness, and the inability to maintain weight.

The cause of obesity is too much food, too little exercise, or both. So we find ourselves asking about some obese patients why they eat so much, while with others the question is why they are so remarkably indolent. The remainder, perhaps the majority, are those who both eat too well and exercise too little.

To some extent these tendencies are inherited, but the rule of "like father, like son" is not always simply an expression of genetic inheritance. Custom within the family plays a considerable role in many cases. It is not surprising that the normal child, in a household where others eat a great deal and who is served large portions, emulates his parents. Social custom operates on a population as well as on a family scale. If a population is characterized by a dietary pattern of an endless supply of rich, fatty food the result can be predicted: frequent cases of obesity. Similarly, habits of physical activity can be developed as well as being inborn.

The rage to reduce weight (or fatness) is a phenomenon of our time and place. Abhorrence of obesity is not instinctive and universal. In many societies, now and in the past, fatness is admired as a sign of health and wealth. Not many years ago American life insurance companies charged extra premiums to the thin, not to the fat, person as they do now. Among the Bantu in South Africa we discovered that a native doctor should be fat, grotesquely fat if possible, if he is to be sought after in his profession. His business card will be adorned with a personal photograph, naked from the waist up, to show that he is healthy and economically successful.

In Great Britain, America, and among the more prosperous segments of society in most populations of the world, to be fat is just too easy in the midst of the plethora of rich, fatty food in which we wallow. It is said that a third of the adults in the United States are trying to reduce, another third ought to do so, and the rest of them are only saved by dyspepsia and ulcers. The only consolation is the fact that the suicide rate is lower among fat people than in the general population.

What does this mean? The monstrously fat person usually is a welter of emotional problems, but the frequency of obesity in the United States does not, we think, reflect a national neurosis there. The high incidence of ordinary obesity is a natural result of an over-rich and fat dietary pattern in the traditional cultural dream of luxury, of the circumstance of having all of this kind of food anyone could eat within the average economic reach, and of the technological triumph of finding ways to keep society and industry running merrily with almost no one doing much more than pushing buttons.

"Who needs muscles?" demanded an enterprising advertisement a couple of years ago. The ingenious pursuit of non-exertion is the route to the least attractive form of obesity, with flabby muscles, rolls of fat, and prolapsed bellies. If such people are prone to disease of the heart muscle as well as atrophy of the voluntary muscles, it may be asked how much of this is due to calorie imbalance, how much to the long-time effect of the feeble circulation that goes with avoidance of effort.

Psychological Aspects of Obesity and Reducing Psychological factors are involved in most cases of gross obesity. This does not necessarily mean any serious emotional problem. People often overeat from boredom and in a subconscious substitution of eating pleasure for other satisfactions. Some men overeat to express appreciation of their wives' efforts in the kitchen. Some women overeat for the same reason - having prepared a good meal they feel they ought to compliment their own cooking - or they set an example to encourage their children to "clean the plate". Much overeating is an automatic result of the fact that entertaining and being entertained too often centres on eating because people cannot think of other things to do.

Many people overeat because it often relieves tensions and promotes sleep. It is difficult to concentrate on your worries while eating a good meal, and a full stomach has a tranquillizing and soporific effect. Some overeating is promoted by the subconscious mental association between eating and health. We all know that sick people often cannot eat and we often use the expression, "You are not eating. Don't you feel well?" Years of childhood conditioning frequently have their effect on the attitude towards eating later in life. Hidden in memory is the echo of the admonition, "Eat up. You want to be strong, don't you? You don't want to be ill, do you? Eat up !"

All these are common psychological reasons why people get fat. More bizarre and warped emotional bases are not as common, we think, as some of the psychiatrists would have us believe. Cases are reported of women whose obesity, suddenly developing after marriage or childbirth, is related to a vague sense that if they stay fat they will not become pregnant or, in other cases, the woman eats "to restore the part of me I lost". More often, we believe, the woman gets fat after delivery because she simply continues habits acquired in pregnancy, eating much and exercising little. Some men overeat because they feel that somehow they are more consequential when they are big and bulky. Such causes of overeating may qualify as neuroses but they are not alarming.

Of course serious mental disease is generally identified with abnormal behaviour, and obsessive eating is an abnormal behaviour. But true psychosis seldom has this expression. The opposite reaction is the rule; refusal to eat and excessive thinness are seen far more often than obesity in mental hospitals. Overeating is sometimes a protection for emotionally unbalanced people who otherwise would exhibit other and more disturbing abnormalities.

This latter situation is sometimes revealed when a reducing diet is instituted. Occasionally the reducer may become greatly depressed and withdrawn, and may substitute fantasy for unfilled emotional needs formerly covered in part by the less dangerous substitution of food. In the worst cases suicidal tendencies may appear.

All of this sounds alarming and suggests that the obese person should be turned over to the psychiatrist. In a few cases this is desirable, but the great majority of would-be reducers do not need, and are probably better off without, such attention. Every reducer has psychological problems to overcome (who doesn't?), but if these are recognized and understood, both successful weight loss and maintenance or improvement of emotional stability can be hoped for. The family doctor can usually help a great deal.

So You are Going to Reduce The first step towards successful reducing is a clear realization as to why you want to reduce, coupled with a firm resolution to go through what may be an ordeal at times. The question should be asked, why and how did you get so fat? If you were not always fat, you must have changed your manner of life, diet or exercise, or both, so as to put you in your present state. Did you begin to eat different foods, have more frequent snacks, take larger portions? Did you slacken off on exercise, give up sports, take to using the car when you might readily have walked?

Your problem is to reverse the process that made you fat, and a real change in your mode of life will be involved. Successful reducing is not simply a question of eating a special diet for a few weeks or months. You want to lose your excess fat and not regain it, so when you start on your programme you should be prepared to give up some of your former habits forever. You must be psychologically ready for successful reducing, so think it through before you get involved in a half-hearted attempt which may do your self-esteem and will power real harm if you fail.

The next chapter, Scientific Reducing, covers the problem of choosing a reducing diet and all the mechanics of reducing. Here we are concerned with generalities and the crucial question of psychological understanding. You can reduce and keep yourself from getting fat again, but your will power needs help.

A chart of your actual weight each week and the target weights for future weeks is a goad and a challenge besides assuring that you do not let yourself slide off into failure because you lose track of how you are doing. Going to your doctor is helpful, not only for the good advice he can give, but even more so because you will have to answer his questions. Have a good heart-to-heart consultation, plus a physical examination, first, and then make a regular series of appointments for the future.

Tell your family what you are going to do and enlist their help. They must know that their determination to help may be under a strain if, as you may, you begin to deprecate the whole idea or become cross and morose. They should be sympathetic but also tough with you. During a rigid reducing programme there are apt to be times when the dispositions of everyone involved are not all sweetness and light.

Reinforcement of your determination may be gained by joining a group of fellow reducers who meet regularly with a little weighing-in ceremony. In America, such clubs - "Fatties Anonymous" is a favourite name - exist in many places. In one city several hundred women are pledged to wear a special ornament whenever they backslide and gain weight. The ornament is in the form of a pink pig!

A "crash" programme of reducing by eating almost nothing for a time is psychologically easier for some people. The use of very strange diets also appeals by being dramatic and somehow seeming to enhance the importance of the dieter and his plight. Ego satisfaction is always important. Such programmes may be used as a part of the long-term plan, but permanent success must include a good maintenance plan of diet and exercise.

We repeat, you can reduce and keep your new figure. This may not solve all your personal problems, but you will certainly be more attractive and you will feel better. And with the diets we advocate we think your prospects of staying out of the cardiac clinic will be improved.

Exercise or Diet?

It is fashionable to deprecate exercise as a means of reducing, the argument being that an hour of vigorous exercise is only the equivalent of a few hundred calories and when you have finished your appetite is stimulated for more calories than you have burned up. We disagree. You will feel better, emotionally and physically, than if you try to do the whole reducing job by dietary reduction alone. Besides, you will have less trouble with sagging skin where the fat used to be.

The advice of Hippocrates, some 2,400 years old, is not bad. "Fat people who want to reduce should take exercise on an empty stomach and sit down to table while still out of breath." The appetite stimulation of exercise does not go to work at once and the immediate effect of vigorous exercise is actually a depressant to the appetite.

Careful studies of the habitual diets of fat people show that in most cases the food intake is not really very large. The trouble is often mainly on the energy expenditure side, too little physical activity to burn up a normal or even a subnormal diet. We have observed reducing with and without increased exercise, and the results are impressive. With obese university students we provided a reducing diet of 1,200 calories daily, and for some of them we added a programme of walking for two hours a day at 3 2 miles per hour on a slight incline. The students who had no special exercise programme lost an average of three pounds a week; those who walked averaged a loss of five pounds a week, improved their fitness, and suffered no more from hunger than did the non-exercisers.

Almost any form of exercise is useful, but very short periods, even if the exercise is violent, do not count for many calories. A few bends and press-ups in the morning will help to keep you limber but do not justify an extra slice of toast for breakfast. Of course, if you have long been inactive you should not attempt too ambitious an exercise programme at the start. Exercise to pleasant fatigue, not to exhaustion and breathlessness. But increase your exercise as you get stronger.