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About the Author
Danny Roth was born in 1946 and educated at Latymer Upper and Reading University, graduating in Applied Physical Sciences before training as an actuary with the Prudential Assurance Company. As teacher and coach, he has published more than twenty books on bridge as well as a play on the 1936 Abdication crisis. He has studied diet, nutrition and obesity over a number of years and this book is the product of his researches. He has also contributed mathematical brain teasers to newspapers as well as acting as editor and proof-reader for magazines. He is married with a daughter and son.
THAT FOUR-LETTER WORD:
A four-section tome discussing every aspect of diet, nutrition and obesity NUTRIENTS, SOURCES FUNCTIONS DEFICENCIES SUPERFLUITIES FOOD TYPES NUTRIENTS SUPPLIED ADDITIVES PREPARATION BODY FUNCTIONS, THE ALIMENTARY CANAL BALANCE SYSTEMS EXERCISE FAT DIETS, TIMESCALE CRITERIA COMPARISONS CONCLUSIONS
To the memory of my parents who sadly passed away long before their time.
Danny Roth, B.Sc. A.I.A.
THAT FOUR-LETTER WORD:
Copyright © Danny Roth The right of Danny Roth to be identified as author of this work has been asserted by him in accordance with section 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publishers. Any person who commits any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. A CIP catalogue record for this title is available from the British Library.
www.austinmacauley.com First Published (2013) Austin Macauley Publishers Ltd. 25 Canada Square Canary Wharf London E14 5LB
Printed & Bound in Great Britain
Acknowledgments My thanks to Dr. George Stein of Bromley, Kent, the staff of the Rowett Research Institute in Aberdeen, Scotland and to Dr. John Foreyt of Behavioural Medicine Research Centre, Houston, Texas USA. for their help in checking the accuracy of the book.
ith statistics, you can prove absolutely anything!
So true, when you have to face the fact that life is based on probability rather than on absolute dogma. You need do no more than look through the window at the block of flats across the road a veritable hive of activity outside! There is a funeral car, a postman and two other young men chatting. There are four flats inside and, in number one, lives Mr. Al Coguzzle. He has spent his whole life doing little but eating cakes and chocolates to a degree which would have made Billy Bunter‟s habits seem monasti c, and downing beer, wines and spirits by the gallon. Exercise? What‟s that? His only exercise has been walking five yards to his car to take him to the local pub and/or restaurant each day. What is the result? A thoroughly deserved early death? Not at all! He is a hundred today and the postman has arrived with the royal telegram. In number two, lives, I am sorry, lived Mr. Discipline. Throughout his life, he has observed impeccable diet and been a religious devotee to physical fitness, taking regular exercise and abstaining from alcohol, smoke and other bad habits. His reward? Another royal telegram? No such luck. He has died from a heart attack brought on for no apparent reason in his late forties and the funeral car has come to pick him up. Two young men live at numbers three and four. Well, need any more be said? These two cases only go to show that the best way to a long and far more enjoyable life is to ignore the medical „experts‟ and submit to your own desires. There‟s no justice in this world anyway. Indeed, there isn‟t until, instead of looking at a couple of individual cases, we consider people in large numbers. Let us, instead of looking at those two men, consider one hundred thousand Mr. Coguzzles and another one hundred thousand Mr. Disciplines. Only now will the truth manifest itself. By far the vast majority of the Mr. Coguzzles, unfit and overweight, will earn their just rewards with early demises from heart attacks and liver disorders. Only very few will survive to seventy and beyond but there will always be the odd one who manages to swim against the furious tide and make it to three figures. Against this, among the Mr. Disciplines, the vast majority will be rewarded with long, healthy and productive lives, satisfying to themselves and, perhaps more important, to others. Only a few will suffer early deaths and there will again be the odd one who beats the tide and, possibly because of a genetic disorder, will die at a tragically early age. You can now see the point. By taking good care of yourself in respect of diet, nutrition and physical fitness, you can increase your life expectancy by many years but there is, even barring accidents, no guarantee. It is purely a matter of playing with the odds. In the chapters which follow, we shall be looking in some detail at the various aspects of diet, nutrition and general physical health and try to form conclusions as to how best to improve our well-being. We shall also try to understand the mass of advice and products which have flooded one of the world‟s biggest (or more appropriately, fattest!) markets the slimming industry probably the one and only multi-million pound industry in which the word „pound‟ has both meanings! It is well known that a little knowledge is a dangerous thing and it isn‟t until you start studying in depth that you realise the extent of your ignorance. Diet, nutrition and obesity (which includes a consideration of underweight) together form an enormous subject and it is no wonder that countless books already take up sizeable space in our libraries and bookshops. However, it is difficult to find one major reference book which deals with the problems purely by concentrating on the principles and their understanding. Still less, as we are
considering a medical subject, do there appear to be any books which explain everything in the simple language of the man in the street who is understandably ignorant of Latin and Greek derivatives incomprehensible words which run to ten or more letters. Medicine has its own language and it is of little use to talk in that medium to those who do not understand. Consequently, in this book, emphasis will be laid not only on the basic facts but on understanding them. Every medical term will be clearly defined and areas where there is still scope for opinion will be examined in detail and conclusions will be formed on the evidence of medical research available so far. Indeed, medicine is far from being a finished science. Until such time as everyone lives in marvellous health and happiness forever, or at least until the heart gives out (bearing in mind that a human being‟s life is a chemical reaction which is not designed to go on indefinitely), the chances are that it never will be. To digress for a moment, the study of the brain, for example, is still in its infancy. However, a fair amount on our subject is known in detail and there are a large number of guidelines which can be laid down with some confidence. First, we shall consider body weight in itself and decide how much each of us ought to be weighing and the physical and psychological consequences of serious diversions from that figure. It is here that our first serious conflict with standard diet literature will arise. Virtually every book on weight-related problems will show a table, usually copied from a life-assurance company‟s figures, of „ideal‟ weights. These will usually be tabulated considering a number of factors, primarily sex, height and age. Let‟s try an example those two young men we mentioned earlier who live at numbers three and four friends of ours, Fred and John. Both are of English stock, both thirty-three, both just under six feet tall. Fred weighs two hundred pounds, i.e. a little over fourteen stone; John tips the scales at one hundred and seventy four, just under twelve-and-a-half. Come on put your money down! Are they: a) both overweight, b) Fred over, John under, c) both under, d) Fred just right, John well under, e) John just right, Fred well over? It is worth a heavy bet that not a single reader will pick the correct answer from the above possibilities in fact none of them are right! The truth is that John is badly overweight but Fred is slightly underweight. Why this is will be explained later and it will then be understood why there is no table of „ideal‟ weights in this book simply because it is impossible to generalise. Vague averages, which is all those published tables are, offer little more than a guide. We shall then detail the „nutrients‟ the chemicals with which the body needs to be fed daily and their food sources and also consider what the body does not need. We shall see the consequences of eating too little of the right things and/or too much of the wrong and learn that quality matters far more than quantity. Again, scores of examples in diet literature insist that overweight is „all about calories‟ (a measure of energy), and give detailed tables of how many such calories every morsel of food contains. While there is some truth in this, its importance is probably of less value than the paper on which it is printed. However, we must acknowledge that the body regularly eats, drinks and excretes and we shall express the functions of the body and its various parts in a series of verbal „balance sheets‟, but it will be noted that figures are conspicuously absent.
Having consumed our daily ration, we must then consider what happens to it inside the body. This is crucial to the understanding of why we should or should not eat or drink certain foods. Under the heading of „Body Functions‟, we shall look at diseases arising from poor dieting and how to prevent them. Curing them is also a huge subject but is outside the scope of this book. It is best to avoid the suffering in the first place, anyway. In conjunction with the body‟s handling of food intake, we must next consider what might be called „eating adverbs‟: time, place and manner. The time element, particularly, demands extensive attention as life is a series of cycles the day, the season, the year etc. as well as distinct periods in the lifespan: childhood, adolescence, reproductive, middle and old age. We shall see that these are far more important than many people realise and that ignorance of a few basic rules has led to many unnecessary cases of overweight and consequent disorders. This conveniently leads us on to the general subject of personal habits. On the positive side, there is exercise; on the negative, habits like drinking and smoking. We shall consider in detail the effects these have on the body and why it is worthwhile to pursue or abstain where appropriate. Our next consideration is that we live in a world comprising a wide variety of people, firstly divided into the two sexes and also into various ethnic or racial groups, each with its own religious convictions practised with varying degrees of adherence. On top of this, climate varies considerably as a function of geography. This, in turn, affects the overall availability of certain foods and we also have to consider the marked variation in affluence/poverty which has a profound effect on diet. It may well be that, in his famous Gettysburg address, the then US President, Abraham Lincoln, solemnly pronounced that „. . . every man was born equal . . .‟ What he was trying to say was that: „Every man should be treated as equal,‟ which is a very different matter. We shall see that, in considering food intake and excretion, the sexes and races are very different. The varying styles of cooking, without which life would surely be very boring, are also relevant to our discussion. Finally, we shall examine in some detail the diets and other „cures‟ for overweight which are currently available on the market. The major problem here is to weed out those which are pure „fads‟ or „cons‟. The perpetrators have simply become very rich by taking full advantage of the desperation of many to lose weight at all costs. That will leave us with those which offer a genuine cure for obesity. The problem is a difficult one if only because virtually all products, even the complete fads, have had their success stories and, at best, it has taken considerable time to prove the fakes beyond reasonable doubt. This is because different people react differently to the various cures. Again it goes back to the question of probability rather than certainty. One of the saddest aspects of diet and nutrition is that, up to 1986, the subject formed a tiny proportion of medical studies. Out of two thousand or more hours of training, medical students would have no more than one afternoon devoted to our subject and, consequently, their knowledge and understanding of it was, at that time, insufficient. Doctors are therefore hardly in a position to either recommend or deprecate action against overweight, much beyond saying that: „. . . the only way to lose weight is to eat less.‟ We shall see that, while this is all too true, there is far more to it. Above all, it is important to realise that, if you want to lose weight and maintain your new healthier weight permanently, we are talking about a complete refurbishing of the body. This takes time weeks, if not months or even years and also demands a general and permanent change of habits. The body is not equipped to realign itself in any other way. The first rule is, therefore, that any „quick‟ cure for overweight is worse than useless and should be ruled out except under strict medical supervision in desperate cases of severe obesity.
We may now set out our table of contents. It has to be noted that there are obvious overlaps between the various subjects; for example, a well-exercised body will be less prone to certain diseases, although not all. Furthermore, nutrition draws on other sciences: chemistry, biochemistry, physiology, agriculture and medicine all play their part. In addition, it has already been implied that environmental considerations like sociology, economics, geography, politics, religion and psychology are relevant to eating habits.
CHAPTER 1 The concepts of overweight and underweight .......................................... 14 SECTION A: NUTRIENTS ........................................................................................ 26
2 3 4 5 6 7 8 9 10 11 12 Proteins..................................................... Error! Bookmark not defined. Carbohydrates .......................................... Error! Bookmark not defined. Lipids ....................................................... Error! Bookmark not defined. Vitamins .................................................... Error! Bookmark not defined. Vitamin A .................................................. Error! Bookmark not defined. Vitamin B-Group ...................................... Error! Bookmark not defined. Vitamin C and the Bioflavonoids ............ Error! Bookmark not defined.9 Vitamin D (Calciferol, E & K..................................................................116 Minerals .................................................. Error! Bookmark not defined.6 Water ....................................................... Error! Bookmark not defined.5 Fibre ......................................................... Error! Bookmark not defined.
SECTION B: FOODS .................................................. Error! Bookmark not defined. 13 Introduction ............................................. Error! Bookmark not defined. 14 Meat ...................................................... Error! Bookmark not defined.2 15 Fish and other seafood ............................. Error! Bookmark not defined. 16 The Dairy Section.................................... Error! Bookmark not defined. 17 The Bakery Section – Cereals, Bread, Cakes and associated Products ......................................................................................... Error! Bookmark not defined. 18 The Greengrocery section – vegetables, fruit and nuts . Error! Bookmark not defined. 19 Fruit ......................................................... Error! Bookmark not defined. 20 Nuts ......................................................... Error! Bookmark not defined. 21 Non-alcoholic drinks ............................. Error! Bookmark not defined.4 22 The World of Additives .......................... Error! Bookmark not defined. 23 Food preservation, storage and preparation ............Error! Bookmark not defined.9 SECTION C: BODY FUNCTIONS............................ Error! Bookmark not defined. 24 25 26 27 28 29 30 31 32 33 Introduction the digestive tract, the alimentary Canal 355 Water Balance .......................................... Error! Bookmark not defined. The Respiratory and Circulatory Systems Error! Bookmark not defined. Sugar Balance........................................... Error! Bookmark not defined. Energy .................................................... Error! Bookmark not defined.5 Glands and hormones............................................................................. 407 Metabolism............................................... Error! Bookmark not defined. Exercise .................................................... Error! Bookmark not defined. Other habits .......................................... Error! Bookmark not defined.46 Smoking ............................................... Error! Bookmark not defined.69
34 The effects of nutrient deficiencies and associated diseases ............. Error! Bookmark not defined.2 35 The functions of the liver and its connections with fat storage ......... Error! Bookmark not defined. 36 Fat..................................................................................................... .......498
SECTION D: DIETS .................................................. Error! Bookmark not defined.1 CHAPTER 37 38 39 40 41 42 43 44 Introduction .......................................... Error! Bookmark not defined.2 The time factor ...................................... Error! Bookmark not defined.3 The life period ..................................... Error! Bookmark not defined.17 Diet comparisons and fasting .............. Error! Bookmark not defined.39 Other diets ............................................. Error! Bookmark not defined.0 Myths and miscellaneous diets .............. Error! Bookmark not defined.1 The herbal solution ................................ Error! Bookmark not defined.2 New Ideas .............................................. Error! Bookmark not defined.2
CHAPTER 1 The concepts of overweight and underweight
In order to decide whether you are overweight, underweight or „just about right‟, it is necessary to know what your „ideal‟ weight is. As has already been indicated, the most important point to realise is that this varies from person to person and that the figures quoted by the medical profession and life-assurance companies, to whom pointers are most important, are no more than averages taken from samples of thousands whose weights vary considerably around that figure. Meet Mr. Average – a truly fascinating character of whom much has been written and who is continually at the centre of discussion. He is about five foot, nine inches tall, has medium brown hair with one brown eye and one blue. He is married to two thirds of a wife, to whom he makes love two and three sevenths times a week, not to mention a quarter of an affair with another woman and one fiftieth of an affair with another man. He has one and a half children and just over half of those are male . . . need more be said? Hopeless, isn‟t it? To make a comparison with someone like that is totally meaningless and of little value. As far as weight is concerned, the first point is to realise that human body weight is the sum total of a number of individual weights of the various body constituents – for Mr. Average, the percentages might be: Water Lean tissue Muscles Bones Fatty or „adipose‟ tissue Internal organs 60 (two-thirds intra-cellular, one third extra-cellular) 5 3 10 18 4
These last five items include various nutrients, among them: Protein 16 12 4 5.4 0.6
as intracellular (muscle) as extra-cellular (collagen)
# For a more detailed discussion see “Oxford textbook of Medicine” (hence OTM) edited by D.J. Weatherall, J.G.G. Ledingham, D.A. Warrell, (Oxford Medical Publications, Oxford University Press) 8.5 For most people, the idea of losing weight simply involves standing on the scales on day one and finding that they are, say, 168 pounds (12 stones). They then go on a diet for a fortnight and stand on the scales again on day fifteen to see a reading of 161 pounds. Seven pounds have been lost – hearty congratulations! Sadly, there is an infuriating but very poignant little afterthought question – seven pounds of what?
Losing weight ideally means losing unwanted fat, „adipose‟ tissue but this is not always what has happened. We shall see in the section on diets that the most obvious cons are products which encourage frequent visits to the washroom resulting in loss of water and, despite the reading on the scale, there is no health benefit to the purchaser. Indeed, most short-term weight changes are little more than fluctuations in total body water. Thus, it must be realised that weight problems centre around adipose tissue and it is the proportion of that, notably around the belly, thighs and buttocks, rather than the total weight, that matters. In the introduction, we met Fred and John. Fred is a professional athlete, working as a physical education instructor, specialising in weight-lifting, and a considerable proportion of his two hundred pounds are heavy bones and large muscles. So keen is he on physical fitness that he has little or no body fat and, in that respect he is, if anything, slightly underweight. Against that, John, who does little or no exercise, is very weak on limbs and muscles and has thin bones with a large, flabby and unsightly pot belly. He weighs about twenty pounds more than he should. Therefore it will be seen that it is the distribution of, rather than the total weight, that is important. We shall, at this point, define build or „frame‟. Some people have far bigger bone structures than others and indeed many „ideal‟ weight tables allow for this. A good guide to frame size (but note that it is no more than an approximation) is your wrist circumference. According to this, a person might be considered to be of small, medium or large frame: Adult males: under 6¼ inches: small; 6¼ to 7 inches: medium; over 7 inches: large. one inch less in each case.
Alternatively, research suggests that elbow breadth has a low correlation with skinfold thickness and is therefore unaffected by obesity. # For a more detailed discussion see J. Yetiv, Sense and Nonsense in Nutrition”, (Penguin Books), p. 260 referring to A. R. Frisancho et al, “Elbow breadth as a measure of frame size for US males and females” American Journal of Clinical Nutrition (hence Am. Jo. Cl. Nut.), vol. 7, no. 2, p. 311 (2/1983) 6 further references are quoted. It is perfectly in order for a person with a large frame to have a higher total weight than his small-frame counterpart, all other things, notably height and age, being equal. Indeed, a given volume of muscle tissue weighs more than an identical volume of adipose; thus the highly trained muscle-strong athlete might actually weigh more than his „overweight‟ counterpart. How, then, do you assess whether you are overweight? The senses of sight and touch are employed. Look for parts of the body which appear to flab or bulge – such excesses should not be there. Then „pinch‟ your body by the side of the chest at the bottom of the rib cage. If there is more than about an inch of flesh, you have cause for concern. While most of the body‟s fat is stored as adipose tissue, there are quantities in the liver, muscles and cellular structures like the bone marrow. Medical authorities define „obesity‟ as being 15 -20% or more over „normal‟ weight (whatever that may be). What they are trying to say is that, if you are carrying adipose tissue amounting to a sixth or more of your total weight, you are in serious trouble. Some authorities tend to be more generous at older ages, arguing that „middle age spread‟ is
one of the inevitable facts of life and it is therefore understandable that older people will „normally‟ be heavier. Consequently, in their „normal‟ weight tables, allowance is made for advancing age. Later on, it will be seen how misguided these „authorities‟ are. # For a more detailed discussion see V. Beal, Nutrition in the Lifespan, (J. Wiley and Sons), p. 10 Serious trouble – or is it? This brings us to the crux of the problem. It can so easily be argued that the „least‟ dangerous diseases are the most dangerous – because they are so often ignored until it is much too late. Overweight will rarely have a damaging effect on general health from today until tomorrow, or even over five years. But allow it to accumulate over a couple of decades or more and it can cause untold damage, as will be explained below. By that stage, it will usually be very difficult, if not impossible, to do anything about it. Furthermore, the longer the period during which overweight is allowed to accumulate, the harder it is to correct it – a classic illustration of the importance of „a stitch in time‟. # For a more detailed discussion, see OTM 8.35 In order to tackle the problem of overweight, the first priority is to understand its causes and distinguish the reasons from the excuses made by so many, particularly those who are reluctant to change their eating habits! We shall present our first balance sheet in respect of intake and outgo of the body on a daily basis: In: food, drink, air inhaled: used for feeding the various body systems, energy, storage as fat. Out: liquid and solid excrement, air exhaled, (of slightly different gaseous content to that inhaled), energy expended in physical and mental effort, sweat. The many processes by which incoming material is used by the body (with degrees of efficiency varying from person to person) are s ummed up by the term „metabolism‟. Overweight is manifestation of any or all of a number of problems. They can be divided into two categories: those with which we are born, likely to be genetic, and those which are brought on by ourselves and/or our parents. 1.1) Genetic There are several abnormalities, usually accompanied by hypogonadism (functional incompetence of the sex glands or „gonads‟): 1.1.1) syndromes with primary hypogonadism and no polydactyly (having more than the usual number of fingers or toes; „poly‟ translates to many or very). a) Prader-Willi – the commonest – about 1 per 20,000 births, displaying: a.1) low osmotic fluid pressure or „hypotonia‟; 2) mental retardation; 3) obesity, although it may not become apparent until age 3-5 but then may become very severe and difficult to cope with because of low intelligence and abnormally increased desire for food or „hyperphagia‟; short stature; subnormal development of genital organs or „hypogenitalism‟;
4) delayed bone development. b) Alström inherited autosomal (non-sex chromosome) recessive condition: b.1) early degeneration of the retina; 2) nerve deafness; 3) and later, diabetes; c) Edwards, similar to Alström but with pigmented retinopathy (a non-inflammatory disease of the retina); d) Vasquez – linked to the X (female) chromosome: d.1) gynaecomastia – excessive development of the male breast; 2) mental retardation; 3) short stature; 4) obesity. 1.1.2) syndromes with secondary hypogonadism – becoming apparent late in life – some women are able to have children. These cases often arise in children whose parents are blood-related or „consanguine‟: a) with more than the usual number of fingers or toes or „polydactyly‟: Lawrence-Moon; Biemond type II b) without polydactyly: Bardet-Biedl both display a/b.1) retinal degeneration; 2) obesity – appearing in childhood and progressively worsening; 3) mental deficiency; 4) decreased visual acuity (keenness – sense perception) during schooldays; can often lead to blindness by age 30; 5) small testes } 6) occasional gynaecomastia } in males 7) „feminine‟ hair distribution } # For a more detailed discussion, see OTM 24.9-10 1.1.3) obesity without hypogonadism: a) early onset: triglyceride storage disease – localised collections of fat are often evident; features include abnormal activation of the enzymes, adenyl cylcase and lipase (an enzyme being a proteinous chemical substance which accelerates or „catalyses‟ body chemical reactions without actually taking part itself). b) Late onset: Morgagni-Stewart-Monel syndrome : b.1) virilism in males: precocious development of secondary masculine characteristics, in females: appearance of secondary male characteristics; 2) obesity; 3) hyperostosis – excessive formation of bone tissue, notably in the skull and is usually found in older women with a variety of neuropsychiatric symptoms with headache; 4) irritability; 5) poor memory; 6) occasional epilepsy. All these are rare and those who are obese and suffer hypogonadism are usually short for their age and often mentally retarded in contrast to those with simple childhood obesity who tend to be taller than their peers and have IQ‟s within the normal bands. Although the exact mechanisms have yet to be isolated in detail, these first two are likely to be relevant: 1.1.4) Malfunctioning of the hunger mechanism. This is controlled from an area of the brain called the „hypothalamus‟ which sends a message indicating lack of food to the
stomach which, in turn, contracts to give the hunger sensation. As will be indicated later, recent research in America has suggested the existence of a gene which indicates satiety to the brain. It is suggested that, in obese people, this gene is either missing or, at best, mal-functioning, with the result that the patient regularly eats too much. 1.1.5) Metabolic abnormalities. People vary in the efficiency of their use of fat and carbohydrate (sugar-related) foods. Often obese people use them more efficiently than the non-obese and thus require less of them than they realise. Relatively more, therefore, is diverted to „storage‟ as adipose fat and, unless it used for extra exercise, it will eventually accumulate to serious overweight. However, it now appears unlikely that the common belief that obesity is due to a „slow metabolism‟ is unfounded. The body has a natural „comfortable‟ weight to which it tends to gravitate and the rate of metabolism tends to adjust itself to that end by controlling the rate at which muscles burn calories. This process still has yet to be fully understood and further study in this area may hold the key to establishing successful weight-loss regimens. #For a more detailed discussion, see Encyclopaedia Britannica – Medical and Health (hence EBMH) 1996, p. 318 The genetic element, notably, it appears, on the mother‟s side, is believed by many recognised authorities to represent a third or more of the problem. A number of studies of twins (identical or „monozygotic‟ same genes, and non-identical, or „dizygotic‟ – half the same genes) and children of obese parents who were adopted by non-obese foster parents demonstrate the magnitude of the genetic factor and thus that too much „blame‟ is placed on poor dietary upbringing. However, they emphasised that it is not the child‟s obesity or otherwise that is determined absolutely at conception, but rather the degree of vulnerability to it. # For a more detailed discussion see A. J. Stunkard, Salmon Lecture, Bulletin of New York Academy of Medicine, no. 64(8), p. 902 (4/11/1986) 37 further references are quoted. EBMH 1991, p. 354, T. W. Teasdale et al, “Genetic and early environmental components in socio demographic influences on adult body fatness” British Medical Journal (hence BMJ), vol. 300, no. 6740, p. 1615 (23/6/1990) 22 further references are quoted. A. J. Stunkard et al, “An adoption study of human obesity” New England Journal of Medicine (hence NEJM), vol. 314, p. 193 (1986) 36 further references are quoted. R.A. Price et al, “Childhood onset obesity has high familial risks” International Journal of Obesity (hence Int. Jo. Ob.) vol. 14, no. 2, p. 185 (2/1990) 54 further references are quoted. T.C.A. Sorensen et al, “Genetics of obesity in adult adoptees and their biological siblings” BMJ, vol. 298, p. 87 (1989) 30 further references are quoted. R.R. Fabsitz et al, “Evidence for independent genetic influences on obesity in middle age” Int. Jo. Ob., vol. 16, no. 9, p. 657 (9/1992) 26 further references are quoted. EBMH 1995, P. 337 seq. referring to S. L. Gortmaker et al, “Social and economic consequences of overweight in adolescence and young adulthood” NEJM, vol. 329, no. 14, p. 1008 (30/9/1993)
These two are examples of primary obesity which is directly linked to early excessive food intake or „primary hyperphagia‟. Further trouble comes after birth as secondary obesity, notably in the early years. Once a pattern is set, it becomes increasing difficult to readjust. 1.2) Hormonal 1.2.1) Deficient activity of the hormone-discharging gland at the bottom of the neck (the „endocrine‟ gland, known as the „thyroid‟); this is referred to as „hypothyroidism‟ – discussed in detail later under „iodine‟ in the nutrients‟ section and again under „glands and hormones‟ in the body functions‟ section. Hormone is derived from Greek hormon, to excite, set in motion or spur on. 1.2.2) Cushing‟s syndrome – apparent in cases with: a) truncal accumulation of fat; b) poor muscular development of the limbs; c) skin thinning; d) striae (skin stripes arising from stretching and rupture of elastic fibres); e) abnormally high arterial blood pressure or „hypertension‟. # For a more detailed discussion, see OTM 10.69, seq. Furthermore, although there is no concrete proof to date, there appear to be a number of syndromes in which obesity is linked to primary abnormalities in sex-hormone secretion: 1.2.3) Stein-Levethal syndrome of multi-pouch, (termed „polycystic‟) ovaries, menstrual abnormalities and hirsutism. Patients who have had their ovaries removed seem to gain weight easily; the exact cause is still unknown. 1.2.4) Secondary amenorrhoea (that is the absence or suppression of blood-discharge („menstruation‟) by females of reproductive age) for reasons other than pregnancy or the end of the reproductive age, the „menopause‟ associated with obesity suggests possible hyperprolactinaemia (excess prolactin (lactation-inducing hormone) in the blood) – when the prolactin level returns to normal, the obesity tends to remit. 1.3) Feeding patterns in infancy Opinions vary in this respect but it is believed that many babies are introduced to solid food too early and fat cells or „adipocytes‟ established in infancy not only perpetuate further obesity but are very difficult to disperse. Later on, in childhood, children are given tasty, sweet-smelling and colourful foods. These are bound to be tempting and they are often encouraged to eat cakes and other non-nutritious foods, often described in nutritional parlance as „junk‟. Indeed, many children are offered sweets, cakes or the like as „rewards‟ for good deeds. Thus they are overfed but undernourished! # For a more detailed discussion, see EBMH 1994, p. 451 1.4) Lack of exercise This and infant obesity can easily form a vicious circle. Obesity in childhood discourages exercise and fat children tend to be further discouraged by the humiliation of being unable to „keep up‟ with their peers. The lack of exercise invites further obesity, still less
exercise and so on. In advancing age, people tend to take full advantage of labour-saving devices and spend far too much time listening to the media instead of being active themselves. Being of an advanced age, as we shall see under „excuses‟ below, is not a reason for being overweight. # For a more detailed discussion see Beal, p. 349 1.5) Environmental A number of studies indicate that socio-economic class is a factor with the poorer classes tending to suffer more from obesity. # For a more detailed discussion, see A. J. Stunkard, “Obesity, risk factors, consequences and control” The Medical Journal of Australia, vol. 148, Special Supp. , p. 521 (1/2/1988) 29 further references are quoted. 1.6) Psychological pressures A feeling of insecurity can often appear in adolescence as a leftover from childhood days – a sign of emotional immaturity. Many sufferers regard the „warmth‟ of food as a symbol or substitute for the love and security they are missing from other humans. Another relevant factor is attitude to one‟s own personal appearance. Some, notably females, care more than others and they are prepared to take pains to avoid obesity. Overweight tends to be self-perpetuating in that such people, tending to be physically unattractive, have difficulty in finding friends and become increasingly sensitive, selfconscious and ashamed of their condition. This leads to fear of further failure and even ridicule and the feeling of self-pity, isolation, reluctance to attend social functions and eventual depression. Relatively few people realise that intense worrying about overweight is often markedly worse than the condition itself. The consequent loss of sleep leads to insufficient energy and a further reason for eating more than necessary. The end of it is often resignation – many simply give up hope and take the attitude that they might just as well enjoy life while it lasts. 1.7) Drugs 1.7.1) The most notable is the contraceptive pill – although here the weight gain is usually small and largely due to water retention; 1.7.2) those used to treat thyrotoxicosis (poisoning of the thyroid gland); 1.7.3) Corticosteroid (hormone extracts from the adrenal cortex) analogues – again little is known about the manner of action; 1.7.4) Cyporheptaidine – for appetite stimulation and treatment of a number of allergies; 1.7.5) anti-depressants – encourage eating – improve appetite of depressed patient who doesn‟t bother to eat or alter metabolism. # For a more detailed discussion, see OTM 8.42, seq. 1.8) It is important to distinguish the above „reasons‟ for being overweight from the very much longer list of „excuses‟ that people usually put forward:
1.8.1) A low basic metabolic rate. It hasn‟t occurred to „sufferers‟ to adjust their eating habits accordingly. 1.8.2) Glands failing to function properly. If that really is the case, something should be done at the first sign of the problem. How often does one hear: „I‟ve been like this for years.‟? 1.8.3) Excess fluid retention, primarily in the female sex: unless the patient is very ill with kidney or heart trouble, in which case (s)he should be in hospital under constant care, or taking steroid tablets (again under strict supervision) excess fluid will, at worst, constitute a very small proportion of excess weight. 1.8.4) Large frame with heavy bones – that in itself does not constitute overweight. 1.8.5) Middle-age spread with less energy expanded with advancing age. This is, of course, due to lack of exercise. Most people give up sport far too early for no good reason. The excuse always given is „slowing down‟ and therefore being „past their best‟. That is no good reason to give up – the important thing is to take part rather than to win. Only recently, the author watched a men‟s doubles badminton match. With the way the participants threw themselves around the court, one would hardly have thought that their four ages totalled well over two-hundred and twenty! It can be done. 1.8.6) Low blood sugar. Here we introduce the hormone, insulin. A hormone is a kind of messenger, being a product of living cells circulating around body fluids (like water, lymph and blood) to produce a stimulating or inhibiting effect (as appropriate) on cell activity. They can work on area s well remote from the gland issuing or „secreting‟ them. The idea is similar to nerves working to and from the brain with the important difference that, while the nerve message is being sent directly to the area concerned, the hormone message is despatched universally on a „to whom it may concern‟ basis. It is a similar contrast to the person-to-person telephone call and the radio message to which anyone can switch on and listen. Eating more carbohydrates than necessary initially leads to an increased blood-sugar level. Insulin is thus released by the pancreas gland to bring that level down to normal but sometimes there is an over-correction, pushing it lower still and causing the urge to eat more sugar. The circle goes round again until the gland (just below the stomach) can no longer produce enough insulin and we reach the excess blood-sugar condition, „diabetes mellitus‟. 1.8.7) Some people claim that they eat very little but insist that everything they do eat turns to fat – sometimes described as a high absorption level. The truth is probably that, often under social pressure, they drink too much alcohol. Such people also tend to do little or no exercise. 1.8.8) Some argue that losing weight lowers vitality and disease resistance (quite the reverse is true) and further gives the feeling of tiredness, depression, irritability and haggardness (similarly untrue, at any rate in the long term). 1.8.9) Fat gives the impression of prosperity (an argument which appears to carry considerable force in poverty-stricken countries), success, power, importance, heartiness, jollity, relaxation and happiness in protection against hurt. That might be true for the less initiated; the true impression ought to be one of poor health and life-assurance risk as well as greed, indiscipline and self-indulgence. 1.8.10) Many consider fat members of the opposite sex attractive in that physical contact is softer. 1.8.11) Many argue that the diets on the market simply do not work and it has to be said that there is a great deal of truth in this as will be explained later in the „diets‟ section. 1.8.12) Obesity has one positive advantage in that wrinkles are less frequent in old age. 1.9) A brief summary follows of the ways in which overweight manifests itself in its associated diseases. These cause the countless deaths which occur each year, having been at least aggravated, if not initiated by, the condition. They will be discussed in more detail in the section on body functions:
1.9.1) The body consists of a large number of systems, one of the most important being the „cardiovascular‟: heart, arteries, veins. It is along this system that the blood flows under pressure. High blood pressure can cause heart-associated or „coronary‟ trouble. Numerically, the disasters caused in this area are easily the most significant. # For a more detailed discussion see Yetiv, p. 261 P. Khouri et al, “Weight change since the age of 18 in 30 -55-year old Whites and Blacks – Associations with lipid values, lipoprotein values and blood pressure” Journal of American Medical Association (hence JAMA), vol. 250, p. 3179 (10/12/1983) 39 further references are quoted. A. Weltman, “Unfavourable Serum Lipid Profiles in extremely overfat women” Int. Jo. Ob.), vol. 7, no. 2, p. 109 (1983) 35 further references are quoted. OTM 13.146-7 1.9.2) The breathing or „respiratory‟ system cannot function efficiently in an overweight body and the need for extra oxygen to be transported through the blood puts a greater workload on the heart. Breathlessness and exhaustion, following even a mild exertion, provides ample evidence. There will be ill-effects on lung function – deterioration of: a) vital capacity, b) maximum ventilatory volume, c) response to pressure or „compliance‟, and d) a heavy chest wall impeding respiratory movements. Overweight children appear to be more susceptible to chest infection and recover more slowly from diseases like pneumonia. It is also likely that obesity is connected with obstruction of the upper airways, leading to apnoea (brief cessation of breathing) and other sleep problems. # For a more detailed discussion, see OTM 15.31, 15.159 1.9.3) Diabetes – the risk increases, approximately linearly, with age and degree of obesity. Older people suffer a decreased capacity of the pancreas to produce the insulin hormone (discussed in greater detail under „sugar balance‟ later). This is particularly undesirable for the obese who need more of the hormone as their resistance to it increases. There also appears to be a genetic link between obesity and diabetes. # For a more detailed discussion, see OTM 4.32, 9.55, seq. 1.9.4) There are further increased risks of strokes and consequent paralysis in addition to diabetes as already mentioned. There seem to be genetic as well as other factors here: for example, non-insulin dependent diabetes is slightly more likely to affect women than men, blacks than whites. # For a more detailed discussion see Yetiv, p. 261 G. S. Bonham et al, “The relationship with race, sex and obesity” Am. Jo.Cl. Nut., vol. 41, p. 776 (4/1985) 19 further references are quoted.
1.9.5) In the obese, disorders of the gallbladder (the muscular pouch-like membrane which stores vital digestive-aiding or „bile‟ liquid secreted by the liver) are more likely to occur. Synthesis of cholesterol (defined as the combination of two Greek words: chole = bile, and stereos = solid; detailed later) by the liver and other tissues increases. While overall cholesterol concentration in the blood may only rise modestly, the total amount in the body increases considerably and with it the rate at which it is excreted in the bile. Bile supersaturated by cholesterol is likely to form gallstones. Women are particularly vulnerable, notably in pregnancy, which suggests that the female hormone, oestrogen, plays an important part in the stimulation of biliary cholesterol secretion. Furthermore, cholesterol saturation of bile increases with use of oestrogen-containing contraceptives and there is an increased production of the hormone in obesity. 1.9.6) Overweights are more likely to suffer greater strain on their backs, leading to excruciating pain and there are increased risks of ruptures and protrusions of organs through their surrounding connective tissues, the violently painful condition known as hernia, most likely to occur around the stomach area. 1.9.7) Excessive pressure on joints, as in the spine, hips, knees and ankles, is likely to aggravate the inflammation of such joints as in arthritis. Bone- or „osteoarthritis‟ is particularly common. The risk of varicose veins also increases. 1.9.8) Obesity predisposes women to blood poisoning or „toxaemia‟ and hypertension during pregnancy. 1.9.9) In women, obesity increases the tendency to fluid retention. # For a more detailed discussion, see OTM 18.29 1.9.10) In women of a more advanced age, overweight is clearly linked to an increased risk of the womb falling down or „prolapse‟, the supporting muscles of the pelvic fl oor having become very lax. 1.9.11) The study of body functions will carefully detail the path food takes from eating or „ingestion‟ to excretion, known as the „digestive tract‟. The muscles associated with this tract can be reduced to lax inefficiency on infiltration with fatty substances. Gastrooesophageal (the oesophagus is the gullet) reflux of gastric juice, including hydrochloric acid and pepsin from the stomach, causes pain and damage to the mucosal squamous epithelium (the scaly tube lining covering slimy matter). # For a more detailed discussion, see OTM 12.44-5 1.9.12) A patient about to undergo an operation should certainly avoid being overweight. Apart from the obvious difficulty for the surgeon in getting through to the appropriate area, there is the increased risk of post-operative chest infection. 1.9.13) Associations with overweight have been established in skin or „dermatological‟ problems, inflammations and boils. The excess growth of unwanted hair, or „hirsutism‟ is also more prevalent in the obese. 1.9.14) Certain types of cancer, notably that of the large intestine. There is evidence linking obesity with breast cancer but this is unclear. 1.9.15) In women, deranged hormonal status leads to menstrual irregularities and profuse menstrual flow or „menorrhagia‟. 1.9.16) Gout – rare but possible in susceptible individuals, mostly male. # For a more detailed discussion, see OTM 9.128
1.9.17) Kidney or „renal‟ disease; 1.9.18) With girls, obesity tends to advance the onset of puberty – with boys, it tends to retard it. # For a more detailed discussion, see OTM 10.107 1.9.19) There are several undesirable psychological effects and it is noteworthy that there will be considerable repetition of the causes to illustrate the vicious circle: a) Failure in physical recreation; b) Feelings of guilt, unhappiness, shame and perhaps envy of others, the degree of which varies with circumstance – for example it is found that overweight girls are less unhappy in a segregated school than in a co-educational one. # For a more detailed discussion see Beal, p. 400, seq. A. J. Stunkard et al., “Psychological aspects of severe obesity” Am. Jo. Clin. Nut., vol. 55, no. 2, 2nd. Supp. , p. 524S (2/1992) 82 further references are quoted. T. A. Wadden et al., “Dissatisfaction with weight and figure in obese girls – discontent but depression” Int. Jo. Ob., vol. 13, no. 1, p. 89 (2/1989) The clouds, it seems, are very black but there are two or three silver linings. In the obese, digestive system or „peptic‟ ulcers are less likely to occur. Also the satisfying feeling of a good chunk of warm fat seems, in some people, to reduce stress and the suicide rate is low among the obese. Even here, however, it must be added that many suffer extra stress through discomfort and loss of working time. Furthermore, deaths from heart attacks brought on by overweight easily outnumber suicides by the non-obese. Finally, it should be added that, although women have twice as much body fat as men, they are the healthier sex who live markedly longer. The reasons will be explained later on. It will be seen, therefore, that the overall case against being overweight is overwhelming. Several studies illustrate that even mild obesity increases mortality risk significantly, focusing on connections with associated disorders mentioned above and distinguishing between the sexes for various age groups. # For a more detailed discussion see Yetiv, p. 261 H. B. Hubert et al., “Obesity as an Independent Risk Factor for cardiovascular disease – a 26-year follow-up of participants in the Framingham Heart Study” Circulation, vol. 67, no. 5, p. 968 (1983) 37 further references are quoted. E. A. Lew et al., “Variations in Mortality by weight among 750,000 men and women” Journal of Chronic Diseases, vol. 32, p. 563 (1979) 9 further references are quoted. OTM 8.39, seq. Nevertheless, there are studies, albeit on relatively small numbers of people, which have argued possible benefits. These have confirmed that obese people display relatively lower rates of schizophrenia; also, in one or two studies which grouped subjects in weight bands, the lowest mortality rate was found among the heaviest! However, these studies are open to question on a number of counts, including dubious data and the fact
that many sufferers of serious illnesses (perhaps brought on initially by overweight) lose weight as death approaches and therefore appear to be in a „lighter‟ group. # For a more detailed discussion, see R. Andres, “Effect of obesity on total mortality” Int. Jo. Ob., No. 4, p. 381 (1980) 21 further references are quoted. 1.10) But before thinking about going to the other extreme, it must be realised that it doesn‟t pay to be significantly underweight either. Here we will define „serious weight deficiency‟ as being 85% or less of normal weight with inadequate warmth and bone protection. There are a number of causes, including: 1.10.1) Inadequate food: this applies primarily, but by no means exclusively, in thirdworld countries. 1.10.2) Psychological disturbances: may be caused by a tension-filled lifestyle or, notably in adolescent girls, a reluctance or fear of eating known as „anorexia nervosa‟, discussed later. 1.10.3) Infectious diseases inhibiting proper processing or utilisation of food. 1.10.4) Metabolic disorders, notably malfunctioning of the thyroid gland. Thus underweight is usually a complication of other problems. Not only must corrective action be taken but food intake must be increased, at least temporarily. 1.11) Just as with overweight, there is a case for being slightly underweight in that the risk of several heart diseases is reduced and thus life expectancy is longer. However, serious underweight can result in a number of unwanted disorders: 1.11.1) Impaired growth in infants and indeed their mental development; 1.11.2) Resistance to infections is reduced; 1.11.3) Reduced energy and therefore work capacity; 1.11.4) Nerves, muscles and sexual functions perform under par; 1.11.5) The workings of digestive system and heart tissues may be impaired. Furthermore, being underweight does not exempt the body from a high level of fat in the blood which could cause a heart attack. How to overcome weight problems will be discussed in more detail in the section on diets but, for the moment, it will suffice to say that underweight and overweight are not diametrically opposite. Thus, eating and drinking all the „wrong‟ things and abstai ning from exercise are not the cure for underweight; a different approach must be taken to ensure that the cure is healthy and permanent.
SECTION A – NUTRIENTS
Each of the seven basic nutrient groups will be considered in detail, starting with the macronutrients, proteins, carbohydrates and lipids, followed by the micronutrients, vitamins and minerals. Finally there will be sections on fibre and water.
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