The carbohydrates, like fat, can protect circulating albumin from destruction and aid its transformation to organic albumin, but it is not proved that they themselves make fat, as at first supposed, for they are very completely destroyed even when eaten in excess. They merely protect other foods from oxidation under such conditions.

Meat and carbohydrates alone increase the fat in the body without the aid of fatty food, for fat, which originates from splitting up albumin, is spared further metabolism. Hence fatty metabolism in the body may be quite independent of fat indigestion.

Dietetic Treatment

The question of the treatment of obesity, owing to the frequency with which the physician has to deal with it, is a matter of great importance, and demands special consideration. The best results from treatment are obtained in patients less than thirty years of age. For a long time it was believed that excessive consumption of carbohydrates was the cause of increased fat production within the body. The pig is fattened on corn, and cattle upon various cereals. Undoubtedly, many persons who are of spare habit can increase their weight by eating a larger proportion of starches and sugars. It is a fact, moreover, that starches contain oxygen in the exact proportion necessary for the formation of water and carbon dioxide, and on being disintegrated in the body, they naturally produce these two forms of waste matter which are promptly eliminated from the surface of the lungs and kidneys respectively. The proteid material of the food requires a larger percentage of oxygen for the metabolism involved in its complete conversion into urea.

It is an undoubted physiological fact that the fat of the body may be made from a variety of different foods, and that some individuals are capable of producing it from a particular class of food materials more readily than from others. Thus one person may become fat from overindulgence in saccharine food and another from eating purely starchy foods and taking large quantities of malt and beer, and still another from the excessive use of quantities of fat meat. Accordingly the rules which are formulated for the treatment of obesity must be regarded as referring to the majority of cases only, whereas there are many exceptions which must be individually studied.

Many special dietetic systems are in vogue for the treatment of obesity. In some cases if the total quantity of food is diminished no special diet is necessary, but in many persons obesity is not due to overeating, but to other causes. Some patients improve at once when they give up all alcoholic beverages. An ounce of food eaten daily in excess of that which is eliminated, and which is capable of being stored in the tissues in the form of fat, very soon produces a considerable increase in the body weight, which in a year's time would amount to many pounds.

As stated above, the majority of the obese eat too much and exercise too little, or at least they have originally eaten more than they consumed, i. e., although they may delude themselves to the contrary and claim to be small eaters, they have at some period consumed too many calories, hence it makes little difference whether the curative diet be restricted in fats or in carbohydrates, so long as the total caloric energy be cut down. As pointed out by von Noorden, the detailed mode of restriction may be left in great part to the individual patient's liking, so long as the general principles are adhered to of reduction in quantity of food and increase in oxidation. As a general statement, from one to two-fifths should represent the degree of reduction in quantity of food in an average case, and in general this may be accomplished by eliminating sugars and alcohol in toto and reducing to a minimum the consumption of fats and of bread, potatoes, cereals, and other forms of starch.

Among the different systems which have been advocated for the cure of obesity the best known are those of Banting, Ebstein, and Oertel. Schweninger's cure is practically Oertel's method by withholding fluid from the meals, and giving all fluid at least two hours after ingestion of food. Schleicher's system is also similar to Oertel's.

The principal systems which have been especially devised for the treatment of obesity will be separately discussed in detail. Nearly all of these systems agree in two principles: First, to reduce the total quantity of food ingested as much as possible without impairing the strength of the patient. Secondly, to diminish the amount of fluid drunk by prescribing what is called a dry diet. The treatment, moreover, is usually accompanied by systematic exercise or bathing, and it is highly important to keep the bowels active.

Some persons attempt to cure obesity by allowing the patient to eat any food he chooses, but insisting that he shall eat only one kind of food at any one meal. As a natural result, the appetite soon palls, and he eats less than he otherwise would. This is an unscientific method, and an unwholesome one for serious cases.

As a general principle, corpulent persons should restrain themselves to as great an extent as possible from drinking fluids, especially with meals. Exceptions to this rule occur when obesity complicates certain other diseases, such as gout or rheumatism, where the use of an increased quantity of fluid may be temporarily necessary in order to act vigorously upon the kidneys.

Hot-water beverages taken half an hour before meals, and again at night and on rising in the morning, are beneficial, and less fluid is required with the meals.

As a rule, never more than five ounces of fluid should be taken with a meal, or fifteen ounces per diem, and this amount may be still further curtailed by giving water between meals instead.

Soups of all kinds should be forbidden as well as alcoholic beverages, and what little fluid is allowed should consist of plain or aerated water. But little, if any, milk should be taken. The food should be as dry as possible without interfering with its flavour and nutrient value. Highly succulent fruits, such as watermelons, and vegetables like raw tomatoes, which consist largely of water, should not be eaten. Sugar should be absolutely forbidden, and fat should be used very sparingly, and only in the form of a little butter. The allowance of farinaceous food should be also cut down as much as possible. It will not usually be found practicable to do without bread for any length of time, but patients are often willing to restrict themselves to a very rigid diet for two or three weeks if the positive hope of cure or amelioration of symptoms can be held out to them, if they are made to understand the rationale of the treatment, and if they are given some objective point to anticipate when a promised improvement will admit of greater laxity in regard to diet.

If desirable, gluten bread may be substituted for wheaten bread.

The deprivation of starchy foods can always. be better and longer tolerated if a little fat is given, and the obese do not well endure deprivation of all fats, even when starchy food is supplied in moderation.

This is more often true of those engaged in mental work than of those employed in muscular exercise. Salts and fresh green vegetables - " vegetables which grow above the ground," except the legumes - should not be withheld.

Lean meat should form the basis of all diet, but an unrestricted flesh diet in obesity may give rise to dyspepsia and gastric and intestinal catarrh.