CHAPTER XXII_Dietetics for Nurses

GOUT, OBESITY, EMACIATION

Gout is a constitutional disease characterized by an inflammatory

condition of the joints. It is caused by or associated with a

retention of uric acid in the blood. Gout is also characterized by the

deposit of uric acid or sodium salts which occurs in different parts

of the body, the joints, the lobe of the ear, the knee and the elbow

being common points where the deposit of these salts ordinarily

occurs. The amount of uric acid is lessened in the urine in cases of

true gout, except in acute attacks, and in this way it is

distinguished from the so-called goutiness in which a urinalysis shows

an excess of uric acid. According to Strouse, this excess of uric acid

in the urine "means a physical-chemical change in the urine and is

quite different from the small amount usually excreted."[156]

~Source of Uric Acid.~--In man the uric acid which is eliminated in

the urine is derived from two sources. It may be taken with the body

as purins in food, in which case it is spoken of as being an

"exogenous" product, or it may be formed in the body from the breaking

down of the nucleoproteins (the highly nucleated cells of the

glandular organs particularly). When the uric acid is formed in this

manner as the result of the metabolism of the body tissues, it is

known as "endogenous." In the normal body approximately one-half of

the uric acid formed is oxidized, while the remaining half is

eliminated from the body by way of the urine.

~Elimination of Uric Acid.~--In gout such is not the case, the body

loses to a certain extent the ability to eliminate the uric acid,

hence it is retained within the body, causing an excess in the blood

stream, and it is this excess uric acid in the blood which causes the

acute attacks and general pain and discomfort which inevitably occur

in chronic gout.

~Purin-bearing Foods as Sources of Uric Acid.~--Formerly no difference

was made in food; all were supposed to cause uric acid formation, but

with the exhaustive investigation of food materials this sweeping

condemnation has been to a great extent removed or narrowed down to a

few foods, those rich in purins being the chief offenders.

~Chief Causes of Gout.~--Without a doubt, overeating, overindulgence

in alcoholic stimulation, lack of exercise, etc., are chiefly to blame

for the large percentage of the cases, but upon investigation it will

be seen that those individuals are as a rule large protein eaters and

that their mode of living is not such as to assist the body in

throwing off the poisons which form as the result of their

self-indulgence.

~Rules to Combat Gout.~--To successfully combat the retention of a

large percentage of uric acid in the blood there are certain definite

rules to be observed: (1) The general diet must be reduced not only in

amount but also in purin-bearing foods; (2) All foods which are liable

to cause digestional disturbances, with the attending evils of

intestinal putrefaction and constipation, must be avoided.

~Alcohol in Gout.~--If the patient is accustomed to alcoholic

stimulants and has been in the habit of taking them constantly for

years, the amount of alcohol consumed daily must be radically reduced

and only the amount prescribed by the physician taken. Alcohol without

a doubt assists in the retention and increases the difficulty of uric

acid elimination by the body. In view of the present knowledge of the

cause and effect of uric acid in the body, the treatment of gout is

directed with the object of relieving the condition (1) by

facilitating the elimination of uric acid from the body, and (2) by

so regulating the diet as to exclude as far as possible those

purin-bearing foods which, by reason of their chemical composition,

augment the general amount of uric acid formed within the organism.

In gout, as in other abnormal conditions, no set rule can be laid down

to cover the treatment of every case. The individual must be taken

into consideration, his daily habits studied and the extent and

character of the disease known before it is possible to prescribe a

treatment or formulate a diet which would adequately meet his needs

under the existing conditions.

~Obesity and Glycosuria.~--Gouty individuals often become obese and

show evidences of glycosuria. Consequently it is important to regulate

the carbohydrates as well as the purin-bearing foods in the diet. Only

the simplest foods are permissible. In acute attacks it has been found

that milk and alcohol cause less disturbance than meat and alcohol.

While the acute symptoms exist all meat should be avoided and the

daily allowance of alcohol cut down. Tea and coffee both contain

purins and should be avoided while the acute stage of the disease

continues. Cereal coffee, hot water tea, hot milk or buttermilk may

be substituted.

~Purin-free Diet.~--A purin-free diet is advisable during the acute

attack. The following is a sample menu of such a diet:

Breakfast--Banana, apple, grapefruit, orange or peach, etc.

Cereals: farina, hominy, or cream of wheat with

cream and sugar

1 egg, soft-cooked

Buttered toast

Cereal, coffee with sugar and cream or hot water

tea (milk and hot water) with cream and sugar

Lunch or Dinner--Poached egg on toast, 1 large baked potato with

butter, 1 mold of fruit jelly with cream

Supper--Rice and butter, bread or toast with hot milk

Apple sauce with cream

_Purin Per Cent._

Cocoa contains 1.00 per pint

Tea " 1.20 per pint

Coffee " 1.70 per pint

Purins are soluble in water, hence those foods that are boiled contain

less than those prepared by other methods of cookery.

~Foods More or Less Condemned.~--Salt has a tendency to bring about a

deposit of sodium urates in the body, and for this reason should be

sparingly used in the preparation of the diet. Alkaline waters are

inclined to produce a like result, consequently should be avoided by

the gouty individual. Condiments and spices are conducive to

constipation, a condition to be avoided if possible under the

circumstances. Certain physicians prohibit the use of oranges in the

diet of gout, while others do not. Strawberries are likewise condemned

and should be eliminated from the diet for both chronic and acute

gout.

~Diet in Chronic Gout.~--In chronic gout it is necessary to maintain

the general health of the patient by a well-balanced diet. This is not

difficult even if the dietary is so regulated as to be well within the

limits of his energy requirements. It is necessary to limit the

purin-bearing foods. Meats are used sparingly and these should be

boiled rather than roasted or broiled. Eggs and cheese and milk should

be substituted for at least part of the regular allowance of meat.

~Exercise and Massage.~--The patient should be recommended to take a

certain amount of mild exercise in the open air, or massage if he is

accustomed to living an indoor life or is confined to office work. He

must be warned against overindulgences of all kinds, especially of

overeating and drinking. A glass or two of hot water before breakfast

is recommended.

~Treatment of Obesity.~--The treatment of obesity when occurring in

gouty patients is much like that used in other conditions. Ebstein

regards obesity under such circumstances as an unfavorable symptom. He

advises a reduction in the carbohydrates to the smallest possible

amount and allows meat and fats in the diet.

~Allowable Foods.~--The following foods are practically purin-free and

may be used in the diet of gout:[157] Milk, cheese, butter, eggs,

nuts, gelatin, fruits, sugar, breads made with white flour, cereals,

cream of wheat, farina, rice, hominy, tapioca, cornstarch, potatoes

and other root vegetables, green vegetables, except asparagus,

spinach, and all fats.

~Avoidable Foods.~--The following foods are rich in purins and should

be avoided in the diet for gout: Sweetbreads, liver, kidneys, beef,

mutton, veal, pork, turkey, chicken, goose, rabbit, duck and other

game, fish, with the exception of cod, sardines, and anchovies, tea,

coffee, and cocoa.

The following list shows the purin content of some of the

above-mentioned foods. The purins are computed by Hall as follows: 1

kilogram contains,

_Grams Purin_

Milk

Butter

Eggs

Cheese

Farina

Rice

Hominy

Potato 0.02

Flour

Bread

Cauliflower

Eggplant

Cabbage

Lettuce

Sugar

Peas 0.39

Asparagus 0.21

Lentils 0.38

Halibut 1.00

Cod .05

Salmon 1.00

Mutton 0.96

Beef 1.10-2.00

Veal 1.10

Ham 1.10

Pork 1.20

Oatmeal 0.53

Beans 0.63

Chicken 1.20

Sherry

Claret

Whisky

Brandy

Beer 0.12

Porter 0.14

Ale 0.14

Chocolate per pint 0.70

To keep the body in good condition and to help rid it of accumulated

poisons, the following diet lists are recommended:

~Daily Dietaries:~

7 A.M.--Hot water, 8 oz.

8 A.M.

Breakfast--Stewed prunes, wheatena and cream

2 eggs

2 slices of buttered toast

1 cup of milk flavored with cocoa or coffee or 1 cup of

cereal coffee with cream

Dinner--Cream of pea soup

Boiled codfish with cream sauce

Mashed potatoes

Cauliflower

Rice pudding

Supper--Cream toast

Baked potatoes

Egg nest

Apple sauce

Hot milk flavored with coffee, cocoa, or 1 cup of cereal

coffee

7 A.M.--Hot water, 8 oz.

8 A.M.

Breakfast--Grapefruit

Cereal and cream

Soft scrambled eggs

Cereal coffee, or milk and coffee

Buttered toast

12:30

Lunch--Cream of tomato soup

Cottage cheese and cream

Baked potato

Baked apple

Bread and butter

6 P.M.

Dinner--Chicken, small piece, no gravy or rich dressing

Candied sweet potatoes

Baked eggplant

Lettuce salad (lemon juice instead of vinegar)

Bread and butter

Orange or wine jelly

Milk

Breakfast--Cereal and cream

Baked apple with cream

1 slice of bacon

1 soft-cooked egg

Toast--butter

Cereal coffee, or milk flavored with coffee

Lunch--Vegetable soup

Scalloped potatoes

Cream cheese

Bread, butter

Stewed pears

Dinner--Halibut steak

Creamed potatoes

String beans

Fruit salad

Sponge cake, orange sauce

Small coffee

OBESITY

Probably no one problem affecting the human family is more widely

discussed than that of obesity. There are numberless "cures"

suggested, most of which contain some good, but they are as a rule

more strenuous than the average fat person cares to attempt, or, if

attempted, persist in.

~Causes of Obesity.~--It is stated that at least fifty per cent. of

the obesity is of hereditary origin, while the rest may be due to

overeating and drinking, unbalanced diets, metabolic changes due to

the approach of menopause in women, and diseases such as gout in which

there is a certain amount of disturbance in the blood and excretory

organs and in which the diet or the disease may be accountable for the

gain of surplus adipose tissue. Women approaching menopause may not

change their diet in the least and there may still be the noticeable

increase of fat.

~Obesity Cures.~--A great number of the "cures" are undertaken not

from a health standpoint but from the esthetic point entirely. It

makes no difference what reason is brought forward for instituting the

treatment, it is the results which count. Of the cures undertaken

which are in themselves good, but which are too strenuous for the

average "fat person" to stick to may be mentioned some of the early

cures instituted and recommended by Banting, Oertel, and Ebstein.

Obesity, then, may be said to be due to (1) heredity, (2) overeating

and drinking, (3) lack of exercise (sedentary life), (4) a combination

of the above causes. Whether the obesity is due to the lack of

exercise or the lack of exercise is due to the accumulation of fat

which causes a disinclination to move on the part of the individual,

can only be judged when a thorough examination into the life and

habits of the patient is made.

~Comparison of Food Intake and Energy Output.~--Many fat people who

claim to be small eaters in reality constantly consume more food than

their age, weight, or mode of living would necessitate. If such

patients could be prevailed upon to keep a correct chart of their

daily intake of food and the amount of exercise taken, they would be

astounded to find how much greater was the intake in comparison to the

output of energy, in other words, how much more food they ate than

they required to keep them in health. A glance at the first tables in

this text will show which foods are utilized by the body chiefly as a

source of energy.

~Uses of Food in Body.~--Physiological chemistry proves that when more

food is taken than is needed for the internal and external work of the

body, the surplus is stored for future use, first, in the liver and

muscles as glycogen for the general expenditures, and, second, as

adipose tissue for future use. Thus it is seen that when the intake is

constantly greater than the energy expenditure there must necessarily

be some way in which the body can store up the surplus fuel, and so

long as the digestion remains good and the amount of exercise limited

there is no reason why there should not be a constant and steady

accumulation of surplus fat which inevitably terminates in obesity.

~Water as a Fat Maker.~--That water is in itself fattening is of

course untrue. A chemical analysis of this fluid shows that it is

inorganic in character and cannot alone either produce energy or build

tissue. However, this food constituent plays a most important part in

all the functions of the body. In the first place the body cannot

utilize food unless it is in solution; water is also one of the best

known stimuli to the flow of gastric juice, and for this reason is an

important factor in the preparation of the food for its absorption and

utilization; since water forms the bulk of the blood, it acts as a

distributor or carrier of food to the different parts of the body.

~Limiting the Fluids in Obesity.~--Thus it is seen that when the

intake of fluids is limited, the body will call upon that surplus

which is stored in every nerve, tissue, and fluid throughout the

entire organism to assist in the necessary work of the organs, thus

reducing the body weight just that much.

~Exercise.~--The athlete who is overweight, due to adipose tissue,

increases his exercise at times, even adding to the weight of his

clothing, causing an increased energy output, profuse perspiration,

etc., all of which causes the body to use its surplus fuel in the form

of the stored fat. Exercise does not break down a muscle, it builds it

up. Thus many individuals who increase the strenuousness of their

exercise complain that their weight is increased even when they

observe a noticeable improvement in their general feelings and

appearance.

~The Appetite.~--The great trouble with most women who undertake an

obesity cure which calls for an increased amount of energy is that

they will develop an increased appetite thereby which they appease

with food instead of forcing the body to use the store in hand, thus

entirely doing away with any good the treatment might have

accomplished. No amount of exercise without a proper regulation of the

diet will prove satisfactory as far as the reduction of fat is

concerned. The following methods recommended by Banting, Oertel, and

Ebstein are included here.

OBESITY DIETS AND CURES

~Banting Method.~--This method is said to be unsuited to those with

weak digestions. Following its use such individuals have been known

to develop renal colic or gallstones; constipation may be present and

the entire system may become so deranged as to render the patient

liable to disease.[158]

~Banting Diet for Obesity.~--Breakfast at 9 A.M., consisting of 5-6

ounces of animal food, meat or boiled fish (except pork or veal), 1

small biscuit or 1 ounce dry toast. Total solids, 5-6 ounces. Coffee

or tea (without milk or sugar), 9 ounces.

2 P.M.--Dinner: Fish or meat (salmon, eels, herring, pork, and veal

excepted), poultry or game; any vegetable except potatoes, parsnips,

carrots, turnips, or beet roots; dry toast, 1 ounce; fruit cooked and

unsweetened; good claret, sherry, or Madeira, 10 ounces. Total solids,

10-12 ounces.

6 P.M.--Tea: 2-3 ounces cooked fruit; 1-2 ounces rusks; 2-4 ounces

solids; 9 ounces tea, without milk or sugar.

7 P.M.--Supper: Meat or fish as at dinner; claret or sherry and water,

7 ounces.

Total daily solids, 21-27 ounces.

Total fluids, 35 ounces.

* * * * *

Oertel pointed out the great benefits which might be derived by those

individuals suffering from certain types of heart disease which are

accompanied by obesity. He made it distinctly understood that while

the treatment in no way affected the heart lesion,--that is, in so far

as altering the character of the disease,--it greatly reduced the work

imposed upon the circulatory organ and permitted a more complete

oxidation of the blood.[159]

~Oertel's Method.~--Oertel bases his dietetic treatment of obesity

upon the heart changes and those which naturally follow in the

circulation. He makes the following suggestions, taking always into

consideration the condition of the patient, whether he is anemic or

plethoric.

"(a) Where there is an abnormally increased amount of fat in

plethoric patients with unimpaired or only beginning changes in the

heart action, the diet should aim at:

(1) An increased supply of protein.

(2) A decrease in the fat-forming substances.

(3) Little or no diminution in the supply of liquids below the

physiologic amount (1500 c.c.--3 pt.)

(b) Where there is obesity in anemic patients, viz. serious plethora,

the diet should aim at:

(1) An increase in the quantity of proteins.

(2) A diminution in amount of fat-forming substances and eventually

(3) a decrease in the amount of fluid.

only the amount of protein but also the abnormally increased amount of

fat is slowly wasting away, they require:

(1) An increase in the amount of protein taken.

(2) A sufficient amount of fat and carbohydrates or even an increase

of same to prevent the falling off of fat.

(3) A diminution in the amount of fluid taken."

Oertel claims that the simplest method of reducing the fat-forming

elements in a diet is to decrease the amount of fat and allow a

certain amount of carbohydrates, regulating the diet according to the

individual. The following table is given by him as showing the minimum

and maximum amount of the different food constituents constituting the

obesity diet:

==========++=========+========+==============+===========

||_Protein_| _Fat_ |_Carbohydrate_|_Calories_

|| _Gm._ | _Gm._ | _Gm._ |

----------++---------+--------+--------------+-----------

Minimum || 156 | 25 | 75 | 1180

Maximum || 170 | 45 | 120 | 1608

==========++=========+========+==============+===========

In instituting a treatment for obesity Oertel insists upon a certain

amount of exercise daily in the open air, the amount to be regulated

by the physician according to the individual case. He suggests that

five or six small meals a day be given rather than a few large meals.

He eliminates soups, tea, and coffee while the cure is being given.

~Ebstein~ suggests a diet in which the carbohydrates and fluids are

reduced but in which the fats are allowed to a considerable extent.

The diet consists of meat, eggs, fish, vegetables (green) and fruits.

The following menu demonstrates his dietary regime:

Breakfast: Large cup of tea (no milk or sugar); 2 oz. bread with

plenty of butter.

Dinner: Soup 4-1/2 to 5-1/2 oz.; meat with fat sauce; green

vegetables; fresh fruit; 2-3 glasses light wine.

Afternoon: Tea as at breakfast.

Supper: Tea, 1 egg, fat roast meat or ham, smoked fish; about 1 oz.

bread with plenty of butter; a little cheese and fresh fruit;

potatoes, sweets and sugars forbidden.

~Dietetic Treatment.~--The following menus are suggested by the

author: The carbohydrates and fats are restricted and the fluids

reduced to a minimum. The meals as far as possible are kept "dry";

soups, milk, cocoa are avoided; water is not permitted at meals;

alcoholic beverages, white bread, butter, potatoes, sugar, candy,

pastry, cakes, puddings, gravies, sauces, bread dressings, griddle

cakes, sirups, molasses, honey, ice cream, cereals, pork of all sorts,

ham, bacon pork chops, etc., olive oil, spaghetti, macaroni, and

noodles are prohibited.

~Allowable Foods.~--The following foods are allowed: Black coffee or

tea, small cup twice daily without milk, cream, or sugar--saccharin

may be used to sweeten if desired; fresh or stewed fruit with the

exception of bananas, raisins, and dates, served without sugar; all

green vegetables cooked or served without butter or fat of any

description; salads, except potato or banana, served with a special

dressing (no oil or sugar); water ices; watermelon and other melons

served without sugar; 1 egg a day; gluten toast, no butter; brown

bread or muffins made with gluten flour and prepared bran.

~The following menus~ may be used as guides in the treatment of

obesity:

Breakfast--1 sliced orange (no sugar)

1 small cup coffee or tea without cream, milk, or sugar

(sweeten with saccharin if desired)

1 poached egg on

1 slice of gluten toast (no butter)

Lunch--Cottage cheese and lettuce salad with special dressing

2 broiled lamb chops

1 slice gluten bread; 3 ounces (1 serving) apple sauce

(sweetened if necessary with saccharin)

Dinner--Roast beef

Spinach or greens (cooked without fat meat)

Green peas

Tomato and lettuce salad with special dressing

Orange or wine jelly (sweetened with saccharin)

1 slice of gluten bread or toast

7 A.M. or 1 hour before breakfast--1 cup of water containing

juice of 1/2 lemon

Breakfast--1/2 grapefruit without sugar

1 small cup black coffee or tea

Beefsteak broiled and served without butter (lean)

1 slice of gluten toast

Lunch--Tuna fish salad (no olive oil in dressing)

1 bran muffin or 1 slice (1 oz.) gluten toast

1 baked apple (without cream or sugar)

Dinner--Roast or boiled chicken (no gravy or bread dressing)

Green vegetables (peas, string beans, cabbage,[160]

turnips, artichokes (without butter))

Fruit salad (special dressing)

Lemon ice

~Amount of Food.~--The amount of food is limited to a certain extent.

Green vegetables may be eaten in abundance, but the protein foods such

as meat, fish and eggs must be limited.[161] The bread (even gluten

and bran breads) must be limited to 1-2 slices at each meal. All meals

are eaten without fluids except breakfast, when one small cup of

coffee or tea without milk, cream, or sugar is allowed. If fruit juice

is to be served instead of fruit, it must be prepared with little if

any water and no sugar. The juice may be poured over cracked ice, if

desired.

The following reducing diet is suggested by Dr. Rose for the use of

over-fat women:

REDUCING DIET FOR OBESE WOMEN[7]

_Fuel value 1052 calories--ordinary requirements 2200 calories_

========================+===============+========+==========+==========

| _Measure_ |_Weight_|_Protein_ | _Total_

| | _Oz._ |_Calories_|_Calories_

------------------------+---------------+--------+----------+----------

Breakfast: | | | |

Apple | 1 medium | 4.9 | 2 | 65

Egg | 1 egg | 2.4 | 27 | 75

Toast | 1 slice | 0.5 | 7 | 50

Coffee[162] | 1 cup | | |

Skim milk | 1-1/2 tbs. | 1.0 | 3 | 10

| | | |

10:30 A.M. | | | |

Bouillon | 1/2 cup | 4.0 | 10 | 12

Water cracker | 1 cracker | 0.1 | 1 | 10

| | | |

Luncheon: | | | |

Lean cold roast beef | Medium serving| 3.5 | 97 | 150

Rye bread | 2 thin slices | 0.7 | 7 | 50

Lettuce and cottage | | | |

cheese salad: | | | |

Lettuce | Ad libitum | | 40 | 85

Cheese | 2-1/2 tbs. | | |

| | | |

4:30 P.M. | | | |

Tea with lemon[163] | 1 cup | | |

Water cracker | 1 cracker | 0.1 | 1 | 10

| | | |

Dinner: | | | |

Boiled cod with lemon | Large serving | 8.2 | 209 | 225

Boiled potato | 1/2 medium | 1.8 | 6 | 50

Cauliflower (plain) | Large serving | 3.0 | 6 | 25

Butter | 1 tsp. (scant)| 0.1 | | 30

Water-cress and egg | | | |

salad: | | | |

Water-cress | Ad libitum | | |

Egg | 1 egg | | 27 | 110

French dressing | 1/2 tbs. | | |

Orange | 1/2 large | 4.7 | 3 | 50

Black coffee | Demi-tasse | | |

| | | |

10:30 P.M. | | | |

Hot skim milk | 1/2 cup | 4.3 | 16 | 45

| | | | ______

Total calories | | | | 1052

========================+===============+========+==========+==========

AUTHOR'S REDUCING DIET

_Approximate fuel value 965.5 calories_

=====================+==============+=========+=========+======+==========

| | _Gm._ | _Gm._ | _Gm._|

---------------------+--------------+---------+---------+------+----------

Orange | 1 medium | 1.5 | 17.4 | 0.3 | 78.3

Poached egg | 1 egg | 5.3 | | 4.6 | 62.6

on | | | | |

| oz.) | 8.4 | 8.5 | 0.3 | 70.3

Coffee (black) | 1 cup | | | |__________

| | | | | 211.2

| | | | |

Cheese | 2 tbs. | 5.9 | 1.2 | 0.2 | 30.2

Dressing | 1 tbs. | 1.5 | | 3.4 | 36.6

Lamb chop | 1 chop | 9.2 | | 12.7 | 151.3

toast | 1 slice | 8.9 | 8.5 | 0.3 | 70.3

| cup | 0.6 | 22.5 | 0.7 | 97.5

| | | | |__________

| | | | | 385.9

| | | | |

| (2 oz.) | 11.4 | | 4.8 | 88.8

Spinach | 1/2 cup | 2.3 | 3.6 | 0.3 | 26.3

Green peas | 1/2 cup | 4.8 | 11.1 | 0.2 | 65.4

Tomato | 1 medium | 0.4 | 3.1 | 0.2 | 15.8

Dressing | 1 tbs. | 1.5 | | 3.4 | 36.6

Orange juice | 1/2 cup (8 | | | |

| tbs.) | | 14.2 | | 56.8

Lemon juice | 1 tbs. | | | |

Gelatin | 1 tsp. | 2.1 | | | 8.4

Water | 1 tbs. | | | |

Bread (gluten) | 1 slice | 8.4 | 8.5 | 0.3 | 70.3

| | | | |__________

Total grams | | 72.2 | 98.6 | 31.7 | 368.4

| | | | |==========

Total calories | | | | | 965.5

=====================+==============+=========+=========+======+==========

_Approximate fuel value 930.5 calories_

=====================+==============+=========+=========+======+==========

| | _Gm._ | _Gm._ |_Gm._ |

---------------------+--------------+---------+---------+------+----------

Fruit | 1 orange | 0.85 | 12.05 | 0.15 | 53.0

Gluten toast | 2 slices | 17.8 | 17.0 | 0.6 | 140.0

soft-cooked) | 1 egg | 5.3 | | 4.6 | 60.0

Coffee (black) | 1 cup | | | |__________

| | | | | 253.0

| | | | |

Oyster cocktail | 6 oysters | 3.5 | 4.20 | 0.68 | 37.0

| oz.) | 5.7 | | 2.4 | 44.0

Cold slaw: | 1/2 cup | | | |

Cabbage | 1/2 cup | 0.002 | 0.001 | 0.034| 4.5

Dressing | 1 tbs. | 1.5 | | 3.4 | 36.0

Gluten toast | 2 slices | 17.8 | 17.0 | 0.6 | 140.0

| | | | |__________

| | | | | 261.5

stuffing) | serving | 18.2 | | 2.1 | 92.0

| size | 1.5 | 3.0 | 0.18 | 19.0

| serving | 1.95 | 6.29 | 2.29 | 34.4

Pineapple | 1 slice | 4.0 | 31.0 | 0.6 | 129.5

Dressing | 1 tbs. | 1.5 | | 2.4 | 37.0

1 apple | 1 apple | 0.6 | 22.2 | 0.77 | 98.1

1/2 egg white | 1/2 egg white| 1.5 | 0.02 | | 6.0

| | | | |__________

Total grams | | | | | 416.0

| | | | |==========

Total calories | | | | | 930.5

=====================+==============+=========+=========+======+==========

~Rules and Regulations.~--The following directions and menus are given

to be used when a reduction in weight is necessary. Care must be

taken not to allow large amounts of even the non-fat-forming foods in

the dietary, since under certain conditions the body will manufacture

adipose tissue of any surplus organic material ingested. Breakfast

must be limited as demonstrated in the tabulated diet sheet.

~Keeping the Weight Down.~--After the individual has been reduced to

approximately the desired weight the diet may be made a trifle more

liberal, keeping in mind, however, that moderation is the keynote in

the obesity regime and will have to be practised to a certain extent

always. It is wise to continue the dry meals and to limit the amount

of butter, cream, and other "fatty foods," to a certain extent. Pork,

with the exception of crisp bacon several times a week at breakfast,

had best be avoided, and alcoholic beverages should be omitted

entirely except when prescribed by the physician. The outdoor exercise

should be continued and only the amount of sleep requisite to health

indulged in. If the individual will faithfully carry out these

directions, there is no reason why the weight should continue to be a

burden. It must be remembered that it is never safe to diet

indiscriminately and without the advice of a physician, since much

harm may come of so doing.

~Value of Massage.~--Massage is an advisable accompaniment to an

obesity diet and will help to prevent a sagging of the tissues which

have been deprived of the supporting fat. The tissues of the face,

neck, and breast are especially apt to wrinkle unless given the

exercise and stimulation from massage. ~Cold baths~ are likewise

advisable, since they stimulate the body to burn up the fat.

OBESITY MENUS

Lunch--Tuna fish salad

Cauliflower

Baked apple

Dinner--Soft-shell crabs

Roast lamb

Spinach

Tomato jelly

Grapefruit

Lunch--Corned beef and cabbage

Stewed pears

Dinner--Clam cocktail

Roast chicken

Asparagus

Fruit salad

Lunch--Broiled oysters; cold lamb

Boiled turnips

Water-cress salad

Dinner--Roast beef

Stewed tomatoes

String beans

Lettuce and tomato salad

Sliced peaches

Lunch--Broiled calves' liver

Greens (mustard, turnip, beet tops, or dandelion)

Orange jelly

Dinner--Crab-flake cocktail

Broiled squab

Artichokes

Stewed celery

Lettuce, Russian dressing

Lunch--Kippered herring

Veal croquettes (baked instead of fried, with tomato sauce;

this dressing is made by adding 1 teaspoonful of chili

sauce to the regular dressing used in obesity diets)

Asparagus

Apple sauce

Dinner--Baked halibut steak, stuffed with oysters

Boiled onions

Boiled carrots

Pineapple and grapefruit salad

Lunch--Broiled calves' brains

Vegetable salad

Melon

Dinner--Broiled chicken

Boiled beets

String beans

Cucumber and young onion salad

Raspberry ice

Lunch--Stuffed eggs

Sliced tongue with spinach or greens

Carrots or beets

Fruit

Dinner--Roast turkey, cranberry sauce

Cauliflower

Tomatoes stuffed with celery, green peppers and onion

dressing

Peach whip

Lunch--Hashed beef

Boiled onions

Stewed prunes

Dinner--Oysters

Baked rabbit

Eggplant (baked)

Spinach

Fruit jelly

EMACIATION

Emaciation as a rule is a symptom of an abnormal condition rather than

a disease in itself. Certain individuals are said to be

"constitutionally thin" and upon investigation it is often found that

this thinness extends back in many cases for generations, many members

of a family being thin no matter what measures are taken to overcome

the condition. However, constitutional emaciation is not so prevalent

as constitutional obesity and, as has already been stated, is more

often a symptom of some metabolic disturbance or pathological

condition.

~Causes of Emaciation.~--~Errors in diet~--insufficient or improper

food--are accountable for most of the cases seen in infants and

children. ~Over-exercise~, that is, when the amount of exercise taken

is not commensurate with the intake of food, is accountable for other

cases. This type of emaciation is found especially in growing

children.

~Disease as a Cause.~--Wasting diseases, such as tuberculosis and

anemia, bring about a loss of weight, while in fevers in general and

typhoid fever especially not only the febrile condition hastens the

metabolic processes but also the activities of the bacteria act

together and break down the tissues of the body, causing a falling off

from the normal body weight. Loss of sleep, unhygienic or unsanitary

surroundings, and capricious appetites probably cause some of the

cases of excessive thinness.

~Thinness in Children.~--Parents are to blame for much of the thinness

seen in children, especially the nervous high-strung children whose

energies outweigh their desire for food or, as is more often the case,

their willingness to eat the proper foods. It is a mistaken kindness

to cater to the whims and fancies of a child's appetite, and much harm

is wrought by allowing the "trash" to overbalance the necessary

building or repair food in the dietary. Not that sugar is not

necessary, for it is particularly so at the age when the metabolic

processes are faster than later in life, but it must be remembered

that the body is being built up both in height and breadth.

~The Need for Building Foods.~--The skeleton and the muscular tissues

cannot be constructed from sugar, hence the diet which consists

chiefly of this food constituent is unbalanced and will sooner or

later bring about disturbances which are very apt to result in

emaciation. ~The causes of emaciation~ may be summarized as follows:

(1) Those cases which are due to pathological conditions such as

tuberculosis, anemia, typhoid fever, etc.;

(2) Those induced by errors in diet and bad habits such as

insufficient or improper food, loss of sleep, over-exercise, lack of

ventilation in the sleeping apartment, which destroys the appetite;

(3) Malformation or deformities of mouth, throat, or stomach which

make it impossible for the individual to partake of sufficient food to

cover the needs of the body;

(4) Heredity ("constitutional thinness").

~Regulating the Diet.~--As has been stated in a former chapter, any

persistent loss of weight or failure to gain on the part of an infant

whose chief business in life should be to grow, should be given

immediate and careful attention. As a rule the diet is to blame; it is

either improperly balanced, insufficient in amount, or poorly

prepared, any of which might readily cause a disturbance to the

delicate apparatus of the child.

~Diet and Habits.~--In adults, the diet and habits of life are in many

cases to blame for the excessive thinness seen in many individuals. If

the trouble can be traced to some abnormal condition, it can only be

removed by relieving or checking the disease which induced it. The

older methods of treating typhoid fever, for example, did nothing to

prevent the progressive emaciation which was the result not only of

the accelerated metabolism from the fever but also from the invasion

of the intestinal tract by the specific bacteria which brought about a

like result. In tuberculosis a similar breaking down of the tissues

occurs, as is likewise the case in anemia and other diseases in which

the functions of the blood-making organs are interfered with. Any of

the above diseases may cause emaciation, and the treatment in most of

the cases resolves itself in removing the cause as far as possible and

in adjusting the diet.

~Selection of Food.~--The dietetic treatment for emaciation is

practically the only one which will materially change the weight of

the individual, since by food alone is the body built. Certain foods

are more capable of being readily converted into adipose tissue than

others, and these must have a prominent place in the dietary.

~Rules and Regulations.~--In obesity it was found that it was

necessary to curtail the sleep and rest, increase the amount of

exercise and decrease the amount of food. In emaciation practically an

opposite regime is adopted. The patient is urged to eat plenteously,

drink copiously of water and nutrient beverages, soup, etc., avoid

worry and excitement, over-exertion and indigestion, to take one or

two naps every day, to retire early, to avoid hot baths and take a

warm cleansing bath followed by a cold shower or sponge bath. Exercise

must be of a mild character; the patient must be warned against

becoming exhausted, since this condition precludes a gain in weight.

~Dietetic Treatment.~--The meals must be carefully selected, well

prepared and daintily served, that all of the psychical benefits from

such efforts may be attained. A nutrient beverage such as cream, egg,

and vichy, reenforced fruit beverages, malted milk, with egg and

chocolate, cereal and milk gruels, etc., may be given between

breakfast and lunch, lunch and dinner and before retiring. The meals

must consist of the simplest foods that the digestion may not be

overtaxed by the quantity ingested.

~Allowable Foods.~--The following foods may be used in the treatment

of emaciation: All dairy products, milk, cream, butter and cheese,

eggs cooked in various ways, soups of all kinds, meats in moderation,

vegetables, especially potatoes, olive oil, and the various salad

oils, cereals, tapioca, macaroni, spaghetti, noodles, rice, bread of

every description, fruit including bananas, grapes, dates, raisins,

prunes, etc., ice creams, farinaceous puddings, sauces, except those

containing vinegar, grape juice and other fruit juices sweetened with

sugar, cocoa and chocolate, malted milk and proprietary infant foods,

honey, molasses and sirups, cakes, cookies and pastry in moderation.

It is advisable to make milk the chief fluid food; to this is added

cream, malted milk, lactose, eggs, and other reenforcing agents.

~Milk Cure.~--Certain physicians advise milk alone, giving from one to

two gallons a day for three weeks or longer. Many individuals complain

that "milk makes them bilious" but, as a rule, this is because the

amount taken is small and the solids insufficient to lend the

necessary bulk to the feces, consequently the peristaltic action

becomes sluggish and the passage of the food mass delayed in the

intestinal tract, furnishing a medium for bacterial growth and

activity. When larger quantities are ingested such is not the case and

the fluid so high in nutrient qualities is utilized by the body for

the building up of the depleted tissues. When the emaciation is the

result of disease the diet is necessarily adjusted to meet the

condition. At times it is most difficult to overcome the anemia and

accompanying emaciation on account of the disease precluding the

giving of the foods especially designed by nature to produce flesh.

This is especially the case in the progressive emaciation in diabetes.

However, in this case the Allen starvation treatment, with the

reeducation of the organs to a toleration for carbohydrates, has gone

far toward overcoming this distressing condition.

~Readjusting the Habits.~--When the loss of weight is found to be the

result of close application to work, lack of fresh air and sleep, or

from errors in diet, a change of climate and occupation should be

made, together with a readjustment of the daily habits, such as

substituting a cool bath for the regular hot one, and sleeping out of

doors or on a sleeping porch instead of in a poorly ventilated

bedroom.

The patient must be urged to eat, regardless of appetite, for in this

way only can the body weight be increased. The dietary must be made up

largely of the fat-forming foods, but not to such an extent as to

upset the nitrogen equilibrium.

The following diet sheet is given to be used as a guide in the

treatment of emaciation. Other foods of a similar composition and fuel

value may be substituted for those given here, to vary the diet.

EMACIATION DIET SHEET

_Approximately 5106 calories_

KEY

A _Protein Gm._

B _Carbohydrate Gm._

C _Fat Gm._

D _Total Calories_

==================+================+=======+=======+=======+========

_Material_ | _Amount_ | A | B | C | D

------------------+----------------+-------+-------+-------+--------

Stewed prunes |6 prunes | 1.02 | 35.26 | | 145.

Sugar |1 tbs. | | 14.7 | | 56.6

Oatmeal |1 tbs. (dry) }| | | |

with cream and |2 tbs. cream }| 3.2 | 25.0 | 6.6 | 172.2

sugar |1 tbs. sugar }| | | |

Poached egg |1 egg | 5.35 | | 4.16 | 58.8

Toast |3 slices }| | | |

Butter |1 tbs. }| 7.9 | 44.7 | 13.0 | 328.

Coffee |1 cup | | | |

with cream and |1 tbs. cream | .40 | .40 | 2.8 | 53.9

sugar |2 tsp. | | 9.45 | |

Milk and cream |2/3 cup milk }| | | |

|1/3 cup cream }| | | | 389.

| | | | |

11 A.M. | | | | |

Cereal milk gruel | 8 oz. (1 cup) }| | | |

with cream | 1 ounce }| | | | 248.

| | | | |

Cream of pea soup | 8 oz. (1 cup) | 6. | 17.65 | 7.66 | 185.9

Potato salad | 3.5 oz. (1 | | | |

| serving) | 1.75 | 15.5 | 15.33 | 210.

Bread | 3 slices | 7.8 | 44.7 | 1.04}|

Butter | 1 tbs. | .8 | 1.4 | 5.6 }| 328.

Cocoa made with | }| | | |

milk | 1 cup }| | | |

Sugar | 2 tsp. }| 27. | 27.6 | 41.4 | 661.

Milk | 2/3 cup }| | | |

Cream | 1/3 cup }| | | | 329.

| | | | |

3:30 P.M. | | | | |

Cream, egg, vichy | 8 oz. | 4.9 | 12.4 | 36. | 393.

| | | | |

Tomato bouillon | 1 cup | | | | 38.

cream | 1 tbs. | .30 | .42 | 5.67 | 53.9

| oz.) | 18.6 | | 17.34 | 230.5

Mashed potatoes | 1/3 cup | 1.16 | 7.5 | 3.5 | 66.5

Cauliflower | 1 serving | 1.53 | 2.99 | .42 | 21.8

Asparagus salad | 6 stalks | 2.00 | 3.72 | .24}|

with | 2 tsp. | .01 | 1.45 | 9.00}| 111.8

Bread | 2 slices | 5.2 | 29.8 | .68}|

Butter | 2 tbs. | .28 | | 24.09}| 419.

Charlotte russe | 1 serving | 2.3 | 11.1 | 22.6 | 257.

Milk | 2/3 cup }| | | |

and cream | 1/3 cup }| | | | 389.

desired | 1/2 cup | | | |

| | | | |

Malted milk | 1 cup }| | | |

made with milk | }| | | |

and reenforced | }| 8.4 | 41. | 10.2 | 288.5

with lactose | 1 ounce }| | | |

==================+================+=======+=======+=======+========

~Methods of Increasing the Diet.~--The above diet furnishes three

times as much food as is needed to maintain the body living a

sedentary life, or about as much as would be needed to maintain a

lumberman at hard outdoor labor in the Maine woods. It would be

impossible for an ordinary individual to handle such an abundant diet

without making the increase in the diet gradually. This is best done

by adding the milk and cream at the end of each meal and a glass of

milk between meals and at bedtime, then gradually adding the fattening

foods already mentioned until the diet approximates the diet sheet

here computed.

SUMMARY

GOUT

Gout is a constitutional disease characterized by an inflammatory

condition of the joints.

~The Joints~ are the seat of chalky deposits of uric acid or sodium

salts.

~Metabolism~ in gout is disturbed, with a consequent retention instead

of elimination of uric acid by the body.

~The Blood~ contains an excess of uric acid which increases greatly

during an acute attack.

~The Urine~ in true gout does not contain an excess of uric acid

except during an acute attack, whereas in the so-called goutiness

there is a constant excess of this acid.

~Uric Acid~ is produced as the result of the metabolism in the human

body of the nucleoproteins and in food of the purin bodies.

~Alcohol~ undoubtedly assists in the retention and increases the

difficulty of uric acid elimination by the body.

~Chief Causes of Gout.~--Overeating, excessive alcoholism, and too

little exercise, especially in the open air.

~Treatment~ consists in regulating the diet both as to the quantity

and type of food eaten; reducing or eliminating the alcohol in the

dietary, and increasing the amount of outdoor exercise.

~Dietetic Treatment.~--The best results are obtained by reducing the

size of the meals and avoiding the purin-bearing foods as far as

possible. Eggs are purin-free and may be substituted for much of the

meat in the diet. In chronic gout it is impossible to eliminate meat

entirely from the diet, but the quantity can be materially reduced and

that which is eaten may be rendered less harmful if it is boiled

instead of roasted or broiled, as in this way much of the purin is

dissolved out. Highly spiced and seasoned foods, rich gravies, etc.,

are apt to cause an acute attack and should be omitted. Excesses of

all kinds must be avoided to enable the patient to live a fairly

comfortable life, free from frequent painful attacks of gout.

OBESITY

~Causes.~--Heredity, overeating, unbalanced diet, chronic alcoholism,

and disturbed metabolism, as manifested in gout and other pathological

conditions.

~Cures~ are more or less of a risk, except when undertaken upon the

advice and under the care of a competent physician. As a rule they are

too strenuous to be carried out alone and are of no good unless

persisted in. Among the best known obesity cures may be mentioned

those formulated by Banting, Oertel and Ebstein.

Most physicians have their own methods of treating obesity, but all

are based primarily on diet and exercise.

~Food~ is the chief cause of obesity and since some foods are more

readily converted into adipose tissue than others, it is necessary to

understand the behavior and functions of the various food combinations

in the body before it is possible to say which are the offending

articles of diet.

~Water~ has no fattening properties of its own. This is proved by a

glance at its chemical composition, but as it acts as a distributor

and carrier of food to the various parts of the body and since the

bulk of all the secretions is composed of water and every tissue in

the body stores this fluid, thus adding to the weight, a consideration

of the intake of water for obesity patients is most essential.

~Appetite~ requires attention. The majority of obese patients eat more

than their energy output calls for, consequently it is necessary to

curb the appetite and increase the energy output in order to utilize

the material on hand in the form of adipose tissue.

~Exercise~ is absolutely essential in order to force the body to burn

up its surplus fat as fuel. The best form of exercise is that which is

taken out of doors. The well-worked muscle is heavier than one which

is unaccustomed to exercise. The latter is infiltrated with fat and

weighs less than muscular tissue, but a muscular body can endure more

than one which is covered with adipose tissue.

~The Heart~ of obese patients becomes more or less affected as obesity

advances and it becomes absolutely necessary in many cases to get rid

of some of the surplus fat in order that the patient may live. This is

best accomplished by dietetic treatment.

~Circulatory Changes~ likewise occur as the heart becomes affected,

making it necessary to institute some dietary measures at once.

~Glycosuria~ in obese patients suffering from gout is not at all

unusual and to relieve this condition the carbohydrates in the diet

must be at once reduced.

~Dietetic Treatment~ is most important. It constitutes the only

rational method of ridding the body of its surplus fat. To do this it

is necessary to regulate the diet both as to quantity and type.

Fat-forming foods are those which the body utilizes most easily for

the production and storage of fat. Any food, no matter whether it is

fat-forming or not, if taken greatly in excess of the needs of the

body, will be stored as adipose tissue.

~Chief Points~ to be remembered in formulating a diet and instituting

an obesity treatment are the necessity for _small meals_ and _dry

meals_, no fluid given at all during the meal except perhaps one or

two small cups of coffee per day, without sugar or cream, the

avoidance of fat-forming foods, sugars and starches in all forms,

milk, cream, butter and oil, potatoes, bananas, fat meats of all

descriptions, especially pork, soups of every description and

alcoholic or malted beverages. It is necessary to limit the amount of

sleep, prohibiting naps during the day, and to increase the amount of

outdoor exercise.

~Massage~ is advisable, especially in those patients who are unable,

on account of their excessive weight or heart symptoms, to take the

requisite amount of exercise necessary for their future welfare.

Massage likewise makes the muscles firmer, often preventing the

disfiguring sagging of the skin caused by depriving it of its padding

of fat.

EMACIATION

~Causes.~--Errors in diet, overwork, over-exercise, heredity,

nervousness, worry, malformation of the mouth, throat, or stomach,

heredity and certain pathological conditions, such as typhoid fever,

tuberculosis, anemia, dysentery, etc., in which the breaking down of

the tissues occurs more rapidly than they can be rebuilt.

~Children~ are often emaciated on account of their unbalanced diet.

They receive an insufficient amount of building food to cover their

growth and development requirements. Parents are often to blame for

allowing the child to overeat of some of the food constituents at the

expense of others. Sugar, for example, is very necessary in the diet

of a growing active child, but all sugar and very little milk and

eggs will lead to an unbalanced diet which may bring about a

condition of extreme thinness later on.

In ~Adults~ the constant eating of the wrong foods, overworking and

persistent worrying, all contribute to the breaking down of the

tissues which ends in emaciation.

~Weight~ is an index to health. Any persistent loss of weight on the

part of an adult or loss or even failure to gain in a growing child,

are indications that all is not right and immediate measures must be

taken to locate and relieve the trouble.

~Loss of Weight~ due to pathological conditions can only be relieved

by removing the cause, after which the diet may be adjusted to suit

the condition.

~Dietetic Treatment~ is practically the only means of combating and

overcoming emaciation, since it is by food alone that the body is

built.

Fat-forming foods, which in obesity were prohibited, have a prominent

place in the diet for emaciation. Padding the nerves and organs with a

layer or covering of fat protects them from the jars and shocks

incidental to daily life, besides lending grace and contour to the

body.

~Foods Which Produce Fat~ are nutrient beverages of all sorts; milk,

malted milk and cream are especially valuable; water, because of its

particular properties and functions in the body; and fruit beverages,

which are made chiefly of water and sugar, are always included in the

dietary. Milk and cream, soups and milk gruels, as well as all dishes

made with milk or cream, add materially to the fat-forming quality of

the diet. Butter, olive and other salad oils, as well as cereals,

potatoes, bread and simple desserts are advised. The diet must be

bountiful, the meals frequent, and lunches consisting of milk or cream

with crackers will hasten the gain in weight.

~Rest~, preferably lying down, is absolutely essential. A period of

relaxation covering from fifteen to thirty minutes should be taken

before or after each meal. The body derives the use of the food for

the storage of fat which would otherwise be required to cover its

energy expenditures.

~Sleep~ is essential to gain, consequently the patient should retire

early and take one or two naps during the day.

~Baths~ should be warm, not hot, followed by a cold shower or sponge.

~Exercise~ must be mild in character; over-exertion precludes a gain

in weight and exhaustion undermines the forces which make it possible

for the body to store fat as adipose tissue.

~Nervous Excitement and Worry~ must be avoided.

~Gastro-intestinal Disturbances~ should be guarded against, since all

the pounds gained through months of treatment may be quickly lost

during one acute attack of diarrhea or auto-intoxication.

~Massage~ is advised. The kneading and gentle manipulation of the

muscles stimulates them to utilize more food material, besides

enabling the patient to eat more by reason of an increased appetite.

~The Milk Cure~ has been used extensively in overcoming extreme

emaciation. It consists in the taking of large quantities, ranging

from one to two gallons per day. It is given every hour or oftener for

a period of one month to six weeks.

~Reenforcing the Diet~ with eggs and lactose is often found of great

value in increasing the weight quickly, as is the giving of one-third

of a glass of cream and two-thirds of a glass of milk after each meal

and at bedtime. The whole scheme of putting on pounds resolves itself

into the giving of proper food in larger quantities than are

ordinarily given, but dividing it up into frequent meals in order not

to upset the digestion and do away with the good already accomplished.

PROBLEMS

(a) Formulate a diet order for a patient with gout in which the purin

foods are eliminated.

(b) Formulate a diet order for an obese patient whose heart is more or

less affected.

a diet order for day suitable for a patient (woman) weighing 110

pounds, whose normal weight is 135 pounds.

FOOTNOTES:

[156] "Food for the Sick," p. 97, by Strouse and Perry.

[157] The amount of food must be limited, since overeating will

precipitate an acute attack. It is best to limit the amount to about a

maintenance allowance or a little more, temporarily.

[158] "Diet in Health and Disease," by Freidenwald and Ruhraeh.

[159] _Ibid._, p. 544.

[160] Boiled vegetable dinners must be prepared without fat meat and

potatoes.

[161] Scientific investigation has proved that both carbohydrates and

fats may be formed in the body from protein. Hence any excess above

that required to keep the body in nitrogen equilibrium is utilized by

the organism for fuel or stored as fat.

[162] "Feeding the Family," p. 84, by Mary Swartz Rose.

[163] Saccharin may be used to sweeten.