Dietetics for Nurses

CHAPTER XXII

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:

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,

To keep the body in good condition and to help rid it of accumulated poisons, the following diet lists are recommended:

Daily Dietaries:

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.

(c) Where there is obesity in adults with anemic symptoms in whom not 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:

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 régime:

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

Dinner: Soup 4½ to 5½ 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:

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[162]

Fuel value 1052 calories—ordinary requirements 2200 calories

Author’s Reducing Diet

Approximate fuel value 965.5 calories

Approximate fuel value 930.5 calories