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The treatment of obesity for children in low income families : a study of the social worker's role in… Watt, Frances Meta 1951

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n\y ft? THE TREATMENT. OP OBESITY FOR CHILDREN  m LOW- INCOME FAMILIES. A Study/ of the Social. Worker's Role i n a C l i n i c a l Setting by FRANCES MET A. WATT Thesis Submitted i n P a r t i a l Fulfilment of the Requirements for the Degree of MASTER. OF SOCIAL WORK in the. Department: of S o c i a l Work 1951 The University ot B r i t i s h Columbia A B S T R A C T : T h i s s t u d y r e v i e w s t h e methods: and degree: o f s u c c e s s o f t r e a t m e n t f o r obese; c h i l d r e n : a t the: n e w l y -founded- M e t a b o l i c C l i n i c at. t h e V a n c o u v e r H e a l t h C e n -t r e f o r Children... The C l i n i c has c o n f i n e d i t s e l f to. the.' t r e a t m e n t , o f c h i l d r e n f r o m Low—income f a m i l i e s ; . . The e x t e n t , and. s i g n i f i c a n c e o f e m o t i o n a l and p h y s i c a l , m a l a d j u s t m e n t s i s r e l a t e d to; t h e c a u s e s o f o b e s i t y and the e f f i c a c y o f t r e a t m e n t given;- t h i s i n d i c a t e s t h e c o n s i d e r a b l e s i g n i f i c a n c e o f s o c i a l , casework, a s a: t r e a t m e n t a i d . . C u r r e n t d o c t r i n e s o n the c a u s e s a n d a t t e n d -ant' p r o b l e m s a s s o c i a t e d w i t h o b e s i t y i n c h i l d r e n a r e r e v i e w e d as a background, a g a i n s t whi.ch. to: e v a l u a t e t h e C l i n i c , d r a w i n g h e a v i l y f o r t h i s purpose- oh the e x p e r i e n c e and f i n d i n g s of Dr.. H i l d e B r u c h i n h e r work w i t h a c l i n i c In. Hew Y o r k . The s p e c i f i c e v a l u a t i o n o f . t h e work: o f t h e C l i n i c - i.s made t h r o u g h case, summaries and i l l u s t r a -t i o n s ... (The w r i t e r w o r k e d a t the C l i n i c d u r i n g t h e s.choo:L s e s s i o n , and. d u r i n g t h e summer o f I9'50.} A . t e n t a t i v e s t a t i s t i c a l , i n t e r p r e t a t i o n of t h e p r o g r e s s with, t h e t w e n t y - s i x . cases,, t r e a t e d d u r i n g t h i s p e r i o d , i s made i n terms, of. the p e r c e n t a g e o f w e i g h t Loss, o r g a i n . i n . r e l a t i o n t o the amount by whi.ch each, c h i l d exceeds, t h e e s t i m a t e d . riormaL weight.. The v e r y L i m i t e d e x t e n t , t o w h i c h t r e a t m e n t o f i n d i v i d u a l , cases, has been s u c c e s s f u l , l e a d s to. r a t h e r -n e g a t i v e c o n c l u s i o n s . The i m p o r t a n c e of c l i n i c a l t eam-w o r k an d p a r t i c u l a r l y o f s o c i a l c asework i n d i a g n o s i s , o f the u n d e r l y i n g c a u s e s o f t h e p a t i e n t l ; s obese c o n -d i t i o n I s c l e a r . But t h e dgr.ee to; w h i c h the c l i n i c a l team's e f f o r t s c an take e f f e c t depends upon, t h e amount of c o o p e r a t i o n w h i c h i t i s p o s s i b l e t o o b t a i n . f r o m the p a t i e n t , a n d h i s f a m i l y . : E v a l u a t i o n must b e a r In. mind, t h a t t h e f o r m a t ion. o f a M e t a b o L i c C l i n i c f o r c h i l d r e n , a t Vancouver.' i s of. v e r y recent, o r i g i n . I t i s concerned, wl.th. the t r e a t m e n t o f a c o n d i t i o n a b o u t w h i c h m e d i c a l , s c i e n c e has no.t h i t h e r t o d e v o t e d much, a t t e n t i o n . , : so t h a t , the C l i n i c work must be s e e n as. the e x p l o r a t o r y and p-ianeerv ACKH0WXEDGEME1TT& I wish to preface' my acknowledgements by express-ing my gratitude to Miss G:. Rubinovitch for stimulating my interest In t h i s study. I should, l i k e p a r t i c u l a r l y to thank Br. L. Marsh for h i s u n t i r i n g assistance throughout the preparation and organization of t h i s study, since without his help I t would not have materialized* For t h e i r kindly assistance i n providing; pertinent information I would l i k e to express my appreciation to; Dr.D. Paterson, p e d i a t r i c i a n i n charge of the Health Centre f o r Children; Dr. D. W i l l e t s , Associate Director of the Metropol-it a n Health Committee and to Dr. B. Shuman, p e d i a t r i c i a n in charge of the Metabolic C l i n i c . I am also most grateful to Miss M. Johnson, who read t h i s study for s o c i a l work content iind who made many he l p f u l suggestions:. i i i TABLE OF CONTENTS CHAPTER PAGE I SETTING OF STUDY . . . . . . . . . . . . . . . 1 Nature of Obesity S o c i a l Significance f o r Children The Metabolic C l i n i c for Children, Vancouver The Group Involved i n the Present; Study II DIAGNOSIS OF EMOTIONAL AND PHYSICAL CAUSES: . . 13 Introduction - the physical condition of obesity Physical causes of obesity: (1) Intra-cranial lesions and other bodily defects, (non-glandular.) (2) Endocrinal disturbances Emotional causes of obesity (1) Personal adjustments, a p p l i c a t i o n to;, children (2) I n t e r - f a m i l i a l adjustments (3) Environmental and s o c i a l adjuatmenta Diagnostic Process I I I TREATMENT1; . . . . i . ; ; ; ; . . ; . . ; ; i 38 Methods of approach i n treating obesity Current thinking i n the treatment of obesity: glandular therpay, dietary therapy, drug therapy Treatment methods, used i n the Metabolic C l i n i c (1) Physical factors -Glandualr therapy, dietary therapy, and drug therapy (2) Emotional Factors Summary IV THE DEVELOPMENT OF THE CLINICAL TEAM AND ITS OPERATION . . . . . . . i . . 56 The C l i n i c a l team, development of policy Some aspects of the ' r e f e r r a l ' process Some aspects of the 'follow-up' process Summary CHAPTER PAGE V EVALUATION OF THE WORK OF THE' MET&BOLIC * " * CLINIC* SUCCESS AND FAILUREi CONTINUING NEEDS. . . 70 A general index I l l u s t r a t i o n by cases s f a i l u r e s I l l u s t r a t i o n by cases:;; successes Margins:! Group Conclusions The need f o r more: s o c i a l work s t a f f The need f o r p s y c h i a t r i c follow-up The value; of group therapy The need f o r an in t e r p r e t e r The need for developing good eating habits APPENDICES A Ind.icato.-ra of Obesity . . Note 1 Wetzel Grid Note 2. Basal Metabolism 93 B: Detailed constituents: of 1600 cal o r i e d i e t Detailed constituents of 19O0 calorie: d i e t 96 99 Table: Details, of Total Children Attending; C l i n i c showing success or f a i l u r e i n weight l o s s . . . . . . . . . . . . . . . . . . . . 102 BIBLIOGRAPHY TABLES SUCCESS OR FAILURE IN WEIGHT LOSS OF CHILD-, KEN ATTENDING THE METABOLIC CLINIC . . . . 71a THE TREATMENT: OF OBESITY FOR CHILDREN IN; LOW INCOME,.FAMILIES A Study of the Sooial. Worker*s Role- i n a C l i n i c a l . Setting - y -CHAPTER: I SETTING. OP THE STUDY Nature of; Obesity It has been stated that obesity Is the moat fre-quent physical abnormality found in mankind. Approximately twenty-eight percent o,£ the world's population are ten percent or more overweight. The handicaps Imposed by obesity have been enumerated by a number of authors: yet frequently phys-icians dealing: with individuals f a i l to^  emphasize to; the pat-ient the. seriousness of this disease. I t is easy to> shrug off "a few pounds of overweight" as something- of l i t t ler conse-quence, but to do so may he ignoring what; i s perhaps-- the best chance to lengthen the l i f e and. diminish the future i l lnessea of the person concerned. Stat ist ic ians have in recent years been pointing out the increase i n deaths from such degenera-t ive diseases as diabetes, cancer and heart disorders:. We may 1. Obesityi derived from the Latin "obesus" meaning eaten up or lean5 gradually the term came to have the opposite mean-ing,, that of being overweights The term•""adiposity" may be used as a synonym and. i s perhaps a better choice since i t l a de-rived-, from the Latin Madtps t t meaning * fat M . 2. E d i t o r i a l , A Study of Impairments found among 10,000 wi-se lec ted examinees, Ar t i c le II, Proceedings Life Ext . Exam.. 1*89-93, July - August, 1939:, page 89. 3 » Ib id . , page 90. 2 jus t i f i ab ly Infer from such s ta t i s t i ca l trends that medicine Is approaching: a point of diminishing returns: and that increas-ing efforts; w i l l reduce the death and i l lness rates only s l i ght ly . Actually, great improvement, in the health of the nation is possible by meana of the correction and prevention of obesity. It i s s igni f icant that In time of war, countries with diminished supplies of food have demonstrated a definite decrease in the incidence of degenerative diseases. Obesity causes a diminished v i t a l capacity, generally through the mechanical res tr ic t ion of respiratory movements 7 • • " 5 by deposits of fat in the abdominal and thoracic walls. I f the duration of this obesity i s long enough, emphysman (disten-tion of tissue) develops and the patient's v i t a l capacity i s permanently Impaired even I f there is an adequate: reduction of weight at a later date. Though obesity may stem from a number of physiolog-i c a l causes the condition may more generally be associated with psychological maladjustments• It i s not yet well known that the theories! that obesity Is due to glandular imbalance, metab-olism; or other physiological factors have been refuted by 4. Metropolitan Life Insurance Companyj Ideal Weights for Men, Metropolitan Life Insurance Sta t i s t ica l Bul le t in . 2416-8, June, 1943. 5. Short, J . J . and Johnson, H . J . , The Effect of. Overweight on V i t a l Capacity, Proceedings Life Ext. Exam., It36-41, March - A p r i l , 1939. Newbourgh and others, who in a series of thorough investiga-tions;, have heen unable to find in the great majority of obese persons any deviations from normalcy In endocrine or metabolic behaviour. The conclusion is; warranted that the condition of obesity is simply due to a positive caloric balance and that these persona eat more food, than they expend in the form of energy. Special Significance for Children The problems associated with obesity have special significance for children; since recent work has revealed that, extent to; which this condition may spring from psychological origins and the manner in which i t can he come a- problem in quite early childhood. Dr.. Bruch, who has done: a great deal of work with obese children has investigated the psychological significance of this disease;. She has shown in a series' of art ic les that obesity due to a. physiological condition occurs in about five percent, of the c l i n i c a l attendances. 6. Newbourgh, L . H . , Obesity? Energy Metabolism, Physiol;Rev.. 24*18, Januaryj 1944. 7. Conn, J.W.,. Obesity: E t io log ica l Aspects, Physiol;Rev., 24*18, January, 1944. Freed, S .C; * Obesity in Greenhill J .P . , Office Gynecology* ed;4, revised Chicago, The Year Book Publishers, March,1940. BrUch, H . , Obesity in Childhood, and Endocrine Treatment, Journal of Pediatrics, 18*36, January, 1941. 8. These include* Physical Growth & Development of Obese 4 The psychic pattern of the mothers of obese children Is; usually as d i s t i n c t i v e as that of t h e i r offspring. Such mothers usually go to extremes i n protecting t h e i r children from even the minor; c o n f l i c t s of l i v i n g , but paradoxically entertain great ambitions f o r them. Their children are s h e l t -ered from the f r i c t i o n s of normal d a i l y contact with other children. They are commonly bathed and dressed by t h e i r mothers f a r beyond the usual age for such care. Br. Brueh found that the obese child. Is commonly the only or the young-est c h i l d In the family. Within such families there i s alao frequently a great emphasis, on food. Deserts and candies are used aa rewards for good behaviour; conversation centres around d e l i c a c i e s of: the table, and the c h i l d gains the f e e l i n g that food i s the end and purpose of l i f e . The mothers of obese children were found by Dr. Bruch to be emotionally starved themselves, often disappointed i n t h e i r husbands or i n the sex of t h e i r children; or worried over domestic s t r i f e . Aa i f i n compensation, these mothers attempt to l a v i s h upon t h e i r children a love that they do not honestly f e e l . Under such conditions they tend, to overemphasize the material things:; 8. cont'd, from p.3. Children, Am.J. of Diseases of: Children. 58s457,Sept. 1959. (b) Basal Metabolism and Serum Cholesteral of Obese Children, Am.J. of Diseases of Children. 58tlOQl, Nov. 1939?. (c) P h y s iological and Psychological Aspects of the Pood Intake of Obese Children, Am. J . of Diseases of Children, 59*739, A p r i l , 1940. 9. H i l l , J o e l , Infant Feeding and Personality Disorders* a. Study of E a r l y Feeding i n i t s Relation to Emotional and Digestion Disorders, Psy ch i a t r i c Qiuar te r l y , 11 * 356-382, July, 1937. 5 namely, food, protection from the unpleasantness of work, and protection from contact with other children "who might play rough*. These mothers are, nevertheless, obteri unable to give their children true: affection. The Metabolic C l i n i c , for Children. Vancouver The tremendous wartime expansion of the population of Vancouver and the concomitant increase in the school popu-lation , brought with i t proportionally large^numbers of chi ld-ren with physical and emotional problemsi As a result of a comment made by the; Associate Director of the Metropolitan Health Committee that five hundred of Vancouver's f ive hundred thousand school children, were thir ty percent overweight, it. was decided that a. sufficient, number bf children would be e l ig ib le for treatment at, the Health Centre for Children of the Vanouv-er General Hospital to warrant the formation of a special c l i n i c . The. number of children that could be expected to attend, such a; Clinic, was; roughly estimated from the assumption that ten percent of the population l ive on incomes low enough to make them el ig ib le for treatment, at the Vancouver General Hospitarl. Out-Patient's Department or Health Centre for Child-ren. According to this estimation, ten percent or five hundred and f i f t y children might be referred to the Metabolic C l i n i c . This group is only O.Ol percent of the total school population, but i f this number is: expressed in terms of c l i n i c a l attendances or rather, potential attendances, the number represents a fa ir sized group. If this group of children were to be treated in the general pediatric: c l i n i c , the prognosis of their d i sea se would he: impeded by two factors.: F i r s t j, there would be a lack of coordination in the treatment prescribed as. a result of the: variance between the medical advice of the different v i s i t i n g doctors. Secondly, the efficacy of the subsequent work of the d ie t i c ian , social worker and public health nurse, in carry ing out the treatment prescribed would be nu l l i f i ed by th i s variance in the medical advice. Consequently such efforts to tackle the problem of obesity would be of l i t t l e value for the purpose of improving the treatment and foHow-tup process 3ince they would not be used to make any val id predictions:. It was for the purpose of devising: an effective method of treatment for the problem of obesity that a. separ-ate c l i n i c was formed, within whose bounds it. has become poss-ible to practice controlled methods of treatment. This clinic- was. called the Metabolic; C l in ic ao; that i t would be possible to study the problem of the underweight chi ld as. well aa other glandular disorders at a la ter date• The term metabolic also has. a psychological value in that, i t does not point so direct ly at the: patient's complaint. This is important in view of the extreme sens i t iv i ty of obese persons, with regard to their abnormality. The Health Centre of which the Metabolic Cl in ic i s now a part, operates as a branch of the Out-Patient Department and is therefore subject to the same administrative policy-concerning staff regulations and' services offered. However, i t functions as an independent body regarding financing of new developments; and capital expenditures; The services provided by the Women*s Auxi l l i a ry of the Vancouver General Hospital , have been invaluable. This organization has, by means of a snack bar, provided soup, milk and cookies for both children and mothers* They have aXao undertaken some of the work of providing: transportation for p a t i e n t s • „ weighing.and measuring the children and assist-ing: with the ciericaL d u t i e s » The Health Centre performs the dual role of a treat-ment centre for children, as well as providing training: for students; As i t serves as a health centre fortthe whole Province as well as in the greater Vancouver area, i t i s thus able to detect disease, in i t s earliest stages. Its services entai l a thorough overhaul and check-up and include such things as tuberculine testing, urine examination, weighing, and the taking of temperatures• Children going to special departments have a l l had a thorough examination before being passed onto the special ists . By i ts role as a place of training for both internees and residents*, the Health Centre provides much valuable c l i n -ical, ma. t e r i a l which i s only available through an out-patient department. The following c l i n i c a l services are offered at 8 the Health Centres- pediatric , ear, nose and throat, orthopaedic, eye, al lergy, infant feeding, diseases of the skin* model well-baby, chi ld psychiatryi rheumatism and cardia, surgicalj neuro-log ica l and metabolic. E l i g i b i l i t y for admittance to the C l i n i c , as mention^ ed in a previous section, i s confined to those whose income is not greater than one hundred and ten dollars, per month for the man, wife and one c h i l d , or a maximum sum increase of twenty-dollars per month for each child thereafter. Sometimes special consideration Is given to borderline cas;es where the family has had a lot of medical expense? in such instances, the social, workers are responsible for assessing e l i g i b i l i t y for treatment and. admission to the c l i n i c . The building: occupied by the Health Centre was form-erly a cafeteria run in connection with the Nurses * residence of the Vancouver General Hospital* i t was completely rehabil-itated during the winter of 1947-48, the expenses being met by a fifteen thousand dollar donation from the Rotary Club. The origins of the Health Centre were largely due to the in i t i a t ive of Dr * Pater son, pediatrician-in-char.ge.. For one year the: sa l -aries and various expenses connected with the Health Centre were maintained by private donations* At present the current expenses, come under the budget of the Vancouver General Hosp-• 10 i t a l Out-Patient's Department. The costs of additional staff, 10. Annuai Report, Health Centre for Children, The Vancouver General Hospital , June 1949 - May 1950, page I. 9 equipment and new developments must s t i l l be undertaken by-voluntary contributions,, though recently some Dominion Health grants have been received. The group Involved i n the- Present Study. This study attempts to analyse and evaluate the ex-perience of the Metabolic- C l i n i c since Its inception and there-by to reveal the: significance: disturbances i n r e l a t i o n to the problems of obesity i n children. It i s therefore necessary at th i s stage to: consider the origins of the group studied a t the C l i n i c . A l l . children coming to the Health Centre for the 11 . • ' " ' • •'• f i r s t time, must be referred by a- Public Health or School Nurse, private; doctor, or a member of a recognized agency. I f a c h i l d 11. A l l . patients attending the Health Centre f o r Children for the f i r s t time must produce a r e f e r r a l s l i p from a. recog-nized, body, such as the Metropolitan Health Committee, another s o c i a l agency or a private doctor. According to; the regulations,^ the Metropolitan Health Committee or the s o c i a l agency, before making a r e f e r r a l , must f i n d out i f the patient i s attending a doctor p r i v a t e l y . In such cases the r e f e r r a l must be v e r i f i e d with the doctor. This step in the r e f e r r a l process: prevents any duplication i n treatment. The doctor usually acquiesces to the transfer of the patient to the Health Centre f o r Children i f the patient; is: e l i g i b l e f or treatment since I t i s much more advant-ageous f o r the patient to receive treatment f r e e . The r e f e r r a l s l i p gives the patient's name, address and a statement of the patient's complaint, This s l i p must be signed by a doctor and may consist of a "blue form'* submitted by the Metropolitan Health Committee or a l e t t e r written by a, doctor serving a s o c i a l agency or i n private pra c t i c e • The r e f e r r a l slips, are checked by the s o c i a l worker i n the Health Centre and a s s i s t In determining; e l i g i b i l i t y . Although the nature of the complaint i s sp e c i f i e d on the r e f e r r a l s l i p , a l l patients are received by the Pediatric: C l i n i c for a. complete medical check-up before being referred by one of the p e d i a t r i c i a n s to a specia l i z e d c l i n i c . 10 i s referred who is already seeing a doctor privately, i t is necessary to check with the doctor concerned before the chi ld Is: admitted; Gases are referred to the Metabolic: C l in ic oh a sel-ective basis from the pediatric attendances. Direct referrals: made by the Public Health Nurses were not i n i t i a l l y considered since i t was fe l t that the number of cases should be kept to a minimum in the early period to facil itate, the development of a routine and some definite pol icy in treatment. The significance of the referral policy adopted by the Glinic l i e s in the fact that a child, may original ly have been referred to the Health Centre for a complaint hot necessar-i l y connected with obesity. Since a l l . cases are i n i t i a l l y sent into the Pediatric C l i n i c , the chi ld would be screened out a t this level for the Metabolic C l i n i c . By this selective process within the Health Centre, the number of patients attending the overweight c l in i c has been controlled. This has enabled the more severe cases to be seen f i r s t and also thoses: cases which presented the most; favourable prognosis,. For the most part the group studied in the Metabolic Cl in ic i s confined to children who are th ir ty percent over the normal weight for their age, height and body bui ld . This per-centage constitutes about 0.9 percent of Vancouver's school pop-ulat ion according to the s tat i s t ics of the Metropolitan Health Committee* (approximately 500 of the 50.0.,OOO school children). 11 Since only those children belonging to low income group families are e l i g i b l e , only about; f i f t y of these f i re hundred petentially overweight children are l ike ly to1 be referred to the Health Centre. In an interview with the writer on J.uly 18, 1950, the, Associate Director of" the Metropolitan Health Committee explained that,, at present,,, due to the limitations of staff and f a c i l i t i e s , i t Is; only possible to treat those children who are th i r ty percent or more over their normal weight. . This cr i ter ion of thirty per-cent is an arbitrary figure set up by the City School Health Services. Eventually the Committee hopes to treat a l l children twenty percent over their normal weight, but this number would, as yet*, present too large a group for the existing nursing; and dietetic staff . The cases admitted to the Metabolic Cl in ic are not s t r i c t l y confined to those children who are thir ty percent or more overweight, because of the referra l process of the Metro-politan Health Committee. Since there is no internal policy in the Health Centre l imit ing the degree of. obesity to be consid-ered for fe ferra l , i t Is quite possible that some of the pedia-tricians may refer children who are somewhat less than thirty percent overweight. The children referred by the Metropolitan Health nurses w i l l , however, a l l be th i r ty percent overweight. As explained in the previous section a i l cases re-ferred to the Health Centre for Children w i l l have to be f i n -ancial ly e l i g i b l e . This regulation is set up i n accordance with the policy of the Out-Patient Department of the Vancouver General Hospital . E l i g i b i l i t y i s confined to married couples earning not more than ninety dollars per month plus twenty dollars per month for each c h i l d . If there is; only one parent responsible for the c h i l d , the amount of earna.ble Income is seventy dollars per month for the parent, plus twenty dollars per month, for each ch i ld . In borderline cases special consid-eration i s given to those families who have had a great deal of medical expense and s t i l l face heavy b i l l s * l o r example, a couple with one. chi ld earning one hundred and ten dollars per month or less , may send their child for treatment at the Health Centre for Children. CHAPTER II DIAGNOSIS OF THE EMOTIONAL AMD PHYSICAL CAUSES Introduction - the Physical Condition of Obesity Obesity can be described as due to an intake of calor-ies in excess of the requirements for energy metabolism, physi-cal ac t iv i ty and growth (protein anabolism). Thus, in the dev-elopment of adiposity there are two important variables, the 12 calorie intake and the calorie expenditure. A relative increase in diet or a relative decrease in the energy metabolism, physi-cal ac t iv i ty and/or rate of growth, w i l l tend to y ie ld a surplus of calories which may be stored as body fat . Most obesity i s due to over-eating rather than to a diminished energy expenditure on a normal dietary intake. Not uncommonly, patients or their parents w i l l c l ing tenaciously to the bel ief that the quantity of food eaten is not large. How-ever, in such cases i t is usually possible to discover a history of dietary excess at some ear l ier date. In other words, once a patient has eaten too much and becomes fat , he w i l l tend to re-main in that condition even i f he is eating only a maintenance diet , and he w i l l not lose weight u n t i l such time as he eats fewer calories than he is burning. 12. Talbot, N .B . , Obesity in Children, Medical Cl inics of  N. Am., V o l , 29, 1945, page 1217. 14 In certain circumstances over-eating may be more common amongst families on low incomes than i t is amongst high income families, D'rv Bruch and Miss Touralne studied forty families attending a c l i n i c in New? York and found from this study that the amount spent on food was disproportionately large in the low income group family. Much greater emphasis was put, on food since f inancial insecurity represented an ever-present threat} consequently there was ar tendency to eat well while It was s t i l l possible, Therefore in such families a low Income: has led to a pattern of over-eating. Physical Causes of Obesity 14 . V Mention has, already been made of the limited incidence of obesity due solely to. glandular or other defects. It i s int-eresting to note^ therefore, that of the twenty-six patients seen in the Metabolic Cl in ic at the Health Centre for Children, only one chi ld was found to he overweight: due to a physiological dysfuntion. Physiological causes of obesity may be class i f ied under two general headings: (1). intra-cranial .lesions and other bodily defects (non-glandular disturbances), and (2) endocrinal disturbances, 15 (l) Intra-cranial lesions and other bodily defects The "Prohlieh syndrome0 consists of disturbances of the 13. Bruch, H i , Touraine, G . t Obesity in Childhood V, The Family Frame of Obese Children, Psychosomatic Med., V o l . a , A p r i l 1940, p.141. 14. See Chapter I, page 2. 15?. Lesion: an injury, wound or morbid structural change. 15 functions involved in nutr i t ion, digestion and assimilation, in the presence of a neoplasm or tumor-like growth at the base of the brain; These disturbances are trophic or nutritional: disturbances and take the form of Infantilism or the persist-ence of childish characteri s t ies into adult l i f e . They include obesity and genital dystrophy or displacement of the genital organs part icularly in the male due to the adipose condition* The c l i n i c a l work of Frohlich i s recognized as showing for the f i r s t time, the relationship between the diagnostic significance of obesity and other nutrit ional or trophic disturbances* How-ever, his assumption that the tumor originated from the hypophy-sis; or pituitary body has not been borne out by subsequent c l i h -• ' 16 i c a i and experimental evidence. The regulation of food intake by the central nervous system Is. not limited to the cerebral cortex.. Another central representation has been discovered in the vegetative nuclei of the hypothalmus. Experimental lesions have been used to demon-strate this association of adiposity with the region of the veg-etative centres. Keller and Noble noted the great greediness and tendency to over-eat. (polyphagia) 0 f animals in which adiposity developed after hypothalmic or infundibular lesions. Prohlich describes pathologic lesions in the hypothalmic region which may 16. Bruch,H., Prohlich Syndromes Report on Case» Am. Journal of: . Diseases of Children. V o l . 58, 1939, page 1282. 17. Keller* A . D . , and Hoble* W,-. Adiposity with Normal Sex Function Following; Extirpation of the Posterior Lobe of the Hypophysis in the Dog, Am. J,. of Physiology, Vo. 113, 1935, page 79. 16; be~< associated, with-adiposity, as neoplasms or tumors* The incid*» ence, however* of such demonstrable organic causes among the large number of patients suffering from obesity is small. Due to the d i f f i cu l ty of Isolating physiological from emotional, causes, one cannot help but. wonder i f certain emotional experiences evoke an Increased desire for food, by hypothalmic stimulation. The hypothalmus regulates and controls the physio-log ica l expression of hunger. The s imilar i ty between: obesity of known central or ig in and simple obesity makes i t l i ke ly that; anal-agous mechanisms are Involved in the production of the condition^ Bodily defects found: in association with obesity, such as retinal degeneration or r e t i n i t i s pigmentosa:, menta-i retards** tion and hypogonadism, would appear to be hereditary famil ial deviations, (2) Ehdocrlnarl Disturbances As stated previously, re lat ively few i f any cases of ob-esity are due to glandular disturbances. It has been found also that, many patients may actually gain weight on thyroid therapy because their appetites, become greater as the result of increased ' • 19 nervous tension induced by the medication, Dr, Bruch has stressed the mental as well as physical 20 dangers of glandular, treatment because of i t s tendency to produce 18* Bruch, H , , Physiological and Psychological aspects of the food intake Of Obese Children, Am, J. of the; Diseases of Children. V o l . 59, A p r i l 1940, page 739. 19:. Freed, S . C . , Psychic Factors in the Development and Treatment of Obesity, The J . of the Am. Medical Assn. , Vo l . 133, No. 6, Feb. 1947, page 369. 20. Bruch, H . * Obesity in Childhood and Endocrine Treatment, The J . of Paediatrics, Vo l . 18, 1941, page 36. 17 or- increase the apprehensive and over-solicitous attitude of the parents, and to block the road to a. rational treatment of obesity. Emotional Causes of Obesity The financial, stress present in pract ica l ly a l l low-income group families should he borne In mind when considering the emotional causes of obesity. This stress or lack of secur-i t y may in i tself : bring; many additional problems because the family is placed under a^  tension which may in i t i a te or contrib-i ute to family discord* Since i t has not been possible to make a comparable study of a group of children coming; from homes in the higher income groups, i t w i l l be d i f f i c u l t in this study to isolate the problems ar is ing from financial insecurity and the problems, stemming; purely from personality d i f f i c u l t i e s . It would be faulty reasoning, to assume from this lack of empirical evidence that families in the higher income groups are capable: of more mature fami l ia l and soc ia l adjustments or that they possess greater ego strengths. One would expect, fam-i l ies : from both income groups to have the same capacities, weak* nesses and strengthst but the family faced with f inancial i n -security has: an added, tension or strain which may a:ct as a cata-lyst In hastening; or bringing about famil ia l discord. Of the twenty-six cases studied at the Health Centre, half the families functioned without the assistance of the father. In five families the father had died* The father was i l l i n four other families, and in another four families the father had either 18 left completely or only returned occasionally. Although these problems are not peculiar to low income groups, the absence or fai lure of the father to contribute support has in these cases meant that the family has had to depend on social assistance or small pensions for subsistence. Absence or incapacity of the "breadwinner* has rendered many of these families f inancial ly e l ig ib le for free medical treatment; at the Health Centre. If a study were to be made of a group of children coming; from 'well to do1 homes i t is doubtful whether the absence of the father would, be proportionally as large. This i l lu s t ra t ion shows how the; economic, status: of the group studied has a, def-inite bearing; on the incidence and type of problems that occur. The emotional causes of obesity can be considered under three general headings: (l) Personal adjustments, (2) Inter-familial adjustments, and (3) Environmental and social adjustments. A. study of the twenty-six children who have attend-ed the Health Centre has demonstrated the complexity of causal factors; in producing an obese condition; For th i s reason i t should, be born in mind that the above c lass i f icat ion of emo-tional causes is somewhat, arbitrary and that; i t w i l l be necess-ary to stress the most, predominant causal factors individually in each case:; (l) Personal Adjustments It i s perhaps hardest to determine the cause of. adi-posity when this condition arises from faulty personal adjust-ments,, since a. ch i ld ' s personality i s highly coloured by his parental relationships'; Moreover, there is something: unique in - 19 each chi ld ' s physiological and emotional make-up, so that he responds to. a particular situation in a different manner from another child exposed to the same famil ia l and environmental influences. The chi ld ' s adjustments to his l i f e situation can he traced back to his ear l ies t social contacts. Mouth or ora l act-i v i t i e s play a; large role In the: young, infant's l i f e . These ac t iv i t i e s have great emotional significance for the baby.. Through suckling at. the mother's breast the infant associates the receiving of food with the warmth of the mother's love. As Alexander puts, i t , "The f i r s t r e l i e f from physical discomfort:, the child, experiences', during nursing:, and thus the satisfaction of hunger becomes deeply associated with the feeling of well 2 1 _ -being and s e c u r i t y . B a n c o c k has stressed the significance of the: early nursing process in the infant's f i r s t interpersonal experiences with the mother, and i t s role as a non-verbal means of communication between mother and ch i ld . Certain children become fixated, at this: oral stage of emotional development due either to? inadequacy or, at times, an excess of maternal love. In later l i f e these individuals may have excessive oral receptive needs. Sometimes we speak of these individuals as; •'oral, characters*' or "unweaned sucklings*. They are very dependent, ch i ld l ike , demanding people. Their craving: for love and security, i f not sa t i s f ied , may be translated into a crav-21. Alexander,, F.-, Gastro-lntestinal Heurbslsr (Chap*VI) * i n Partisy Diseases of the Digestive System, Lea & Febiger, 1941, page:159. 22. Babcock, C.G". * Food and Its Emotional Significance, Journal of Am. Dietet ic Assn., V o l . 24, 1948, page 390. 20 ing for food! because of this unconscious infantile association of 'being fed* with 'being loved. ' This intimate association of eating with love and security continues throughout life: . The particular psychological i l lness characterized by a return to; this oral stage of emotional development i s de-pression. Some c l i n i c a l observations have concluded that over-eating seems to be a specific- defence against depression* and ; -. -;• " ' 23 that when some fat people lose weight they become; depressed. The common denominator is-this concept of ora i i ty . Despite violent, protestations against their obesity, and despite the; exhortations and dietary advice of the i r physicians, many fat people continue: to over-eat. This paradox, suggests the poss ibi l-i t y that over-eating; subserves some strong emotional, need. It i s also generally agreed among psychoanalytic investigators that oral fixations are prominent psychological features in &1-. coholism and other drug addictions. Application to Children. An example of this compensatory reaction could be seen in the: case of Penny T;., a g i r l of thirteen who attended the Metabolic Cl in ic for- some months, but could not seem to lose weight. Every time that. Penny was questioned as. to whether she real ly wanted, to lose weight, she immediately became intensely anxious, proclaiming 3trongly that, she; real ly did want to lose weight and would, honestly t ry to st ick to her diet . However, at 23. Hamburger, W.W., Emotional Aspects of Ohesity, The Medical  C l in ics of North America;. March 195*1, page 486. 21 each successive v i s i t to the Cl in ic there was no marked improve-ment and, although she declared that, she: was following her diet , there was always some jus t i f icat ion for a dietary indulgence. On closer investigation i t was found, that Penny only attended the; c l i n i c to* please her mother, with whom she was both very de-pendent and also- most; hos t i l e . Penny was a : most, confused g i r l . Her father * of whom she: had been very fond, le f t her mother about four years;; ago and had subsequently taken no further int-erest in Penny. This, desertion had been extremely d i s i l lus ion-ing for her. Penny's mother* a. rather weak person, has in the meantime; been l iving; with another man and has had two children by tilnu Penny, who l ives at home, i s quite fond, of her mother, but does not respect her for what, she had done:. That food re-presents a form of emotional satisfaction for Penny has been demonstrated in the repeated coincidence of. upsetting; occurrences in her home l i f e with her dietary transgressions. Obese children have generally been observed to be less active than non-obese children. This tendency may be fost-ered by mothers who f a i l to give encouragement and opportunity when their young obese child: expresses; a desire: to do things for i t s e l f . In such a situation the chi ld gradually loses interest in becoming independent, and. passively accepts the services of others. Dr. Bruch made an inquiry into the aspects: of muscular ac t iv i ty of one. hundred and sixty obese children in Few York and found that in seventy-seven per cent of these children there... 24. Bruch, H . , Obesity in Childhood, Am. Journal of Diseases of Children, V o l . 60, 1940, page 1099. was: a: marked delay in a b i l i t y and willingness to take* care of themselves:. Enuresis occurred as a para l le l expression of Immaturity in forty per cent of the children studied. Similar findings have: been made in the study of the: twenty-six; child-ren attending the; Metabolic Cl in ic at the Health Centre. The accompanying; symptom of enuresis has occurred in proportionally the same number of children and the: frequency of incidence appeared to; be higher in boys. This attempt to keep the child, in a dependent position Is a; manifestation of the possessive and over-protective mother. Aa a- result, of this over^protective attitude of the mother the ch i ld tends to. be shy* unaggressive and withdrawn. He becomes oversensitive to possible insult and injuries and his lack of self-reliance and self-confidence might; be explain-ed as a- response to the repeated rebuffs which h i t & fat child from day to day and isolate him from normal social contacts. The chi ld ' s feelings of inadequacy and helplessness which are fostered at home by the mother- make him feel incap-able of competing or communicating with his peers;. Since he falls. to> obtain any satisfaction from his outside contacts he resorts to eating which, as. mentioned ear l ier , represents a form of love and security to the c h i l d . One situation seems; to lead to another,, setting up & chain reaction of cause and effect. Eating gives the chi ld the satisfaction which he f a i l s 25. Bruch, op. c i t . page 1101. 23 -to a t t a i n i n his: outside contacts and also maintains, or i n -creases his s i z e . He finds that h i a adiposity becomes a pro-tective wail againat society and, a: very convenient; b a r r i e r be-hind, which he can withdraw when he i s unable to face his ex- , ternal environment* Obese patients tend to become quite host-i l e towards, society and do not wish to lose t h i s adipose tissue Which affords. a; physcial defence against active participatiion i n society/. Due to the child's induced reluctance to attempt to pa r t i c i p a t e i n ordinary day-to-day a c t i v i t i e s he develops a: fear of everyday events. Even such experiences as d a i l y en-trance into, school become loaded with traumatic s i g n i f i c a n c e . Despite this, withdrawal from a c t i v i t y , the c h i l d s t r i v e s f o r personal growth and independencet consequently h i s physical size becomes the only manifestation of t h i s development. Bod-i l y largeness gives the c h i l d a sense of power and strength, which his- actual human relationships have denied him. In h i s r a p i d rate of growth* early sexual maturation and. the expansion of his; body size.-, the obese c h i l d b e l i e s a l l attempts to, keep 26 him small and independent. Diet or the limiting; of food intake presents a very real, threat to the obese c h i l d . Since food, has assumed such emotional significance the withdrawal of food symbolizes the withdrawal of a f f e c t i o n and sec u r i t y . The. parents begin to re-26. Bruch, Hi :, Psychiatric Aspects of Obesity in Children, Am. Journal of. Psychiatry, Vol. 99, 194 , page 756. 24 cognize the child's association of food with a f f e c t i o n and: apprec-iate the traumatic: effects of such a withdrawal of food. Don B. *s case is: a good i l l u s t r a t i o n of this; point, since he became so» h o s t i l e towards h i s mother when she t r i e d to keep him to his diet that; she was forced to; acquiesce to> h i s demands.. Don's mother had devoted a l l . her time and a f f e c t i o n to her husband who was demanding of her. Since she found i t hard to give warmth and security to Don the giving of food symbolized the a f f e c t i o n that she could, not give herself:. (2) Inter-familial. Adjustments:. When the family s i t u a t i o n is. not. a. normal one, the genesis of a. d i s t o r t e d emotional, and s o c i a l development i n the ch i l d may take several forms.. If the mother's at t i t u d e toward the c h i l d is. one of. h o s t i l i t y , r e j e c t i o n or over-anxiety, she w i l l tend to concentrate an the mechanical aspects of his care; food assumes unusual important, and. an abnormal emotional s i g n i f -icance. In a d d i t i o n , the urge to. s h i e l d the c h i l d from harm re s u l t s i n overprotection. What; causes the mother to react i n t h i s manner? Dr. Bruch describes; the. overprotective mother as one who i s d i s -s a t i s f i e d i n her. marital r e l a t i o n s or Is without community out-l e t s for her ambition. This type of mother concentrates on her home and her children In her s t r i v i n g s f o r personal s a t i s f a c -tion and achievement; By keeping: her c h i l d i n close personal contact and by ministering to him, she fosters In him the need for her continued attention. With threats of, wit hoi ding her 25 a f f e c t i o n she t r i e s to control and mould him to her w i l l . By doing t h i s she prevents him from developing personal independ-ence and establishing s a t i s f y i n g r e l a t i o n s with an outside 27 world i n which she hers e l f has not found security. Penny T.'s mother i s an example of a woman who i s overprotective for possessive reasons. Although she made Penny attend the Metabolic C l i n i c i t was from a desire for s o c i a l approval rather than from any r e a l wish to see Penny lose weight. Her mother indicated i n one interview that Penny was a very use-f u l person to have around and that she was also a good compan-ion. She r e s i s t e d any suggestion to help Penny become less with-drawn s o c i a l l y by developing outside i n t e r e s t s . It was also i n t e r e s t i n g to note that Penny's mother did not attempt to sup-port or encourage her to keep to her d i e t . Mrs. T. was over-protective in her approach, p a r t i c u l a r l y i f outside situations appeared to be too much f o r her daughter whereupon she would t e l l Penny to come home and stay with her. Penny was continu-ously h o s t i l e to her mother since she was s t r i v i n g to he inde-pendent, but f a i l e d to receive the necessary support and en-couragement that she also needed. In considering the motivations of an overprotective mother, p a r t i c u l a r l y those amongst the low income group famil-i e s , i t should be noted that such reactions may often be comp-ensatory. Dr. Bruch found i n her study of the family backgrounds 27. Bruch, H., Obesity i n Childhood and Personality Development, American Journa I of Orthopsychiatry, Vol.11, 1941, page 467. 26 of obese children that many mothers had suffered great poverty and often hunger In their childhood and were thrown upon t h e i r own resources at. an early age. They had reacted tn their- early experiences with s e l f - p i t y and resentment and had been blocked In emotional, development,. They had continued to look upon l i f e i n the light- of t h e i r early disappointments and f a i l u r e s , and had been unable to loosen the ties, to th e i r past. In a primi-t i v e way they t r i e d to create for t h e i r children that "normal* carefree childhood of which, they f e l t , they themselves had been deprived, and which was represented for them i n a l i f e of id-le-28 ness and In aabundance of food. This was not uncommon i n the families who had children attending the Metabolic C l i n i c . Sev-e r a l mothers mentioned with pride that they always kept °a good table «V Robert F. 1 s mother, who was, quite obese herself, i s an example of this; type of mother who desired to give her. c h i l d -rent what she had not had hers e l f . Her husband was; i l l and un-j able to work so she supported the family by 'charring'. A l -though her earnings were li m i t e d , Robert*s mother mentioned that the three: of them thought nothing of eating two or. three steaks each at a meal. The family l i v e d i n a dark and dingy a t t i c suite but, to use a colloquialism, *ate l i k e kings?i Robert*s mother t o l d the s o c i a l worker, that she had- been brought up on a small farm i n Saskatchewan and, had known what i t meant, to be hungry; consequently she always, made sure that her own children ate; wel l . 285. Bruch, H. and Touraine, G.* Obesity i n Childhood, V/, The Family Frame of Obese Children, Psychosomatic Medicane, Vol. 2, A p r i l , 1940, page!41. - 27 From the foregoing discussion i t may he seen that a mother may be overprotective towards her c h i l d * either to< s a t i s f y her needs to possess him or to insure that, the c h i l d does not s u f f e r i n the* same' way that she did* There may be, however, a- more complicated reason for t h i s overprotecteve reaction; Dr. Bruch and Miss Toura-ine', i n t h e i r a r t i c l e on the family background of the obese child,, point out that a fund-amental r e j e c t i o n may be compensated for by overprotection and 29 excessive feeding;; These manifestations of physical care and attention belie the- mother's r e a l f e e l i n g s . Bruch found that more than f i f t y per cent of the children studied had. been un-wanted. Some of the mothers admitted that they had. attempted to induce an abortion before the c h i l d was born, others sa i d that the c h i l d was. a- 'mistake*. These families were also; con-spicuous by t h e i r small size*, This was borne out by the f a c t that seventy per cent of the children were e i t h e r only children 30 or else the youngest i n the family. Most of the children attend-ing the Health Centre In the present study were either only children, or else the oldest or even the youngest c h i l d i n the family. The mother's feelings of r e j e c t i o n or h o s t i l i t y towards the c h i l d stem from her own unsatisfactory childhood experiences as; a; re s u l t of which she finds i t hard to give a f f e c t i o n . She may f e e l insecure and unable to extend her l i m i t e d capacity for 29. Bruch* op.cit., (Am. Journal of Orthopsychiatry Vbl.llJp.467 30. Bruch, H», Touralne, G., op. c i t . p. 142. 28 -a f f e c t i o n to a- child'. On the other hand the husband may be weak and dependent and may be h o s t i l e towards the c h i l d because it: i s &: competitor for the mother's a f f e c t i o n . Don's case i s perhaps the best example of a. mother who: could, devote her attention only to her husband; Don's mother had. had a very unhappy childhood and found I t hard to give very much of herself to her children as her husband was s i c k l y and demanded a l l her time and at t e n t i o n . Don has an older brother and s i s t e r who are s t i l l l i v i n g a t home. There are two; more- s i s t e r s and. a; brother who are a l l married and l i v e away from home. The brother and s i s t e r who are s t i l l l i v i n g ; i n the home are quite; h o s t i l e towards t h e i r mother and. show her l i t t l e consideration; U n t i l the death of her husband, Don's mother had given; him l i t t l e attention.. Since h i s mother gave him food, t h i s became a: symbol of her a f f e c t i o n and. Don derived a; great deal of emotional s a t i s f a c t i o n from eating. In some cases the re j e c t i o n of the c h i l d i s more , noticeable i n the father. This was so i n Ron H.'3 case. Ron was the; f i f t h c h i l d i n a family of s i x . His father began drinking very heavily while Ron *s mother was carrying him. This man has never accepted or t r i e d to befriend Ron and has a- very poor r e l a t i o n s h i p with Ron's two older brothers. There has been a certain amount of c o n f l i c t i n the home, p a r t i c u l a r l y i n connection with the father's drinking., and B i l l y ' s mother who i s unable to give a great deal of a f f e c t i o n or security, admitted that she gives Ron things to eat to compensate f o r 29 any f r i c t i o n or upset that has occurred i n the home. Food to Ron represents, a form of emotional secu r i t y . The absence of the father from the faintly constella-t i o n , as discussed e a r l i e r , leads to f i n a n c i a l insecurity and presents i n some cases an additional tension; The: mother Is faced with complete r e s p o n s i b i l i t y for the family and must man-age: oh a li m i t e d income. In such a s i t u a t i o n i t i s not always possible for the mother to give her chi l d r e n a l l the care and attention that they need. This family tension i s not the sole cause of the child's obese condition but i t magnifies the traumatic experience of the loss of. the father. In each of the f i v e eases attending the Metabolic C l i n i c where the father had died i t was noted, that the obese condition f i r s t became appar-ent, shortly a f t e r t h i s incident. Strong emotional, t i e s have also, been noted i n those families where the father has l e f t the home. In" two cases there are very d e f i n i t e h o s t i l e feelings/ on the part of the children concerned towards the father f o r r e j e c t i n g them and leaving the home; The child, i n both cases blames the mother for d r i v i n g the f a t h e r out of the home; The reaction of the two other children whose fathers are out of the home has been that of a. very strong i d e n t i f i c a t i o n with the father. Both these cases are teen-age g i r l s ; consequently th e i r age might be quite a fa c t -or. In any case t h i s sirong i d e n t i f i c a t i o n introduces; f r i c t i o n In their r e l a t i o n s h i p with their mothers. In these home environ-- 30 ments described there i s a lack of adequate emotional s e c u r i t y . These children are. d i s i l l u s i o n e d by t h e i r parents and interpret the father's absence as a personal, r e j e c t i o n . Consequently food f o r these p a r t i c u l a r children becomes charged with high emotional value since i t i s one of the most fundamental sources of s a t i s fa c t i on. (3) Environmental and Social Adjustments The obese c h i l d * as mentioned e a r l i e r i n t h i s chapter, i s very sensitive to possible insults: and injuries*. This sensi-> t i v i t y Is encouraged by the overprotective attitude of the; moth-er* A"n adequate sense of security and competence i s lacking as the c h i l d goes, up the scale of his developmental ladder and there consequantly evolves an i n a b i l i t y to cope adequately with h i s environment. He tends to exclude himself from the normal a c t i v i t i e s of soc i e t y and thus he continues to f a i l i n devel-oping interests and s o c i a l s k i l l s necessary f o r adequate adjust-/ ment to his environment. Most of the children attending the Health Centre were i n c l i n e d to be withdrawn and were reluctant to pa r t i c i p a t e i n school a c t i v i t i e s . In some cases there were signs; that the: c h i l d wanted to be more active but f e l t too conspicuous. In other cases the c h i l d showed no i n c l i n a t i o n or desire to be a c t -ive but was quite content, s u p e r f i c i a l l y at l e a s t , to go home to his; radio program or comic s t r i p . However, t h i s attitude appear-ed to? be a form of r a t i o n a l i z a t i o n rather than a: r e a l desire. The obese c h i l d i s continuously reminded of his coridi'-t i o n since he i s usually the biggest c h i l d i n the class and out-31 strips, his peers i n size and body b u i l d . His embarrassment i s nbt diminished by the f a c t that he i s usually clumsy i n h i s movements and thereby made more self-conscious. Contrary to what one would expect, the over-weight c h i l d tends to seek the company of children younger than himself, since his discrpancy i n size i s then commonly accepted as being due to his greater age. This phenomenon was noticed i n a number of the cases attend-ing the Health Centre* Perhaps, i n view of the previous, d i s -• cussion, this: f a c t o r i s riot so surprising since the obese c h i l d i s emotionally immature for his age and because of the over-protective attitude of his mother w i l l tend to play with c h i l d r reri whose games are not 1 so rough*. In the lower income group families the over-weight c h i l d must suffer on another count since he must wear outsized clothes which, being 'handrme-downs', are usually very shabby. This s i t u a t i o n , of course, i s not unusual for a normal c h i l d i n t h i s group, but. the over-weight boy or g i r l i s not l i k e l y to get new clothes as frequently and must often make do with some shapeless, garment which i s much too big or too small. This i s perhaps: more acute i n i t s ef f e c t on teen-age g i r l s , but i n a l l cases i t can. have a d e f i n i t e bearing on the chil d ' s willingness to p a r t i c i p a t e i n s o c i a l a c t i v i t i e s . Ron H.'s. case, which was mentioned in the previous section as an example of paternal r e j e c t i o n , is: of significance at t h i s point i n i l l u s t r a t i n g the difference that the loss of a few pounds can. make i n regard to s o c i a l a c t i v i t i e s , Ron f i r s t 32 attended the Metabolic C l i n i c at the Health Centre i n the spring of 1950;. He was seven years old and weighed one hundred and t h i r t y - f i v e pounds. His mother explained that the other children on the street would not play with him and also that, as he could not run he was excluded from p a r t i c i p a t i o n i n games at school, Ron spent h i s spare time s i t t i n g by the radio and reading. By Christmas 1950, he had lost; twenty-five pounds. It was at about this: time that. Ron's mother related that one of the neighbours has asked Ron to come and play with her children; Ron played baseball this spring and has given up s i t t i n g by the radio. Children of foreign-born parents often tend to be over-weight and Bruch noticed t h i s fact i n her c l i n i c a l study ' 31 ' of New York f a m i l i e s . Three of the twenty-six children attend-ing the Vancouver Metabolic C l i n i c f e l l Into the obese category; These childre n present a problem both i n diagnosis, and treatment since the language d i f f i c u l t i e s involved are a. b a r r i e r i n commun-ic a t i o n ; Although c u l t u r a l factors and d i f f e r e n t eating habits are usually involved i t i s not possible to determine whether there are any other possible contributory causes. The tenacity with which such parents c l i n g onto the language and customs of t h e i r home country often m i l i t a t e against the attempts of the younger generation to adopt the mores and customs of their new country. In rec a p i t u l a t i o n , then, the determination of the caus-a l factors of obesity depends heavily upon an understanding of the underlying psychological causes and p a r t i c u l a r l y upon the 31. Bruch, Op. c i t . , (Psychosomatic Medicine), page 143. 33 emotional problems within the patient's family. This i s p a r t i c -u l a r l y s i g n i f i c a n t i n the case of children. A review of the pert-inent l i t e r a t u r e on obesity f a i l s to reveal any i n t r i n s i c meta-b o l i c , endocrinologic or physiologic abnormality i n the usual 32 case. From the twenty-six cases studied i n the Metabolic C l i n -i c the most predominant cause of obesity seemed to a r i s e from emotional factors involved in the parent c h i l d r e l a t i o n s h i p . In nineteen out of the twenty-six cases the mother manifested some form of over-protectiveness of the childo Open re j e c t i o n of the c h i l d has been noted i n at least eight of these cases. The mother gave indications of being overpossessive i n another eight and compensatory reactions were noted i n the remainder. If an attempt were made to c l a s s i f y the predominant causal f a c t o r s , they would seem to f a l l into two main groups. Those are physical factors and emotional f a c t o r s . The physical factors may be sub-divided into glandular and non-glandular disturbances. The emotional factors can be further sub-divided into parent c h i l d relationships characterized by varying types ov over-protection. Thus, overprotection may be due to over-possessive, compensatory or r e j e t i v e f e e l i n g s . Diagnostic Process In order to make an accurate diagnosis the doctor must have certain background information concerning the patient. 33 This includes a dietary h i s t o r y , a copy of the Wetzel g r i d , 34 a determination of the Basal Metabolic rate, and both medical 32. Hamburger, op. c i t . , page 487. 33. See Appendix A note Cl) f o r d e t a i l s concerning structure of g r i d . 34. See Appendix A note (2) for d e t a i l s concerning determination °f Metabolic Rate. - 34 -and s o c i a l h i s t o r i e s . Before seeing the patient the doctor reviews these various reports so that he Is well, prepared f o r the interview. The dietary history i s completed by the c h i l d with the assistance and guidance of the school nurse before attending the C l i n i c . This history consists of a record of a l l the food that the c h i l d has eaten during a period of one week. On the day that the c h i l d Is to attend the G l i n i c for the f i r s t time this food record or history i s sent i n by the school nurse. The d i e t i c i a n at the C l i n i c interviews, the c h i l d and accom-panying parent and discusses the diet with them, making a- note of any further pertinent information regarding food habits. The C l i n i c nurse contacts the school nurse for i n f o r -mation f o r the. Wetzel Grid; It has been d i f f i c u l t in many cases to obtain weights, for more than the past year or two. This g r i d gives an indica t i o n of the degree that the c h i l d has dev-iated from the normal weight f o r his height, age and body b u i l d . It. i s perhaps important, to ask whether the grid I s a suitable Indicator of obesity i n children with, abnormal bodr i l y dimensions. A comparison of the measurement per se deter* mined from the grid, and of the s k e l e t a l age, as measured by 35 the t r a d i t i o n a l roentgenographic method, i s desirable. There must be good agreement between these two indicators before one i s j u s t i f i e d i n replacing: the well-established, though tedious, 35. Roentgenographic Method? Roentgen, a German p h y s i c i s t (1845-1922) found that rays from the cathode had p e c u l i a r pene-tr a t i n g powers through matter opague to other ether rays. Photographs may be taken of bones, metallic substances,etc. 35 roentgenographic method by the new and simpler ©nei It has been found that the s k e l e t a l age i s a much more r e l i a b l e figure to use i n the prediction of future growth and development;. How-ever, in general* the Wetzel. Grid has proved to be of s p e c i a l value i n demonstrating three things* F i r s t l y , in the graphic recording and early recognition of abnormal changes i n the child's height-weight r e l a t i o n s h i p . Secondly, i n the deter-mination of the appropriate c a l o r i c intake from the height, weight and age rela t i o n s h i p of the c h i l d . F i n a l l y , i t is; poss-i b l e to; predict maturation and future development. The calculation of the rate of the basal metabolism of the children attending the Metabolic C l i n i c has been a guide i n r u l i n g out the p o s s i b i l i t y that the obese condition of the c h i l d could be caused by hypo-thyroid functioning; A l -• 37 though Bruch questions the v a l i d i t y of t h i s c a l c u l a t i o n , i t has been used only as a means of confirming the diagnosis. The use of body surface standards i n the determina-tion of the metab51ic rate of adults has been s u r p r i s i n g l y accurate, but these standards cannot be applied i n the case of ch i l d r e n . Due to the. rapid, changes i n the body surface i n a ' " 38 growing child, height standards have been used. Dr. F/.B.Talbot 36. Bruch, H., The Grid f o r Evaluating Physical Fitness (Wetzel), J . of the. Am. Medical. Ass ^ n.. Chicago, V o l . 118, No. 15, 1942; page 1290. . 27. Bruch, H., B a l a l Metabolism & Serum Cholestral of Obese Children. Am. J . of the Diseases of Children, V o l . 55, Nov. 1939* page 1.001. 38. Talbot* F.B., Basal Metabolism Standards for Children. Am. J . of Diseases of Children, Chicago, Vol.55, No.3, March 1938* page 455. , 36 and his associates- have done a great deal of work i n t h i s are*, and have based one- set of standards on body weight. They obtain-ed, figures of heat production from' children whose weight was normal for their height, consequently the standards can be called the height, standard or the standard f o r the "expected weight". A. medical hi s t o r y is. taken when the c h i l d attends the general Pediatric. C l i n i c for the f i r s t time. Since a l l c h i l d -ren, who are referred to the Health Centre must f i r s t be seen i n the Pediatric; C l i n i c this; examination i s an essential process In diagnosis. Arrangements are made f o r the determination of the Basic Metabolic- rate at the time that the c h i l d Is referred from the Pediatric C l i n i c to the Metabolic C l i n i c . This r e f e r r a l procedure I n i t i a t e s the. diagnostic: process since the c l i n i c nurse upon n o t i f i c a t i o n of referral, proceeds to n o t i f y the school nurse and the c l i n i c ; s o c i a l worker. The former, as mentioned previously, is. responsible f o r the dietary history and f o r supplying information f o r the Wetzel G r i d . The s o c i a l worker i s responsible f o r contacting the parents of the; c h i l d i n order to obtain d e t a i l s concerning the child's s o c i a l h i s t o r y . Informa*-tion i s found about the patient's family, personality, and the adjustment of h i s family to society. Any information "relating to d i f f i c u l t i e s which are experienced In the home i s p a r t i c u l a r -l y important. Sometimes it. i s possible thereby to assess the amount of Interest or cooperation that can be expected. The information contained, i n a l l these reports i s shared by the c l i n i c a l team andwhen possible a. short conference 37 i s held before the patient i s seen. This discussion gives a l l the members of the team a more complete picture of the c h i l d and i t helps the doctor to formulate an appropriate plan of" treatment before the c h i l d i s a c t u a l l y seen. CHAPTER III TBEATMJffNT' Methods of Approach i n Treating Obesity The treatment of an obese condition i s no a v a i l unless the patient is; willing; to co-operate. Therefore; before consid-eration can be given to the type of treatment; given, i t i s nec-essary to determine the patient-s reaction and whether i t w i l l be possible to help him accept treatment. I t has been evident i n some cases attending the Metabolic C l i n i c that the c h i l d had no interest, i n dieting, or In tryi n g to lose weight. This lack of i n t e r e s t has varied, from reactions of Overt, h o s t i l i t y to attitudes of passive indifference towards treatment. Therefore the determination of the patient's desire to ca»operate becomes a prerequisite i n the treatment process. Current thinking i n the Treatment of Obesity, It i s desirable f i r s t to consider some of the l a t e s t views; on the treatment of obesity with respect to both p h y s i c a l and emotional f a c t o r s . Such preliminary consideration w i l l help us i n reviewing the treatment methods, which have a c t u a l l y been used at the Metabolic C l i n i c . Glandular Therapy The incidence of obesity arising; from physiological 39 disturbances has been remarkably low* .Consequently there: has been l i t t l e published material on the treatment; of obesity ar is ing from intra^-cranial lesions, tumors, etc* Dr. Bruch, however, has discussed, the dangers of glandular therapy. She feels that the assumption that glandular therapy is entirely ha^rmless is as dangerous as-, the assumption that glandular maldevelopment i s the probable, cause of obesity. Severe re* actions to such therapeutic injections are: not uncommon; Since gonadotropic substances have been in use for. only a. few years nothing can be said at present about desirable consequences in later l i f e . The poss ib i l i ty that the overstimulation of the immature gonads: may resul t in functional, impairment can-39 not be disregarded. While inherent constitutional, factors may play a definite role in the development of obesity, important cont-ributory factors are often revealed by a study of the envlr-*. onmental forces. As mentioned in the previous chapter, most obese children are exposed to excessive overprote etion and', over-solicitude * The outward manifestation of these attitudes bare-ly covers the underlying hos t i l i ty and rejection on the part of the mothers. In such an environment, which does not offer adequate emotional, security, food, gains an inordinate import-ance and represents, satisfaction, security and love* The at-mosphere of fearful apprehension confers upon social contacts 39. Bruch, E » * Obesity in Childhood, and. Endocrine Treatment, The Journal, of Paediatrics., V o l . 18, 1941* page 36. 40 and muscular- ac t iv i t ie s ,the meaning of danger, threat, and in-security. The development in such surroundings of obesity and of Immature and overdependent behaviour becomes comprehensible. In a: family with this attitude of over-anxious concern, the diag-nosis of an endocrine disorder in the c h i l i may only have an aggravating effect. It serves only to intensify the parent's attitude of general over.pro.tectiveness and to increase and just i fy the excessive care lavished upon the ch i ld . The psychological implications of glandular therapy in relation to- the chi ld 's future development and maturation should, be weighed carefully against the physical implications. Since there has not. yet been any evidence of the effects of glandular therapy on the chi ld in later l i f e , the potential psychological damage that can be done, by such treatment should be considered carefully. Dietary Therapy Although diet in i t s e l f w i l l not solve the problem of obesity i t is; a most important factor in conjunction with psych-' ological support and other forms of therapy. Depending on the s ize of the child and the degree of obesity, a. d ie t is usually prescribed which gradually cuts down on the food intake. Although over-eating; is often vehemently denied by such' fat children and their parents, the actual intake is always in excess of that of. normal children. Parents often become anxious when the chi ld i s on a diet and are convinced that they w i l l starve. The comment has. been made several times by an 41 * overly solicitous parent that MI just couldn't; let, Johnnie go to school without a: l i t t l e h i t extra*. For this reason It Is very necessary for the diet ic ian to give the mother a, detailed explanation of the diet and how I t is made up. Development, of good eating, habits asre> however* more important, than adoption of a temporary diet , since the ch i ld w i l l always be predisposed to obesity unless his eating: hab-its; change. Both parents and child need to be educated In this respect and should, have an understanding; of food values. Drug Therapy I t has been found necessary to some cases to give the child a: more material form of support than that, afforded solely by verbal encouragement. In such cases Amphetamine sulphate (benzedrine sulphate) is prescribed to- curb the • ' : . - 4 0 • " appetite. It has been: found that only rarely does this drug; f a i l to curb the appetite, except in those patients whose drive1 for food Is overpowering and who probably require psycho-therapy; These patients res is t subconsciously any suppression of the appetite because of the great pleasure derived from eat* ing, even though they may consciously express a. desire to have 41 their appetite curbed. In some instances the suggestive powers of p i l l s of no medicinal value have proved to be of psychological value in the treatment process. Some children find that they need 40. See Penny T* Chap. II , page 2,0. 41. Freed (M.D.) S.C> Psychic Factors In the Development and Treatment of Obesity, J . Am. Medical Association, Chic-ago, 111., V o l . 133, No.6, Feb. 1947, page 371. 42 -to have a; prop in the form of p i l l s despite the fact that there i s no; physiological, need for medication. It is: necessary to remember in treatment, part icular ly in the; case of younger children, that every type- of support and encouragement is needed since the motivation or- desire to loose: weight, is not always strong. Emotional Factors:. If good feeding practices, are instituted by an under-standing and loving mother who has insight into the. needs of her ch i ld , there w i l l result a relationship between them which w i l l be sustaining to> them both in future: times of stress. The feeding process w i l l become the matrix: for healthy development not; only in nutrit ion but in motor, and social development. Parents often f a i l to realize: the significance of this early attention to the needs for food, warmth and c lean l i -ness and the progressive security and competence which comes with proper parental devotion and guidance. If a child; feels, loved and wanted he has l i t t l e need to find emotional security by such substitute mediums: as food. In treatment is necessary to assess, the willingness of the parents to face themselves rather than project their personality d i f f i cu l t i e s onto the c h i l d . Very often i t is not possible for such people to face their own d i f f i cu l t i e s and they can only express: these: things; through the c h i l d . They state; that the; ch i ld w i l l •'never stop eating", or that "he w i l l never leave me for a minute*. Such statements distort, rea l i ty 43 by implying that, the onus i s on the. c h i l d and not on the parent. Such a parent, would f i n d it- Impossible t.a> admit that, she had no capacity to give the c h i l d security and love other than by the supplying: of food. I f i t were possible f o r such parents to; admit that they had. no>t r e a l l y wanted the c h i l d and for them to accept t h i s fact without f e e l i n g g u i l t y , treatment would be si m p l i f i e d . However, since such a s i t u a t i o n is; quite: rare, i t Is- necessary to work along with the parents and to carry the treatment as f a r as they are willing;, . I f the mother f e e l s threatened by a revelation of her own d i f f i c u l t i e s , then one must-work with the parent through the c h i l d . In many cases the degree of help that can be offered i s very li m i t e d since the! parents do not; r e a l l y want to see the i r children lose weight. The pediatrician-in-charge at the Metabolic C l i n i c has found generally that the cases coming to him p r i v a t e l y are much more co-operative i n treatment, than those, cases coming to the Health Centre, The i n i t i a t i o n of the private and c l i n -i c a l attendance i s different. The patient who sees the doctor p r i v a t e l y i s seeking medical ar_dvice of his. own v o l i t i o n . HoW^  ever, the pa t i e n t who attends the. Metabolic; Clinic; does so either because he has been referred from one of the other, c l i n -i c s within the Health Centre or because a Public Health Nurse, who; has noticed his condition as being conspicuous among h i s school-mates, has made a r e f e r r a l with his mother's permission. Thus the circumstances surrounding the I n i t i a l attendance of the case a t the C l i n i c i n the. Health Centre i s not always conducive 44 to complete cooperation since the chi ld ' s mother may have fe l t impelled to comply with the suggestion of treatment only be-cause of soc ia l pressures. Due to the nature of this referra l process, one can generally anticipate superficial cooperation only, with underlying, resentment, and h o s t i l i t y . Although each case attending the Metabolic. Clinic, is seen i n i t i a l l y by the social worker, there is not sufficient opportunity to make. a. detailed social history from separate interviews; with the chi ld and, parents". Such a detailed history would, of course, be presented to the doctor along with the dietary history. Those cases that show signs; of a deeper dis-turbance should, be referred for psychiatric help and therapy. Group Therapy Some children find i t easier to discuss their prob-lems In a. group situation rather than by means of individual interviews., Group therapy is directed towards soc ia l adjust-ment, and enables each chi ld to make the necessary adjustments and adaptation in a. part icular ly favourable environment. Group participation can contribute many good, features to treatment. For example, the mutual support and competitiveness of the group gives more incentive to the children for losing weight; Consideration of the leas successful members within any group, however, necessitates careful control of the degree of competi-tion with the group. Through group participation a. chi ld may also: develop a. better understanding of his own emotional prob-lems; which may be related to his over-eating. 45 Treatment methods Used i n Metabolic C l i n i c Since the Metabolic C l i n i c i s r e l a t i v e l y new, t r e a t -ment methods have been used on an experimental basis. The approach has been necessarily f l e x i b l e , so that I t i s d i f f i c u l t to attempt at. this, time anything more than an a r b i t r a r y c l a s s i -f i c a t i o n of treatment, groups. That the treatment services which the C l i n i c has t o offe r are limited by lack of s t a f f and other fa.ciliti.es w i l l become apparent In the following section and f i n a l chapter. At present the group of children attending the c l i n i c : Is not large but. any increase would, place considerable s t r a i n on the e x i s t i n g s t a f f . The methods employed and problems a r i s i n g in the treat-ment process w i l l be discussed under the two headings of (l) physical factors and (2) emotional f a c t o r s . Where possible, p r a c t i c a l i l l u s t r a t i o n s w i l l be presented from c l i n i c a l attend-ances,. (I) Physical factors a. Glandular Therapyt Thyroid treatments have been given t o one case attending the: c l i n i c . Glyne i s ten years, old and believed to- be a c r e t i n . At: t h i s point, i t i s d i f f i c u l t to assess the success, of the thyroid treatments that she has had. Glyne lost. 12 pounds i n the f i r s t , s i x months of her attendance at the: C l i n i c but there has been no recent weight decrease since she i s now close to the normal weight, for her height and age., It i s d i f f i c u l t to predict the prognosis i n a case such - 46 as this since Glyne i s not. able to accept the r e s p o n s i b i l i t y of her own diet, due to her retarded mental development. b. Dietary Therapy: The type of d i e t prescribed w i l l vary with the patient's c a l o r i c Intake at the time of admission to the c l i n i c . In eases where the mother Is cooking f o r a large family and would have d i f f i c u l t y i n preparing a separate meal for the patient, or i n cases where the mother has a low I.Q., half the: o r i g i n a l helping i s recommended. This Is not always s a t i s f a c t o r y , but i n some cases i t presents less, f r i c t i o n f o r the patient and family. If the patient, as a member of a large family, i s i n c l i n e d to be withdrawn and appears to be s e n s i t i v e j i t i s wiser not to: single him out and make him more conspicu-ous by requiring him to eat d i f f e r e n t meals. Special diets of 1600 and. 1900 cal o r i e s respectively ' ' " 42 ' • are prescribed for most cases. The d i e t i c i a n explains the d i e t to the patient and mother and points out where i t can f i t i n with the family menu.. Where possible the d i e t i s a l t e r e d to f a l l i n l i n e with what the patient has been having;. Incidentally the d i e t i c i a n i s able. to. give the mother advice on budgetting, since the d i e t is. geared f o r a low income. There i s the occasional obese patient, who seems t o be able to respond: to diet alone without the a i d of drugs or psycho-l o g i c a l support. This was so in the case of Tom B. who attend-ed the Metabolic G l i n i c for three months and l o s t ov/er seventeen pounds during the period, I j ? & m was f i f t e e n years old* about, s i x 42. See Appendix B f o r 1600 and 1900 ca l o r i e diets 47 feet t a l l , and quite inte l l igent * He showed great interest in his diet and was most cooperative, .Tom always: attended the Cl in ic by himself so; that very l i t t l e was known about his fam-i l y ; However-, i t would seem' that he had a. real, desire to* lose weight. The success of treatment in this case can be a t t r ib-uted to the degree of motivation, c. Drug Therapyt Amphetomine sulphate has. been pres-cribed in a: number of cases to curb the appetite. I t has not been given to the chi ld u n t i l there was proof, after sr. number of: visits . , that there: was: a.: need for some a r t i f i c i a l means of curbing the appetite:. In some Instances aphetomine sulphate has not been as successful as Seblin, a. bulk food which gives a feeling of sat iat ion. This situation occurred in B i l l y ' s case. B i l l y was eight years old. and as described in the previous chapter was the second youngest in a family of s ix children. His mother was; ov/erprotective and fed B i l l y to compensate for the con-f l i c t s or tensions that occurred in the home* B i l l y fe l t that amphetomine sulphate did not help him a great deal but found that Seblin did. help him over his hungry period:. One can only conjecture on the fact that the amphetomine sulphate Is taken In p i l l form and. the Seblin i s more l ike a. cereal in presenting a, large volume of mass intake. Psychologically there may be more satisfaction In eating a few spoonsful of Seblin bulk than in swallowing one p i l l * since the sensation of eating is not removed In the second case; 1 4 8 - -As yet there has been no experimentation at the Me tar bo Lie C l i n i c done with sodium, bicarbonate, p i l l s to determine the psychological value of such a, harmless medication. In cases where the c h i l d cannot expect much psychological support from his family, i t may be of assistance to give some such a r t i f i c i a l means: of support. (2) Emotional Factors Due to the l i m i t a t i o n s in casework s t a f f i t has not been possible to make a detailed, study of each, case and a. prop-er 'follow-up* has only been possible in a. few. instances. Con-sequently the number of cases from which to draw d e t a i l e d mat-e r i a l Is rather l i m i t e d ; However i t i s possible to c i t e two instances which i l l u s t r a t e the value of casework on a support-ive r e l a t i o n s h i p l e v e l . Ron H. *s case has been mentioned several times but some of the pertinent f a c t o r s involved w i l l be r e i t e r a t e d i n order to discuss, t h i s aspect of his treatment. Ron was eight . . . . . . .... . ^ ... . . . . . . . . . . . . . years o l d . When referred to the Metabolic: .Clinic l a s t spring he weighed 134 pounds. Although he was quite cheerful, and happy when he was i n the C l i n i c his mother complained that he was not, mixing with the other children and was not p a r t i c i p a t -ing i n any of the school or sporting as c t i v i t i e . s . Ron spent his time reading funny books and l i s t e n i n g to the radio. She a l s o mentioned that, he was enure t i c . Ron was the second youngest in a: family of. s i x . His father (Mr .H.)., began, to drink very heavily while Mrs. H. was 49 carrying Ron. Mr. H. has never taken much interest i n Ron and does not get on with Ron's two older brothers. There has been considerable c o n f l i c t i n this home, with much of it. focussed on the r e s u l t s of Mr. H. *s drinking bouts. Mrs. H. has; an ex-pression-of long-suffering on her face, and this seems to be carri e d over to her personality. She seems to be incapable of giving any a f f e c t i o n or security, p a r t i c u l a r l y to her-hus-band, and has. been i n the habit of giving; Ron something extra, to eat in order to compensate f o r any family turmoils or up-se t s . Mrs.. H.'s apparent helplessness, has won the children to; her side i n any family c o n f l i c t s , so that Mr* H. i s put in the position of competing: with his Children f o r his wife's- a f f e c t i o n . Ron showed, only f a i r l y favourable progress for the f i r s t few weeks a t the C l i n i c but a sudden decrease i n weight? was noted l a s t J u l y . This sudden improvement occurred a f t e r the; following incident i n his home. The mounting tension from Mr,. H^'s continued drinking- had terminated in a., family row after which Mr. H. had. threatened, to leave h i s wife; He stay-ed away from the family f o r a week during which time h i s wife began t o take l e g a l a c t i o n . This frightened Mr. H., who re-turned home resolved to t ry and improve his ways. He took Ron to a: b a l l game and t r i e d to show a. genuine inte r e s t i n his son; Since this time, conditions i n the home have been somewhat improved and Ron has l o s t quite s t e a d i l y so: that by November 1950, he had. lost: twenty-five pounds. Mrs. H. re-ported also that his enuresis had disappeared and that he was 5 0 -hardly ever i n the house. However, i n l a t e November Ron began to have temper tantrums and cried If he was. denied food. It was arranged that he- should have some play-interviews:. Through these interviews Ron was; able to work of f some of hi a annoyance and anger over his d i e t which he had not been able to express at; home. Ron had been able to cooperate on his diet f o r a period of s i x months with encouragement from the doctor and from h i s family by means of bribes. The continuation of this, n u t r i t i o n a l de-priva t i o n and the f r u s t r a t i o n of not being able to be angry with h i s mother was apparently more than he could stand. Mrs. H. reported that. Ron was no longer having; tantrums a short period a f t e r the play interviews started. Through these i n t e r -views Ron was helped to understand his; ambivalent feelings twoards h i s mother. He was shown that I t was quite under-standable f o r him to be angry about h i s d i e t , but that when he f e l t mad he could perhaps go outside and work i t o f f on a f o o t - b a l l . In t h i s case one can; see the pattern of an overpro" tective but r e j e c t i n g parent. The limitations: In the treatment given Ron should more properly be considered i n the next chap-ter but w i l l be discussed here i n order that the reader might-better appreciate the relevant factors i n the case (under d i s -cussion). As in most; cases the focus i n treatment should more appropriately have been directed at the parents; However, since Mrs. H. did not send Ron to the Metabolic C l i n i c i n order-51 that she might receive help, the focus of treatment had to be concentrated upon Ron. Ron's parents were both very dependent, and having f a i l e d to f i n d the looked-for support i n each other, Mr. H. had. resorted t o alcohol and Mrs* H. to her c h i l d -ren, winning t h e i r support and sympathy by her martyr-like a t t i t u d e . In such a family c o n s t e l l a t i o n there is- l i t t l e room for the giving of emotional security to at c h i l d such as Ron, p a r t i c u l a r l y as he was born under rather disturbing circumstanc-es; i e . , the s t a r t of his father's drinking bouts. As there i s l i t t l e hope that Mr. and Mrs. H.'s basic personality patterns can be changed, Ron should be helped to accept existing condi-tions. At the moment he i s beginning to accept the ambivalent feelings that he holds towards h i s mother. I t i s Important that Ron should not f e e l g u i l t y about h i s negative feelings towards her since they are normal. Later Ron may r e a l i z e that he was not p a r t i c u l a r l y wanted and he w i l l need help to accept th i s f a c t . Re has been able by means of dietary and supportive help to become more a c t i v e * He has become more sel f - c o n f i d e n t and outgoing. He i s beginning to understand some of his f e e l -ings and does not f e e l as g u i l t y about them; In contrast to Mrs. H., Penny's mother was over-protective from overpossessive motives. Penny was the oldest c h i l d l e f t i n the home, and she had four younger brothers and a baby s i s t e r ; Though Penny was: only fourteen, she had had to bear a great deal of the r e s p o n s i b i l i t y for bringing up her brother3* She was extremely r e s e n t f u l about the burden of 52; t h i s r e s p o n s i b i l i t y . Penny's mother, Mrs. T., had been married twice. She had shown a- pattern of l i v i n g with a man and having two or three children before the marriage was le g a l i z e d * After the marriage something would happen and the couple would separate. Mrs. T. was trying to get a: divorce from her second husband so that she could marry a t h i r d man by whom she had bad two c h i l d -ren, whilst a. t h i r d c h i l d was on the way. Mrs. T". depended on Penny for help i n the home and f o r companionship. I r o n i c a l l y enough Mrs.T. was a f r a i d of Penny possessing the weakness which she had displayed i n her.own l i f e . For this reason Mrs. T. fostered i n Penny a fear of men. Penny was quite mature for her age and was experienc-ing the c o n f l i c t s of adolescence. She wanted to be independ-ent and to be free of her r e s p o n s i b i l i t i e s at home but her obese condition fostered t h i s very dependence and prevented her from breaking; away. She was: confused about her feelings f o r her mother whom she both loved and d i s l i k e d . Penny was also; quite d i s i l l u s i o n e d with her. father who: had been Mrs. T.'.s second, husband. Penny had been very fond of her father but re-acted to his lack of interest in her by f e e l i n g that she d i s -liked, him; This negative f e e l i n g was furthermore extended to a l l men in general because of Mrs. T~. 's forebodings, which had. unfortunately been substantiated by the promiscuous a c t i v i t i e s of the high school boys i n the d i s t r i c t where the T.*s l i v e d . Pood had acquired great emotional significance f o r 53 Penny, since she had very few friends or outside contacts. She would have l i k e d to be active both i n school and s o c i a l l y but self-consciousness about her size coupled with her lack of con-fidence made her seek companionship with children much younger than herself* and made her derive emotional s a t i s f a c t i o n through food. I t was obvious: from the f i r s t day that Penny attended the c l i n i c ; that she was a. very upset and confused g i r l . Support-ive casework help was given and for a short period. Penny became much more outgoing and happier i n appearance.. This change d i d not, however, l a s t a f t e r Penny was. moved from the Junior High School to a. larger High School. Although she has not f e l t as conspicuous for both her age and size since she attended t h i s school, Penny has found i t harder to compete with other, c h i l d -ren. Consequently she has withdrawn and i s not as active soc-i a l l y . Mrs. T'. has apparently fostered t h i s withdrawal since she fears that Penny may leave her; This case is. i n t e r e s t i n g because i t il l u s t r a t e s ; the perversity of an overpossessive parent. Although Mrs. T. i n -s i s t s that Penny attend the Metabolic. C l i n i c , she does not support t h i s action by helping and encouraging her daughter to d i e t . It would seem that Penny must attend the c l i n i c only that her mother might claim s o c i a l approval f o r looking a f t e r her w e l l . In a c t u a l i t y Mrs* T. fears the p o s s i b i l i t y of los i n g her daughter: as Penny loses weight and Is enabled, to p a r t i c i p -ate more e a s i l y i n a wider society. Penny on the other hand, - 54 Cannot give up the food which gives her the emotional s a t i s -f a c tion and security that she f a l l s to get from her mother or her-outside s o c i a l contacts. Heedless to say the prognosis of this case is very poor and Penny i s not attending the c l i n i c at present* She could be greatly helped towards s e l f - r e l i a n c e and self-confidence If her mother was: r e a l l y interested i n seeing her lose weight. These two cases I l l u s t r a t e the complexity of f a c t o r s to be considered In diagnosis and treatment. Treatment Is l i m i i t e d not only by technological and f i n a n c i a l f a c i l i t i e s , but' also by the family background. This lack of r e a l interest or cooperation i n treatment constitutes the most common l i m i t a t i o n arising: from the family background. Group therapy would have been of great value i n the treatment of Penny Ts. & group experience reveals to children who are unduly sensitive about t h e i r p hysical condition that, they are not unique and I t thus, helps them i n learning to mix with other children. Last f a l l two. group meetings were h e l d f o r some of the c h i l d r e n attending the Metabolic G l i n i c . The c i t y n u t r i t i o n i s t led the discussions at these meetings, which were of an experimental nature only. These p a r t i c u l a r meetings were not Intended to be therapeutic: i n nature but. were con-ducted as discussion groups with the objective of encouraging the children to discuss the d i f f i c u l t i e s i n d i e t i n g . They did, however, indicate that such meetings could, i f w e l l organized, be h e l p f u l . 55 Summary Treatment consisting only of a mechanical reduction In food Intake i s often doomed to f a i l u r e . Endocrine treatment, with extremely rare exceptions, has ho j u s t i f i a b l e place in the management of obesity i n childhood. I t i s not only useless, i t may even prove harmful through the impairment of sexual develop-* ment or some mysterious abnormallity. To be of r e a l value,, therapy should help the c h i l d to grow independent and s e l f - r e l i a n t and to make constructive use out of his good, physical and mental endowment, so that he can find,' more dynamic outlets for- his inactive drives than the st a -t i c form of p h y s i c a l largeness. CHATTER IV THE DEVELOPMENT; OF THE CLINICAL TEAM" AND ITS' OPERATION  Tne C l i n i c a l Team : *~ ••• 43 Reference has already been made to the manner i n which the doctor, d i e t i c i a n , s o c i a l worker and nurse were able to cooperate together i n the diagnosis and treatment of c h i l d -ren attending the clinic;, A better appreciation of the r o l e played by the s o c i a l worker in the team, and the means by which casework methods have been able to contribute: to the e f f o r t s of the c l i n i c * may be obtained from a study of the formation of the c l i n i c a l team and the evolution of i t s p o l i c i e s . E a r l y i n A p r i l 1950, when the new Metabolic C l i n i c f o r children was to be started, the: s o c i a l work supervisor a t the General Hospital discussed the? proposed s t a f f requirements with the p e d i a t r i c i a n i n charge of the Health Centre, It was decided that there would be need for a d i e t i c i a n and a s o c i a l worker. It was. agreed- that the d i e t i c i a n from, the Out-Patient's Department (O.P.D.), and a s o c i a l worker would be assigned to; t h i s c l i n i c . An outline of p o l i c y for the c l i n i c was also devel-oped at t h i s time;. It was decided that the d i e t i c i a n should see every case referr e d and make out a. dietary history; The nurse working In the c l i n i c would be responsible for obtaining 43* See Chap,II, page 3 3 , Diagnostic Process 57 the necessary information f o r the Wetzel Grid. Cases would be referred to the s o c i a l worker i f family d i f f i c u l t i e s seemed to be present or i f there was evidence of personality problems. At this time the idea of a c l i n i c a l team had not been formulat-ed and i t s p o t e n t i a l value was not appreciated. Development of P o l i c y After three months of operation there was f e l t to be a d e f i n i t e need f o r closer l i a i s o n between the di f f e r e n t mem-bers of the c l i n i c ' s s t a f f since there were signs of a lack of coordination between the work of each member. Accordingly on June 24, 1950, the f i r s t s t a f f meeting since the formation of the c l i n i c was hel in order to discuss some of the d i f f i c u l t -ies which had been experienced. The p e d i a t r i c i a n i n charge of the c l i n i c , the s o c i a l work supervisor, the d i e t i c i a n , the nurse and the c l i n i c s o c i a l sorker attended t h i s meeting, where the aims and methods of the c l i n i c were reviewed. Every-one agreed that the c l i n i c had f a l l e n short of i t s o r i g i n a l i n -tention i n that no ef f e c t i v e treatment approach to the problem of obesity had yet been evolved. It was f e l t p a r t i c u l a r l y that there was l i t t l e coordination or team-work i n the approach of the s t a f f to the patient. I n i t i a l contact with the patient was analyzed and i t was decided that i n future when each new patient attended the c l i n i c that he should f i r s t been seen by the d i e t i c i a n and s o c i a l worker. Thus the dietary and s o c i a l h i s t o r i e s could be assembl-ed and discussed with the p e d i a t r i c i a n i n charge of the c l i n i c 58 b e f o r e he saw the p a t i e n t . I d e a l l y , i t was f e l t t h a t a p l a n of treatment should be decided upon by the c l i n i c a l team be-f o r e the doctor saw the p a t i e n t . T h i s would f a c i l i t a t e co;-» o r d i n a t i o n between members and s e t the team i n a c t i o n . The r e f e r r a l p rocess was: d i s c u s s e d and i t was d e c i d -ed t h a t the present method of r e f e r r a l on a s e l e c t i v e b a s i s should be continued u n t i l the c l i n i c was equipped to handle a l a r g e r group. The group a t t h i s time c o n s i s t e d o f approximate-l y f i f t e e n p a t i e n t s . UTp to th i s , p o i n t Dr. Paters on had been the o n l y p e d i a t r i c i a n r e f e r r i n g cases from the g e n e r a l p e d i a t r i c c l i n i c * I t was agreed t h a t the other p e d i a t r i c i a n s i n the H e a l t h Centre should be informed o f the s e r v i c e s of the Meta-b o l i c C l i n i c . A number of other p o i n t s brought c u t a t t h i s , masting* though not. d i r e c t l y connected w i t h method, were c e r t a i n l y con-cerned w i t h approach. Cl) S i n c e the technology of treatment of o b e s i t y i s r e l -a t i v e l y hew, i t was emphasized that i t would be necessary to m a i n t a i n f l e x i b i l i t y i n approach and to be ready to i n v e s t i g a t e or accept Improved methods of treatment. C"2) The method of r e f e r r a l f o r s o c i a l s e r v i c e was d i s -cussed.;; it-.was r e v e a l e d t h a t sometimes the d i e t i c i a n p i c k e d up the problem w h i l e taking: the d i e t a r y h i s t o r y and r e f e r r e d the case to the s o c i a l worker* or the s o c i a l worker s e l e c t e d cases from among the c l i n i c a l attendances who appeared to he emotion-a l l y d i s t u r b e d . I t was agreed that t h i s was an unsystematic method of r e f e r r a l . 59 (3) The value of having a large number of student nurses and internes attending the c l i n i c : was questioned. It, was pointed out that on many occasions the patient:- had been obvious-l y embarasaed by the gathering. The presence of such a large group was l i k e l y to unnerve the patient and made his attendances at the c l i n i c an ordeal. However, i f the Vancouver General Hospital was to remain a tr a i n i n g h o s p i t a l , the presence of a. group of Internes and of d i e t e t i c and nursing students; was, a very necessary adjunct; I t was therefore the duty of the s o c i a l worker to see that the patient had an understanding of this function of a, t r a i n i n g h o s p i t a l . I t was decided that i f a c h i l d seemed to be p a r t i c u l a r l y embarrassed, even knowing the reasons for the presence of the group, arrangements could be made f o r such a patient to be seen by the doctor alone. It. was agreed that regular meetings were d e f i n i t e l y of value i n leading to closer cooperation i n teamwork and i n assessing the effectiveness of the treatment methods. Some; Aspects of the Referral Process Pr i o r to the f a l l of 1950, the Public Health Committee had adopted the following: approach to the treatment of obesity. The Public Health Nurses i n the schools kept a Wetzel Grid f o r each c h i l d . ( !It i s found that the highest percentage of obese children deviate from t h e i r normal channel before the age of eleven years.; i f any c h i l d showed marked and permanent signs 44. Bruch, H., The Grid f o r Evaluating Physical Pitness (Wet-zel) , Journal of Am. Med. Assn.. Vol.lLS, No.15, 1942, page 1289. 60 of being overweight the school nurse then advised the ch i ld and parents about, diet* If the parents and child were inter-ested and wi l l ing to cooperate, the nutr i t ionis t would also supervise the chi ld ' s d iet * In the view of the Associate Director- of the Metropolitan Health Committee there was add-i t i o n a l gain from; the v i s i t of the nutr i t ionist to the chi ld ' s home since i t led. to a better understanding of the family's income, a b i l i t y to budget and food habits; There was a l imitation in the Metropolitan Health Committee's. (M.H.C.) approach to the problem, since the. com-mittee was not permitted to give the child a complete medical, check-up but; had. to refer the patient to ,a private doctor with whom the Public Health Burses, cooperated. Consequently, there was a. variety/ of. medical approaches to the problem and there was no standardized medical treatment, as is possible In the Metabolic C l i n i c of the Health Centre. (Since there is only one doctor seeing a l l the patients in the Metabolic C l i n i c , treatment can be standardized and modified i f necessary). A meeting was held in the f a l l of 1950 and i t was agreed that the Public Health: Nurses should* in the future, refer a l l children for obesity* Up to this time direct re-ferra l had been discouraged since the Cl inic was not equipped to handle a large group. Early in October, one of the social workers from the Health Centre vis i ted the Metropolitan Health Committee to dis-cuss the techniques of the referral and follow-up processes in order to c l a r i f y these procedures and to decide upon the best means f o r the two bodies to work together. The following, memorandum was drawn up as a result, of th i s visit;, s e t t i n g up the p o l i c y which was to be followed, ( l ) The- Pu b l i c Health Nurse i n the school w i l l r e f e r the over-weight c h i l d to the Health Centre Pediat-r i c C l i n i c with the specific; probfem of obesity, ( i t ) The so c i a l worker w i l l make out a s o c i a l h i s t o r y for the case a f t e r i t has been seen In the Pediat-r i c C l i n i c . In doing t h i s the s o c i a l worker w i l l be clear with the Soc i a l Service Index; and the Public; Health Nurse i n the usual way. ( i i i ) The c h i l d i s then referred to the Metabolic C l i n i c to see the d i e t i c i a n and the p e d i a t r i c i a n i n charge of the Metabolic C l i n i c . Civ) A l e t t e r w i l l be written to the Director of School Health Services informing: him of findings. (For a l l cases referr e d by Public Health personnel, a report must, be submitted to the Director)), (v) The social, worker w i l l follow those cases where a, need f o r casework i s Indicated. She w i l l work clo s e l y with the Public Health Nurse In t h i s and contact her for any information which she can give concerning the family, the child's behaviour and the program i n school, (vi) Those cases which the s o c i a l worker w i l l not be v i s i t i n g w i l l be followed by the Nurse. - 62 (v i i ) It may be arranged that, the student diet ician w i l l visit- the home, partly to gain experience in home v i s i t i n g and partly to give assistance regarding dietary recommendations. In this memorandum the Assistant Director of the Met-ropolitan Health Committee made two recommendations. F i r s t l y , that the Public. Health Nurse could be of assistance to the C l i n -i c by having the child keep a food record for a few days before his or her appointment, at the Health Centre. When the child i s seen at the Pediatric Cl in ic the record would be sent along. This recommendation has been carried out and has proven to be most helpful to the. d iet ic ian in making up the dietary history. The second recommendation was that the vis i t , of the student diet ic ian should i f possible be timed to coincide with that of the social worker or Public Health Nurse in order to maintain continuity of service to the family. As the student diet ic ian is with the Metropolitan Health Committee for one month only, i t would be too confusing for the family concerned to have such a wide variety of v i s i to r s ; This l a s t recommenda-tion has not. been implemented for cases attending the Health Centre. In cases where the socia l worker i s v i s i t ing the fam-i l y , i t is f e l t that, the presence of another person would lead-to confusion since the public health nurse is already v i s i t ing in the home.. In such circumstances the family could, very easily feel that their private l i fe ; was being too closely i n -vestigated.; S3 . ^ Some Aspects of the 'Jfollowaupi* Process • v, I t is necessary to describe the part, played; by some of the workers.and to indicate the significance even of the patient's environment, in order to .be- able to appreciate the complementary role of the social worker In the follow-up pro-cess, the 1 d ie t ic ian , for example, often develops quite a close contact with the patient and his family, thus serving to strengthen the' efforts of '''-the social worker. Besides explain-ing a specif ic diet., as prescribed by the doctor to the patient or accompanying parent, the diet ic ian has to adopt; and coord** inate this diet to. the patient r s previous regular- food, habits so that the change w i l l not seem too drast ic . This may nec-essitate recommending substitute constituents and w i l l require a detailed knowledge of the family food budget. Moreover, since the average, family receiving treatment at the Health Centre cannot afford dietary: extras,: the prescribed diet must be economical as well as nutr i t ional ly balanced. The dietician may subsequently go over the diet with the patient, after i t has been followed.for a while and time has been allowed for. en-counterlng any potential d i f f i c u l t i e s . This check-*up may i n -volve a certain amount of interpretation of. the meaning of diet to the patient. the diet ic ian at. the Metabolic C l in ic has 'been part-icular ly sensitive to emotional d i f f icu l t ie s and has helped the social worker on many' occasions in being able to present another view point. Very often, the patient w i l l discuss with 64 the d i e t i c i a n problems associated with the intake of food, since the l a t t e r have- a d e f i n i t e bearing on his s o c i a l adjustment. He may not .mention such problems to the social, worker since he i s hot aware of t h e i r s i g n i f i c a n c e . This handicap was evident i n the case of Babs- B. The d i e t i c i a n had previously seen Babs.1 grandmother * Mrs. M . , i n the Metabolic: C l i n i c of the Out-Patient Department and was able, to talk to Babs about her family. Since Babs f e l t that the; d i e t i c i a n understood some of the problems, i n her family back-ground she was able to discuss: some of her own d i f f i c u l t i e s whi.ch she had not f e l t free to mention i n her f i r s t interview with the s o c i a l worker, Babs resented the amount of respons-i b i l i t y which had been forced upon her i n the home. Her own mother being; bed-ridden, her gran^jarents were looking a f t e r the home. Mrs., M., handicapped by being excessively over-weight, r e l i e d on Babs, to do most of the housework. Since most of her. free time was taken up with these household duties * Babs had very few fri e n d s , and food had become a form of compensation f o r her lack: of s o c i a l contacts and a l s o for this lack of secur-i t y In her home. The work done by outside personnel i s often e s s e n t i a l In aiding &nd supplementing the role of the s o c i a l worker. For example, the P u b l i c Fealth Nurse, besides making the r e f e r r a l and supplying data f o r the Wetzel Grid, may be able tP. give other pertinent Information r e l a t i n g to the child's, personality* progress at. school and family h i s t o r y . The food record which Is also of value to the G l i n i c i s completed by the c h i l d under 6 5 the supervision of the nurse. Where the s o c i a l worker Is not available to work Intensively with the c h i l d or family, the nurse Is i n fact the main l i n k between the Clinic, and the fam-i l y i In the same way, the teacher can serve as a valuable source of information regarding the c h i l d , since she i s able to observe the nature of the child's social, adjustment In the school. Moreover i t i s at school that, the c h i l d i s often able to resolve many of. the problems i t w i l l meet in s o c i a l adjust-ment, and. the teacher can help i n t h i s respect by encouraging the c h i l d to be more aggressive and less; withdrawn i n class p a r t i c i p a t i o n . The c h i l d can also be made, to f e e l accepted by the other children In the school through the teacher's e f f o r t s , and t h i s i s e s p e c i a l l y important when I t i s remember-ed, that t h i s school, contact takes up the major p a r t of the ch i l d ' s day. Children from low income families often have a number of brothers and s i s t a r s and consequently they respond very favourably to any personal interest that Is shown in them. The school teacher and public health nurse can there-fore between them be of very great help to the c h i l d in bring-ing about th i s desirable s o c i a l adjustment. The value of t h i s 'outside' teamwork was. demonstrated i n the case of Penny T. Penny was obviously not getting on well a t school; her marks were very low and she showed great reluctance to mix with her school mates. Mrs. T. fostered Penny's tendency to withd'raw. However, Penny responded well to anyone who appreciated her d i f f i c u l t i e s so the s o c i a l work-* 66 er whose contact with Penny was of. necessity limited to the C l i n i c , discussed Penny's case with the teacher and. school nurse., With an understanding of Penny's problems, both the teacher and the school nurse were able to supplement the soc-i a l worker's- contact, and Penny showed a. marked, improvement as a result of the additional attention. She became Interest-ed in playing on the school basket-ball team and was generally much happier within herself'. The socia l worker found that Penny was subsequently able to view her problems in better perspective: and that.she could understand and accept both her mother's attitude and her own feelings. What might be described as a favourable alignment of environmental forces, in the treatment process i s achieved when the socia l worker i s able to: obtain the cooperation and int-erest of the chi ld 's family. Through interpretation of the services of the; Clinic: and the. value of. diet , the family can become an integral part in the treatment, process. Since the psychological factors In. obesity are mostly centred In the parent-child relationship or in the ' s ib l ing relationships ' , the constructive assistance of the family is one of the main goals: in treatment. This goal, is not always easily achieved, since a family wil l , often appear to be willing; to cooperate, whilst, being unconsciously antagonistic to treatment. There are a number of reasons for this antagonism. 45. Sibl ing Relationship$ - generally refers to children with respect to their real parent, but, may also imply a re l a -tionship whereby some other person is approximating the parent ro le . 67 The mother may be over-protective of the c h i l d and f e a r f u l of seeing I t suffer.. She may have been feeding 1 the c h i l d ex-cessi v e l y to compensate for her feelings of h o s t i l i t y or re-j e c t i o n . Again food may be her only means of compensating: f o r the lack of emotional se c u r i t y i n the home. I f the mother i s p a r t i c u l a r l y possessive she may f e e l that by keeping, her c h i l d fat, that; h i s o r her outside a c t i v i t i e s : w i l l be r e s t r i c t e d , and being unattractive to other children, he w i l l be found to spend more time at home. For any of these reasons, the mother may not cooperates w i l l i n g l y i n the treatment plan. One may well ask why such mothers would paradoxically permit t h e i r children to attend a Metabolic C l i n i c . Usually i t i s because the public health nurse or teacher has talked to the: mother about her child's obesity* causing her- to f e e l that she w i l l be c r i t i c i z e d i f her c h i l d i s too- obese, and s o c i a l pressures force her to encourage the c h i l d to. lose a l i t t l e weight. But such mothers usually never intend, to follow the diet ; r i g i d l y . Whilst one mother may be loath to force her c h i l d to diet* since the giving of food, Is her only way of giving; a f f e c t -ion and security, another mother w i l l force her c h i l d to diet f o r punitive reasons. This manifestation i s p a r t i c u l a r l y e v i -dent, where the mother has; a masochistic type of personality. In t h i s case, d i e t presents a new area of c o n f l i c t and the ex i s t i n g mother-child h o s t i l i t y f e e l i n g s are aggravated. Such considerations focus our attention more d i r e c t l y 68 -upon the significance of the part, played by the social worker in the c l in ica l , team-. Every patient that attends the c l i n i c could benefit; from casework at. some level which might vary from interpretation on a superficial basis to insight therapy, requiring the aid of a. psychiatrist . Besides, her unique role In developing favourable: family relationships in the treatment process, the social worker also- aids the other members of the team In the follow-ing ways. The socia l worker's f irst , contact with the patient i s usually made at the time of the; l a t ter ' s admittance for treatment to the Health Centre when an 'admission sheet' Is; f i l l e d out. This i n i t i a l contact i s helpful in giving the worker an idea, of what Is involved in the: case and also in establishing a relationship with the patient. Both these factors are of value when more detailed information is sought for the social history which is prepared and presented to the doctor before he sees the patient. The social worker also acts as a l ia i son with the outside personnel; i e . , public health nurse or. teacher, or other collateral, and the c l i n i c . This job of coordination involves not. only exchanging, of information but also making; arrangements for treatment etcetera. Other agencies, inter-ested in the case concerned are contacted through the services of the Social Service Exchange. Summary It can be seen that, since i t s inception, consider-- 6 9 able progress has: been: made by the Metabolic- C l i n i c i n f i n d -ing the extent to which each person might be able to contrib-ute to successful treatment. The f l e x i b i l i t y of approach on the part: of the s t a f f members has enabled the gradual develop-ment of a p o l i c y which has strengthened the manner i n which each worker has been able to supplement the a c t i v i t i e s of h i s or her associates. There seem grounds f o r believing that the p o t e n t i a l contribution from casework i s s t i l l l i m i t e d by inadequate f a c i l i t i e s and that a better appreciation of the social, worker's role could lead to further improvements i n the results of the C l i n i c ' s work. CHAPTER V EVALUATION OP THE CASES ATTENDING THE METABOLIC CLINIC: SUCCESS, AND FAILURE: CONTINUING. NEEDS, The fact that, no single index of success or f a i l u r e can be Isolated j u s t i f i e s the existence of. the Metabolic C l i n t i c since from the foregoing; chapters: i t i s apparent; that, the a c t u a l loss: of •weight; i s not always, the primary consideration i n the treatment of the obese child,. Although the ultimate: objective of the c l i n i c i s to enable the c h i l d to lose weight, permanent, success i n this respect; depends on the improvement i n the s o c i a l adjustment of the c h i l d rather than i n the Loss of a few pounds;. A. number of f a c t o r s , therefore, w i l l have to be kept in mind i n assessing the work of the Metabolic C l i n i c , This work cannot be evaluated i n the l i g h t of the success or f a i l -ure In weight losses alone since obesity i s a symptom of. a p a r t i c u l a r p h y s i c a l or emotional condition. Ideally, treat-ment, should be focussed on the cause of the obese condition. However, i n cases where the: cause i s d e f i n i t e l y emotional, i t i s not always possible or wise to point, up the r e a l origins of the c h i l d ' s adjustment to over-eating. Because the child's adipose condition gives concrete evidence of a need f o r treat-ment, obesity becomes the apparent f o c a l point or purpose of treatment. The success of the treatment i s governed, by the following four f a c t o r s ; 71 (1) the degree of cooperation of the patient and his family; (2) the meaning of food to the patient and to his family; (3) the ego strengths; of both patient and fam-i l y , ( t h i s becomes apparent a f t e r assessing the Incidence and nature of other problems occurring i n the family); (4) the a b i l i t y of the patient and family to accept: help. These four' points w i l l be used i n assessing the work of the Met-abolic; C l i n i c . Limitations i n treatment are not confined only to* the patient and his family background but a r i s e also from lack of resources within the c l i n i c i t s e l f . Therefore the lim-i t a t i o n s of both sides w i l l have to be considered before valid! conclusions may be drawn from t h i s study. Since, however, treatment i s apparently concerned with weight loss;, the l a t t e r can be of some value as a tentative i n d i c a t o r of success or f a i l u r e . Such an assessment, can be made by means of the average monthly weight loss of the twenty-six children attending the Metabolic C l i n i c . £L numerical evalua-tion of treatment* on t h i s basis;, i s seen i n F i g . 1. A General Index In order to understand the significance of the numbers In F i g . 1, i t i s necessary to r e a l i z e that this group of twenty-six children i s only homogeneous i n respect to t h e i r obesity. The degree of obesity varies i n each case as does the age* height, body build and sex. There i s , moreover, considerable variance In the length of time during which the c h i l d has been 7 1 a -P i g . I-::-: SUCCESS OR FAILURE IN WEIGHT LOSS OF CHILDREN ATTENDING THE METABOLIC CLINIC L o s s ( o r g a i n ) o f w e i g h ^ e x p r e s s e d as p e r c e n t a g e o f r e q u i r e d w e i g h t l o s s , a v e r a g e d on a m o n t h l y b a s i s . I n d ex o f w e i g h t s l o s s o r g a i n > e x p r e s s e d i n p e r c e n t x " R e q u i r e d w e i g h t l o s s " was d e t e r m i n e d f o r ' e a c h c h i l d i n r e l a t i o n t o age, w e i g h t and body b u i l d . N.B. One e x c e p t i o n a l c a s e n o t shown on c h a r t showed w e i g h t i n c r e a s e o f 50% of e x c e s s w e i g h t . See A p p e n d i x C f o r / s c h e d u l e g i v i n g d e t a i l s o f F i g . I . 72 In attendance at the c l i n i c since some cases have attended reg-u l a r l y f o r ten months or more,, whereas others have been seen only once or twice,. Due to th i s variance between each case the chart can only be: used as an a r b i t r a r y tool i n evaluation and may not always: give a valid, i n d i c a t i o n of success or f a i l -ure* In order to obtain a more comparable measure as between patients, the percentage of the average monthly weight l o s s or gain has been estimated i n r e l a t i o n to the amount that each c h i l d exceeds the: normal weight for his; age, height and body b u i l d . The average normal weight for each child, is; e s tablish-ed only within a. certain range so that the figu r e indicating the amount of overweight i s an approximation. Patients: who have been seen only two or three times or who have attended the c l i n i c , for a period of two months or less have been shown on the chart as. potential, casses of weight, loss or gain. I t has been found that the preponderance of weight loss occurs during the early stages of treatment. Consequently, cases with few attendances have been distinguished on the; chart by cross hatching which indicates that they have been c l a s s i f i e d prov-i s i o n a l l y since t h e i r continued attendance might relegate them to; a d i f f e r e n t and. probably lower, group. Seven out of the twenty-six children, or approxim-ately twenty-five per cent who have attended the Metabolic C l i n i c , have not been, successful. Two of these children attended the C l i n i c once only, so that i t is impossible to determine what degree of success could be expected i f they re-73 turned. For the purposes of t h i s study, however; these two cases- have been counted, as f a i l u r e s on the assumption that they were not s u f f i c i e n t l y interested to return or that d i e t -ing would have deprived them of something that they were not prepared to give up. It. i s also known that these two children were s t i l l i n Vancouver at. l e a s t for some time a f t e r t h e i r only attendance. The other f i v e cases would appear to have f a i l e d f o r a; v a r i e t y of reasons; However, in each case there i s noted a d e f i n i t e lack of interest on the part of the patient, and his family. Moreover obesity was less marked i n these f i v e c h i l d -ren than i n the remaining 'success' group, since the l a t t e r were on the average thirty—seven pounds over-weight whilst the f i v e f a i l u r e s were approximately twenty-four pounds over-weight. Such a small sample permits only a tentative postu-l a t e , but i t seems l i k e l y that this greater degree of obesity of the 'success' group offered a greater incentive to reduce. I l l u s t r a t i o n by Gasess Failures: It i s possible In these f i v e cases of f a i l u r e that obesity had not i n I t s e l f become a problem i n the minds of the c h i l d or his family. This was d e f i n i t e l y so i n the case of Helen H., a: g i r l of f i f t e e n who showed no Interest i n losing; weight.. She was merely f i f t e e n pounds over-weight, and would, probably not manifest any interest i n l o s i n g weight u n t i l her tendency towards adiposity seemed to become a. problem to her. Maladjustments within the homes of the other four 7 4 cases were such as to overshadow that r e l a t i n g s p e c i f i c a l l y to the child's obese condition. For example, Ezra G. *s parents were Hungarian immigrants with very poor understanding of the English language. Not only were the i r eating habits d i f f e r e n t but an. older unmarried daughter who was a cripple gave b i r t h to twins while Ezra- C. was s t i l l attending the c l i n i c . T h i s incident, though irrelevant to the case i n question, was i n -dicative of the emotional needs of some members of his family. Moreover, since Ezra G. !s mother, s i s t e r and one brother i n p a r t i c u l a r are also considerably over-weight, his condition was probably not considered unusual. Because of the language d i f f i c u l t i e s , i t has been very hard to communicate with Ezra's parents and he himself has not been p a r t i c u l a r l y t a l k a t i v e , but rather inclined, when v i s i t i n g the, c l i n i c to s i t with a: subdued and t e r r i f i e d expression giving monosyllabic answers to a l l questions* As i t seemed impossible to establish a work-ing r e lationship with Ezra or his family, and as their lack of cooperation bordered on outright resistance, i t . was agreed by the c l i n i c a l team that i t was useless to continue attempting something that was not wanted. Don B. was considered a f a i l u r e becuase the exper-ience of his own l i f e had given diet or a shortage of food i n -take: too much, significance for him. Shortly before Don f i r s t attended the Metabolic C l i n i c , his father died of cancer of. the stomach. One can imagine a long period when Don's father required very careful feeding arid a great deal of attention i n order to induce him to eat at a l l . Consequently food had 75 taken on a great significance f o r this boy who was eleven years old when his father died. The death of Don's father ax a re-r suit of the disease and the attendant enforced starvation made a deep impression on Don. His very h o s t i l e reaction to any deprivation of food i s therefore understandable. Don's mother, who was i n c l i n e d to be neurotic, found that this struggle to get Don inter.este.dgin losing weight was too much. I t was agreed that as Don was not grossly over-weight (twenty~five pounds) i t would be less disturbing f o r both h i s mother and .himself i f he did not attend the Metabolic Clinic:. I t was also f e l t that help could be more appropriately offered through the Psychiatric C l i n i c . Itaa D.*s family, l i k e that of Ezra C., i s faced with a number of problems s u f f i c i e n t to outweigh any interest that might be shown i n her losing: weight. Ina's parents, pre-occupied with th e i r own d i f f i c u l t i e s , do not get along; together and Mr. D. i s frequently away from the home, Mrs* D. i s a neur-o t i c type of person and devotes a l l her attention to the boys i n the family. Ina d e f i n i t e l y feels unwanted and. misses the support and a f f e c t i o n of. a more normal home l i f e . Under the present strained family conditions Ina finds i t d i f f i c u l t to devote her interest and attention to t r y i n g to lose weight. This family i s well known to the Health Centre and there are many strengths which could be u t i l i z e d in helping Ina to reach a point at which she could diet with success. Fbr example, she needs help i n learning to accept her mother's a t t i t u d e and. i n 7 6 understanding her own reci p r o c a l feelings towards her: parents. This i s an example where more casework heLp would be of great benefit i f i t were a v a i l a b l e . Soy M". appears to be the lea s t successful case judged by the chart oh weight loss or gain; However, the f i f t y p e r cent weight increase measures the amount by which Roy exceeds the normal weight for his height and age. Since he i s only ten pounds over-weight, the increase of f i v e pounds which he made during the s i x weeks, that he attended the c l i n i c represents one hal f of the amount by which he i s over-weight; It was f e l t that Roy would not benefit from continued treatment at the c l i n -i c due to his home conditions. Roy's parents, who are on soc-i a l assistance l i v e with his s i s t e r who has two daughters old-er than he, as well as a son who i s younger. Roy^s s i s t e r has a: form of p a r a l y s i s and Is bed-ridden. Her f i r s t husband was k i l l e d during the war and she now has a common-law husband, who i s In and out. of the home. Consequently, there i s a great deal, of Insecurity i n thi s home.. Roy's mother, who weighs over three hundred pounds, Is being sseen i n the Meta-bolic: G l i n i c of the Vancouver General Hospital OutwPatient's Department. The Gity Social Service Department are. also In contact with t h i s family. Due to the other contacts already established with t h i s family, i t was f e l t that since casework help could, not be offered to Roy himself i t would be better i f he were hot seen at the c l i n i c . He i s not l i k e l y to bene-f i t from diet, without such casework; neither w i l l his condi-t i o n Improve u n t i l such time as his home circumstances are 77 ameliorated and his family able to take more interest i n his welfare. B r i e f analysis of these seven cases reveals a common obstacle to the degree of progress and success, which obstacle i s manifested in the complete lack of cooperation and interest on the part of the parents or c h i l d or both. This l i m i t a t i o n could be la r g e l y overcome If more casework help were a v a i l a b l e . Interpretation concerning the meaning of obesity could be help-f u l to. those cases a c t u a l l y desiring help with t h e i r personal d i f f i c u l t i e s and able to accept, such a i d . However, i n such cases, as i n a l l others, i t Is necessary to s t a r t from the pat-ient's viewpoint by discussing; the things which he brings up himself and then subsequently to work through these problems with him i n order to help him relate his d i f f i c u l t i e s to his excessive oral needs. Ina B. might have benefitted from i n -tensive casework relationship since the st r a i n s of her upset home l i f e precluded her intere s t In los i n g weight. If she were helped to understand her parents, her anxiety would, be greatly reduced and she would perhaps be able to channel the s a t i s -f a c t i o n of her needs fo r security and a f f e c t i o n away from the excessive intake of food. With a better understanding of her parents should would perhaps be able to learn In what areas should could, anticipate a f f e c t i o n from them and which areas she should become more independent. Don B. i s another boy who could benefit from psych-i a t r i c help. It i s doubtful whether he could ever accept 78 help through a- Metabolic: C l i n i c since the d e p r i v a l of food points too d i r e c t l y to the core of his disturbance, that is: the association of death with the withdrawal of food. With-out the s k i l l of a psy c h i a t r i c therapist attendance i n such a. cLi n i c would do more harm than good. Members of the c l i n i c f e e l that i n a case such as t h i s , referral, to a p s y c h i a t r i c c l i n i c : i s more appropriate. As a re s u l t of t h i s consideration of the c l i n i c ' s unsuccessful cases, three recommendations can be madet ( l j There i s a need for more casework services} i e . * increase i n casework s t a f f ; (2) There i s occasional need f o r psy c h i a t r i c help i n therapy. The c l i n i c has at. pres-ent the. services of a p s y c h i a t r i s t for diagnostic purposes only; (3) There is, need for an interpreter on a. v o l -untary or short-time basis for those with language d i f f i c u l t i e s . I l l u s t r a t i o n by Cases; Successes Some of the more s i g n i f i c a n t factors determing success i n treatment are also evident i n the following cases. The f i r s t two cases, Betty 0. and Tom B., are noted f o r the de-gree of cooperation shown by both parents and children. Betty G. attended, the c l i n i c f or three months u n t i l she reduced to her normal weight. However a f t e r discharge from the c l i n i c she regained weight. Betty has been seen in the Health Centre P s y c h i a t r i c C l i n i c and both she and her mother are receiving casework servicers. It i s f e l t that i t may be necessary for her to return to the Metabolic C l i n i c when some of the present 79 d i f f i c u l t i e s are overcome; In helping Betty at present- the Metabolic C l i n i c would only be duplicating the services of the Psychiatric C l i n i c . This i s interesting as a 'success* case because, despite the strains and tensions that had been in this, home, Betty and her parents were able to take an i n t -erest and cooperate In d i e t ; Lasting success i n maintaining normal weight w i l l depend on both Betty and her mother, being able to overcome some of the emotional d i f f i c u l t i e s connected with the death of Mrs. 0:. f's f i r s t husband, who was Betty's father* Betty's gain i n weight a f t e r leaving the Metabolic C l i n i c also indicates the greater need for t r a i n i n g i n good eating habits rather than temporary adoption of a d i e t . This need was noted i n the other most successful case, that of Tom B. Tom'attended the C l i n i c for a period of four months and l o s t approximately twenty pounds during that time; Un-fortunately l i t t l e i s known about Tom's family or of his personal d i f f i c u l t i e s i f any, since he was able to maintain a regular weight loss each month through di e t i n g alone. Tom was discharged from the C l i n i c in July, 1950, and returned. In May, 1951, having gained eight pounds. He was put back on a. nineteen hundred rcaillorie diet and his weight returned to; normal; These two cases also reveal the l i m i t a t i o n s of assessing the degree of success, or f a i l u r e by the amount of weight l o s s alone. Though Betty 0. has attained a higher percentage of weight loss* Tom B. might be rated as a more I 80 successful case i f the degree of personal adjustment and the cooperation i n treatment which he showed are also considered. Although the degree of obesity f o r each case i s approximately the same, Tom had twice the amount of weight to lose in actual pounds. Despite the fact that Tom l o s t only four and a h a l f pounds per month whereas Betty l o s t three, a d i r e c t l y r e l a t i v e comparison of weight l o s s between the two cases would be a very a r b i t r a r y c r i t e r i o n f o r measuring the success of treatment. Anne K., Bee E., and Nancy 0., a l l attended the C l i n -ic: f o r a month or l e s s , consequently they can only be consid-ered as; 'potential cases'; Anne and Nancy have been seen only twice and l i t t l e i s known about their backgrounds. Nancy kept to; her diet for the two weeks between her v i s i t s to the Clinic, but a f t e r her second v i s i t she consistently broke her appointments and has not returned. Anne showed l i t t l e i n t e r -est i n l o s i n g weight although she d i d lose two- pounds in two weeks. Perhaps one of the reasons f o r her lack of interest and cooperation stems from the emotional and economic strains i n her home. As Anne's father was crippled the family sub-s i s t e d on her mother's allowance. Although l i t t l e i s known of these two cases i t seems probable that i f a s o c i a l worker had been available to spend more time with them on admittance to the c l i n i c and had been able to help these g i r l s relate t h e i r obese conditions to t h e i r personal problems these g i r l s would have been encouraged to desire help. This Is assuming that they were secure enough to be able to discuss their per-sonal f e e l i n g and problems and able to accept insight into 81 the reasons, for t h e i r feelings and needs. Bee E. showed good progress i n her f i r s t two v i s i t s * l o s i n g four pounds i n a month, but then she gained two; pounds in the second month. If Bee had continued to attend i t i s doubtful i f she would have continued to lose weight because of her home s i t u a t i o n . Be has a very poor relationship with her adoptive mother who i s extremely hostile:. There were several instances when Mrs.. E. attempted to degrade Bee i n f r o n t of the c l i n i c team by openly discussing her real parents or by r e l a t i n g other very personal Information about Bee. Mrs. E. seemed, t o t a l l y unaware of her own needs for help and i t soon became apparent that the c l i n i c was a means of pun* ishing Bee. In view of these facts i t was decided that Bee should discontinue attendance at the c l i n i c . I f there had been more casework s t a f f at the c l i n i c t h i s c h i l d could have been helped, though the treatment would have involved a long term contact; Through such a relationship I t might be poss-i b l e to help Mrs. E. he r s e l f . A group of six children amongst the. patients attend-ing the c l i n i c , have a l l l o s t from f i v e to ten percent of t h e i r excess weight per month. It i s interesting to note that t h i s group have a l l attended f a i r l y regularly and that i t Is the only group which does not. include any 'p o t e n t i a l 1 case s. Glyne Pi (mentioned i n a previous chapter), i s be-liev e d to be a c r e t i n and has had some thyroid treatments; - 8 2 Due to her limited mental a b i l i t i e s she can only be guided by her mother and has not exhibited any outward reaction to the d'ietv Glyne's success i n dieting therefore depends en-t i r e l y on her mother. During the f i r s t six months Glyne lost: twelve pounds but her weight has not changed during the l a s t few months. Any further treatment should be directed towards Mrs. P. who could benefit from help on a supportive and ad-visory basis. Ron H. showed a steady weight loss u n t i l shortly be-fore Christmas when he began to protest quite v i o l e n t l y a t his dietary r e s t r i c t i o n s . Ron has been one of the very steady attendants of the cl i n i c : . His mother has been quite cooperative but tends to indulge Ron i f she f e e l s that his diet i s going to be too much f o r him. Besides having a d i e t , Ron has had. amphetomine sulphate tablets to reduce appetite for a: short period and now he has 'seblin*, a. bulk food. Ron has also had play interviews with the s o c i a l worker to help him work off some of the annoyance and anger that he has not been able to express f r e e l y i n his home. Only a: limi t e d amount of success may be anticipated i n working with Ron himself since his parents are not w e l l adjusted and- need help themselves. M a r i t a l disharmony has been the cause of the insecurity i n Ron's l i f e . Perhaps when he i s older Ron w i l l be able to understand his parents but at present he i s s t i l l a t ah age when he needs encouragement and a f f e c t i o n above a l l else. Considering the limi t a t i o n s i n thi s case the treatment has been f a i r l y successful. Complete success, 83 However, rests on the a b i l i t y of his parents to accept help for t h e i r own personality d i f f i c u l t i e s . Group therapy could also contribute a great deal to Ron's well being i n his r e l a -tionships with his school mates. Ron's parents unconsciously hindered the complete success of the; treatment whereas Robert F. *s mother quite consciously and deliberately fed Robert when she f e l t he was losing weight too quickly. Robert was grossly over-weight and was put on a r e s t r i c t e d d i e t . Amphetamine sulphate was also prescribed In an attempt to help him curb his appetite; This, was counteracted, however, by his mother who; was also excess-i v e l y f a t and who frankly admitted that she did. not want her son to become too. t h i n . Robert has l e f t town to: work with his brother In a. lumber m i l l up the coast. This overpossess-ive mother could, have been helped, by means of a casework rel a t i o n s h i p , to accept the fact that her son has a right, to; be an independent i n d i v i d u a l . In contrast to Mrs. F., Daphne's mother followed the d i e t more r i g i d l y than Daphne; Daphne S. is. f i f t e e n , with a f r i e n d l y and j o l l y personality; Her interest was c l o s e l y associated with her feelings of what she f e l t that, she should do, rather than with what she r e a l l y wanted to do; DUe to her enthusiastic and happy nature, Daphne may not have found her over-weight condition too much of a problem, and consequently she may not have attempted to follow the d i e t too s t r i c t l y . However* one wonders whether her gaity was not the r e s u l t of an a_ttempt to win approval amongst her 84 school mates which she feared she might lose due to her Phys* te a l largeness. Daphne did not attend the c l i n i c regularly enough to establish a relationship with the s o c i a l worker and i t was not possible to have more than b r i e f f r i e n d l y chats. The degree of cooperation that can be expected from a c h i l d depends not only on his other Interests, such as in Daphne's case, but also on Uae need or compulsion to please parental f i g u r e s * Wynne H. was most, cooperative, as were her parents. The H.'s were older parents, Mr. H* being an. Invalid pensioner. This couple have demanded perfection and i n mosts respects have received I t . However,, since coming to the Met-abolic G l i n i c Wynne has developed some personality problems, and she i s at present attending the Psychiatric: Glinic. be-cause; she has been stealing and has developed nervous; t i c s . The ultimate success of this case w i l l depend on the casework help she receives i n r e l a t i o n to these problems. As an example of the reaction to, a land, of plenty, John G.1 s parents,; who; are immigrants from Germany, have grossly over-fed him.. John i s three and h a l f years old and weighs f i f t y - e i g h t pounds. Since attending the Metabolic C l i n i c he has l o s t three pounds. At present treatment i s li m i t e d by language d i f f i c u l t i e s . The need fo r an interpreter i s apparent i n this case as In that of Ezra C.*s, who Was d i s -cussed amongst the f a i l u r e group; Marginal Group The l a s t section of the •success:' group i s composed 8 5 of children who have l o s t excess weight at a rate of f i v e percent or l e s s . They should be regarded as borderline cases and th e i r continued attendance at the c l i n i c depends on the small degree of interest or cooperation which they manifest. Eileen I., who i s fourteen, i s the daughter of I t a l -ian Immigrants. Eileen's parents have not helped her with her diet but an older s i s t e r has become interested and haa been quite cooperative. Eileen has been given 'seblin' to help curb her appetite and she Is on the sixteen hundred c a l -orie d i e t ; In the s i x weeks that she attended the c l i n i c she l o s t four pounds, and then gained two. It was only poss-' i b l e to anticipate e r r a t i c progress: since Eileen has. a number of emotional and s o c i a l problems. The Juvenile Court and the City S o c i a l Service Department have contact with this; g i r l . There Is ho doubt that her obese condition i s related to these personality problems. When another agency already has contact, with a c h i l d the s o c i a l worker i n the Metabolic C l i n i c works in close cooperation with t h i s other agency; The s o c i a l i z i n g nature of group therapy could prove to be of great value; i n helping such children as. Eileen I. or Wynne H., who manifest their d i f f i c u l t i e s i n s o c i a l ad-• \ • justment through delinquency. Group therapy f o r the c h i l d i n conjunction with adequate casework services to both the Child and his parents would helpp such cases toward s a t i s f y -ing t h e i r heed f o r love and aattention i n a more acdeptable manner than delinquency. Sandy McK.'s family i s also i n contact with the-- 86 City Social. Service Department. Mr. McK. died a year ago leaving his wife and three children of whom Sandy, aged t h i r t -een i s the youngest. Sandy's.mother i s neurotic and does not encourage him to keep to his d i e t . Over-eating has been a form of. compensation for Sandy since he did not put on ex-cessive weight u n t i l a f t e r the death of his father. Success i n Sandy*s case w i l l be l a r g e l y determined by the degree of help which his mother can accept since she i s at present so preoccupied with her own feelings and problems that she has l i t t l e time for her children. There are two so-called 'potential* cases i n t h i s group. The parents, of these two g i r l s are t o t a l l y uncoopera-t i v e . Lucy J . *s father i s suspicious of c l i n i c procedure and f e a r f u l of any treatment that might be offered. It i s not surprising therefore that Lucy has not returned to the c l i n i c . Day P.Is. parents are too preoccupied with their own troubles to be concerned with Day's d i f f i c u l t i e s . She showed i n i t i a l i n t e r e s t i n her diet but. as i n Sandy McK.'s case, she f a i l e d to get the parental, support that: she needed. As mentioned e a r l i e r , more could be done fo r these cases providing that, there was s u f f i c i e n t casework s t a f f to spend more time with each c h i l d and his respective parents. However, in Lucy J . *.s case i t is, doubtful i f even t h i s service would be s u f f i c i e n t , since her father was so possessive that, he even associated her l o s i n g weight with becoming more a t t r a c t i v e and enlarg-ing the p o s s i b i l i t y that some other man would claim her a f f e c t i o n s . 87 These l a s t few cases which are.borderline in terms of the amount of success to be anticipated bring into focus the decision which must be made i n a l l s o c i a l agencies. A quandry exists, between p r a c t i c a l considerations and the be-l i e f that no c h i l d or adult i s beyond reach of help; No -matter how w e l l an. agency i s staffed there i s a l i m i t to the number of people that i t can serve. The solution of the: quandry l i e s i n selecting only those cases which w i l l benefit most, from the services a v a i l a b l e . The f i n a l decision as to> whether a c h i l d should continue to attend the c l i n i c : Is gov* erned by the f i r s t four: points mentioned a t the beginning of th i s chapter;; namely* the ego, strengths, degree of cooperation, a b i l i t y to accept: help, and the p a r t i c u l a r significance of food, to the patient and his family. Four cases were act u a l l y discharged from the c l i n i c as a r e s u l t of this selection on the basis of response to; availEble treatment f a c i l i t i e s . A l l four showed l i t t l e or no interest i n losing weight and their attendance was the r e s u l t only of the suggested r e f e r r a l from a doctor i n one of the other c l i n i c s , at the Health Centre or from a Public Health nurse. In these cases, the g i r l s , or their mothers i n t h e i r wish f o r social, approval, f e l t obliged to comply with the suggestion. In two cases, because' of t h e i r own personality and m a r i t a l d i f f i c u l t i e s the mothers showed no interest, i n helping their daughters. Lois D.*s mother did not get on with her husband and resented the a f f e c t i o n he showed t h e i r daughter* Moreover, Lois showed l i t t l e Interest. In her d i e t 88 because of her h o s t i l i t y towards her mother who represented a c o n t r o l l i n g authority; She- transferred some of th i s host-i l i t y towards the c l i n i c , since she associated the c o n t r o l imposed by the d i e t with her mother, B&bs; B:. *s mother, was an i n v a l i d and the daughter of Roy M. *s mother. The s i t u a t i o n In this family was des-cribed, e a r l i e r and i n the l i g h t of these d i f f i c u l t i e s i t did not seem wise to:» impose further r e s t r i c t i o n s upon Babs* She was quite morose i n her attitude and seemed too preoccupied with other matters to be concerned with d i e t . Penny T. and Jean P. were likewise discharged as their mothers would not, cooperate; and r e s i s t e d attempts to help being given by the c l i n i c . Penny's mother resembled Lucy J.'s father i n being over possessive and i n regarding the child's obese condition as a means of maintaining her dependence. Jean's mother f e l t that treatment, would be i n -e f f e c t i v e since she and most of her family shared her daught-er's over-weight condition. Conclusions: Parental support, and i n t e r e s t i s Important i n every case. Consideration of possible factors determing; the degree of parental cooperation shows ho d e f i n i t e c o r r e l a t i o n be-tween family structure and the probable degree of success i n treatment. The absence or death of the father*, although of frequent occurrence, appears f a i r l y evenly throughout the entire range of 'success* or ' f a i l u r e * cases. S i m i l a r l y , 89 i n t h i s l i m i t e d group the child's position i n the family does not seem to he a determining factor of success. The degree of cooperation seems to depend rather upon the frequency and nat-ure of other problems occurring i n the home. However, the ex-tent to which such problems w i l l prevent, parental cooperation in treatment w.1.11 depend on the family's unity and a b i l i t y to face these adverse conditions. (1) The. liTeed. f o r More S o c i a l Work S t a f f This survey of the f i r s t year's work of the c l i n i c Shows the need f o r more casework as w.ell as for s o c i a l work-ers to help i n t h i s part, of the treatment process. Meeting: these needs would, allow, f o r : (a) A more extended contact with the patient at. ad-mittance to the c l i n i c . This would help to re-move- the patient's anxiety about treatment, or help him to appreciate Its need. Such contact would give the patient, a better under standing of the emotional, implications; of obesity. (b) Casework services on a more in t e n s i v e l y thera-peutic: basis;. These services may vary from help on a supportive basis to that on an insight bas-i s . By means of the former process the p a t i e n t i s able to discuss his problems f r e e l y and gains more confidence i n himself through the strength of the relationship 1. This type of help i s more concerned with the solution of the immediate problems:, whereas insight therapy helps the pat-ient to change his personal adjustment which i s not j u s t a solution to present problems but a. means of preventing s i m i l a r s i t u a t i o n s recurring. Help through i n s i g h t i s offered to patients who are able to accept and understand, the underlying reasons or motivations for their behaviour. There-fore help on a supportive basis i s short; term i n that, i t i s focussed on immediate problems; but help through i n s i g h t therapy aids the patient make a better l i f e adjustment which i s the long; term-prevention basis, for r e p e t i t i o n of his present problems. 9tt (2) The Need fo r Psychiatric Follow-Up In order to be able to provide more intensive case-work services p s y c h i a t r i c services w i l l be needed on a ther-apeutic: basis. At present the c l i n i c has the services of a very good diagnostic p s y c h i a t r i c clinic:, but only f o r one day every second week. It would be of great value to the Meta-bolic C l i n i c i f such therapeutic work could be carried out, since many of the children: who have attended the c l i n i c would have benefitted from p s y c h i a t r i c help. This lack of p s y c h i a t r i c and s o c i a l work service has the greatest l i m i t a t i o n i n planning treatment at the Metabol-ic C l i n i c , and such success as has been attained so f a r has been due mainly to- dietary services offered. Children who are deeply disturbed or who suffer seyeie home maladjustments, have tended to d r i f t through the c l i n i c , often dropping our or being- discharged because of t h e i r lack of i n t e r e s t i n diet which a c t u a l l y i s due to t h e i r preoccupation with person-a l and family problems. (3) The Value of Group Therapy A high proportion of the twentyWix children attend-ing the Metabolic C l i n i c had d i f f i c u l t y in 'mixing', or in adjusting themselves s o c i a l l y outside of t h e i r f a m i l i e s . Some of these children would have found i t easier to discuss t h e i r problems i n a group sit u a t i o n rather than by means of i n d i v -IduaL interviews. The role of group therapy has been d i s -cussed- In the previous chapter on treatment methods. 91 (4) The Heed; for an Interpreter The need f o r an interpreter becomes apparent in the case of Ezra C.. and John G. At present the C l i n i c i s not large enough to: warrant such services except on a casual part-time basis;. Since less, than twelve per cent of the children who have attended the c l i n i c have foreign-born parents t h i s service would not; be required for more than two afternoons a. months. The l i m i t e d amount of such aid required i n no way detracts from the very real. need. (5) The Heed, f o r Developing Good. Eating Habits The experience with the two. most successful cases, Betty 0. and Tom B., has indicated to the c l i n i c a l team the need for an understanding of diet and food values by the children and t h e i r f a m i l i e s . With good feeding habits i t should, be possible for children to maintain normal weight. Adiposity i s caused primarily by an excess of c a l o r i c intake over energy expenditure which i s stored as f a t t y tissue* Since each individual has a d i f f e r e n t rate of energy exped Iture, what appears to be s u f f i c i e n t food for one person i s an excess for someone else. Therefore i t i s necessary i n teach-ing children and parents good feeding habits to give each c h i l d an indication of the amount of food that he should eat each day to maintain normal weight and meet his energy re-quirements. Though the lack of success i n the c l i n i c which this study reveals leads to rather negative conclusions, i t s 92 -revelation of the problems to be overcome i n the treatment; of obesity are a very posi t i v e contribution. That the attainment of success Is not easy i n such a c l i n i c : can be appreciated by a. better understanding of those limitations; which, it: i s hoped, have become more apparent through t h i s study. These concluding recommendations f o r future development are based therefore on a recognition of such limitations:. (1) The need f o r more s o c i a l work s t a f f . (2) The use of psychiatric follow-up or therapy as. well, as the diagnosis of deeply disturbed children.. (3) Group therapy, the selective introduction of." which could prove to be of value In some cases. (4) The services of an Interpreter to f a c i l i t a t e the treatment of children of foreign-born parents. (5) The need for emphasis upon the development; of good eating habits which could be e f f e c t -ed, by discussion groups, for both parents and children. APPENDIX A INDICATORS OF OBESITY Note L: Wetzel Grid This device i s used for recording the child*a height, and weight i n order to, determine the extend of deviation from normal. The area' of normal, progress on the g r i d i s divided into seven growth channels. I f subsequent measurements follow; the course of one, of the established channels i t may be con-cluded that the child, i s healthy and i s progressing normally. The- importance of the g r i d i s that i t recognizes differences of body type, since the seven channels of the grid, allow f o r the c h a r a c t e r i s t i c s of different: growth l i n e s . The channels proceed from the Lower l e f t hand corner of the chart to the upper r i g h t hand corner; The channels to the r i ght of the median channel, represent slender b u i l d , those to the l e f t , represent stocky b u i l d , Therefore the channel on the extreme r i g h t represents poor ph y s i c a l status and that, on the extreme l e f t , represents, obesity. Abnormal changes i n weight may be expressed by an upward trend* i e . , deviation of the growth l i n e to the le f t , indicating; an increase In weight. A downward trend of. the l i n e , or deviation to the r i g h t , would. Indicate a decrease i n weight. The seven channels indicating height and. weight pro* gress are subdivided by so-called developmental l i n e s . These - 93 "3 94 l i n e s are related to standard schedules of developmental pro-gress and are c a l l e d :.auxo dromes. Comparison of the measure-ment, per se, determined from the g r i d , and of the s k e l e t a l age, as measured by the t r a d i t i o n a l roentgenographlc method, must: show a good agreement before one i s j u s t i f i e d i n replac-i n g a welt established, though tedious, method by a new and 1 " simpler, one. I t has been found that the s k e l e t a l age i s a-' much more r e l i a b l e figure to use In the prediction of future growth and development,. Note 2i Basal Metabolism 2 The determination of the basal metabolic rate has a c t u a l l y been, of l i t t l e value i n the diagnosis of the causes of obesity. I t s use has been the r e s u l t of a, popular miscon-ception, that people who are predisposed to adiposity do not have as: large energy; requirements as people who. are of a slimmer b u i l d . According to t h i s thinking, the obese person haveng lower energy requirements: w i l l store the excess food In the form of f a t t y tissue.. This has proved to: be f a l l a c i o u s p a r t i c u l a r l y i n r e l a t i o n to children. I t i s to be expected that a rapidly growing c h i l d requires proportionally more energy per u n i t of body substance 1* Bruch, H.,. The Grid for Evaluating; Physical Eitness (Wet-zel) , J . of Am. Medical. Assn.. Chicago;, ¥01.118* No,15, 1942* page 1290. 2. The basal metabolic rate (BMR) i s a special index of meas-urement of the heat produced within a. patient eighteen hours a f t e r taking a mixed meal. 9 5 -than a slowly growing c h i l d or adult. However* the fact that obese children grow and mature at a fa s t e r rate than normal i s hardly consistent with the assumption that t h e i r requirements f o r growth are less, than those of normal children. In a study of the degree of a c t i v i t y of the obese 3 c h i l d as compared to the non-obese c h i l d , Dr. Bruch found that abase- children were not so; a c t i v e . Their recreational a c t i v i t i e s , other than muscular exercise, showed l i t t l e i n d i -cation of creative self-expression. The ma-jiority of these children sought entertainment by frequenting movies or p e r s i s t * ent l i s t e n i n g to the radio^ and reading at the comic, s t r i p l e v e l . A s t r i k i n g c orrelation was observed between a marked appre-hension on the part of the parents, concerning the dangers of s o c i a l contact and physical exercise-, and the a c t i v i t i e s of the children themselves. A. comparison of food intake aid mus-cul a r a c t i v i t y revealed that these two f a c t o r s have an opposed emotional value. On this basis the increased food intake of the obese c h i l d i n the presence of decreased muscular a c t i v -i t y becomes comprehensible. 3-. Bruch * H., Obesity i n Childhood. Am. J . of Diseases of  Children. Vol.60* 1940, page 1082. APPENDIX B DETAILED CONSTITUENTS OF 1900 CALORIE DIM ' PRCT. ! CALS.' CALGo PH0S. IRON *i n v n 'VIT.A. •THUU' ' MIN RIBO-FLAVIN 1 'NIACIN «.7IT.D.« Milk 1 Quart {hi oz.) ' h3.i 1 8 0 0 . • l o ^ 5 1.1k 1 . 2 3 • 1 9 6 8 .049 2 . 0 9 ' 1.23 • 12.3 • 2 5 . 5 ' Butter h tspc 1 .1 ' lh7. » . 0 0 3 Ooo3 .04 ' 6 6 0 .00 ' .02 ' 24. ' Bread Whole wheat 3 slices f" thick 1 8.6 • 2 3 6 . 1 .024- . 3 3 2„?0 . 1 6 2 o 0 9 1 2 . 8 8 ; Cereal ^ cup ' 3.7 » 96. » . 0 1 . 0 9 1 . 3 0 1 — . 1 6 5 .04 1 . 3 0 * — 1 Milk Pudding 1 h.i ' 1 3 5 . * . 0 9 — .53 • 2 7 8 » . 0 3 8 . 1 6 . 5 1 —. 1 Fruit 2 servings \ cup each' 1 i;h ' 119. 1 „ 0 2 . 0 3 . 8 0 1 1 3 5 6 . 0 9 6 ' . 0 7 1 .82 3 3 . 6 ; ; Vegetables 3 servings \ cup each • h.s 1 1 1 9 . 1 . 1 1 .12 2 . 6 1 1 6 9 0 6 . 1 6 5 ' . 1 7 1 1 . 2 3 ^ 3 . 5 1 — 1 Eeg 3~h per wk0 \ per day ' 3=8 ' h?. ' . 0 1 ' . .06 .81 ' 3*42 . 0 3 6 ' . 1 0 ' . 0 3 ' 2 7 . ' Meat 2 servings l^r oz„ each 1 1 6 . 3 ' l 6 3 o ' . 0 1 1 . 2 0 1 3»6o 1 3 4 5 6 . 1 0 0 ' . 6 1 * 6 . 7 0 6 . 7 ' 6 . ' Potato 1 small 1 2 . 0 1 85. ' . 0 1 ' . 0 5 ' . 7 2 1 2 0 .110' .04 * 1.20 ' 1 7 . 1 — 1 TOTAL 8 7 . 9 'W. 1 1 . 7 9 1 2 . 0 5 ' 14.34 '14986 « . 9 2 1 " 3 . 3 7 '14.41 • 1 1 3 . 6 ' 82.5.' - 97 -REDUCING DIET SUITABLE FOR A SHOWING SCHOOL CHILD (Approxo 1900 Calories) TOTAL FOOD TOR ONE DAY  Meat or Substitute 1 serving daily (at least) - meat 2" x 3" x •J" or substitutes fowl, fish 0 egg„ cottage cheese, Canadian cheese„ Milk - 1-^  pints to 1 quarts Butter - h teaspoons° Bread (whole wheat)- 3 slices £ inch thickness. Cereal (whole grain)- cup„ - 1 serving,, cup. - 2 servings, cup each - 3 servings„ ^  cup each - 1 small - 3 or k weekly Milk Pudding  Fruit Vegetables  Potato BREAKFAST Unsweetened fruit or fruit .juice - cup0 Any one of the following? 1 apple, apple Juice,, 1 orange,, orange juice, grapefruit juice, prunes. Cereal Bread Butter Milk - ^ cup whole grain cereal,, e0g<>, rolled oats, or whole grain combinations on market. - 1 slice \ inch thickness. - 2 teaspoons - cup (6 oa„) At least 3 mornings per week an egg should be substituted for cereal in above breakfast. LUNCH Meat or Substitute - 1 serving (meat 2" x 3" x^" (egg may be poached, scrambled, soft or hard cooked) Vegetable Fruit  Bread  Butter  Milk  OR LUNCH BOX  Soup Sandwich - 1 cup (see vegetable lis t ) or 2 servings \ cup each. When in season make a salad. \ cup tomato juice or tomatoes should be used often when green vegetables not in season. Raw vegetables are particularly good sources of mineral and vitamins. - \ cup fresh or canned (see fruit l i s t ) . - 1 slice,, \ inch thickness. - 2 teaspoons - \ cup (6 ozo) - cup canned or home-made. - 2 slices bread,, \ inch thickness. Butter - 2 teaspoons. Filling of egg„ meat„ fish or cheese. Vegetable - \ cup tomato juice or tomatoes or any vegetable. T r a i t 2/3 cup fresh or canned (see fruit l i s t ) Milk - •£ cup (6 0 Z 0 ) Sandwich and vegetable may be interchanged. For example, with tomato and lettuce sandwich 1 hard cooked egg or 1 one-inch cube of cheese may be carried. APTBR SCHOOL  Milk  Bread Vegetable  Potato Milk Padding MSAT LIST 8 Beef - £ cup (6 02o) - slice, inch thickness, or 1 arrowroot biscuit or two Graham wafers or 1 rye krisp cracker or 1 rusk or 1 bran naiffin or 1 serving unsweetened fruit, e.g. 1 apple or 1 orange 1 serving 2" x 3" x |" without gravy - Liver should be served once weekly. cup (see vegetable l i s t ) . 1 small „ cup0 > _cup 1 serving, l/3/custard, junket, rice, sago, tapioca, bread pudding, cornstarch pudding, ice cream or 1 Ice cream cone. £ cup (6 oz 6) £ cup (6 oz.) •Jr slice, inch thickness or 1 arrowroot biscuit or 2 Graham wafers or 1 rye krisp cracker or 1 rusk or 1 bran muffin or 1 serving unsweetened fruit. VBGBTABLB LIST 8 Artichoke Asparagus Beetroot Broccoli Brussels sprouts Cabbage Carrots raun LIST? Apples Apricots Blackberries Cherries Gooseberries Cauliflower Lettuce Chard Marrow Green Peas (not canned) Onions Cucumber Endive % g plant Kale Grapefruit Grapes Melons Oranges Peaches Veal Lamb Parsnips Radishes Rhubarb Spinach Pears Pineapple Plums Lemons Red Currants Chicken String beans Spring onions Tomato Turnip Watercress Squash Mushrooms Strawberries Raspberries Blueberries Limes Liver Heart NQTBSs 1. 2. DON'TSs 1. 2. A standard measuring cup should be used to measure amounts of food. Clear fat free broth, oxo, bovril, bouillon or consomme add no food value to the diet and may be taken as desired. Avoid the use of sauces, gravies, salad dressings and cream. 0 No fried foods are allowed. Meat should be cooked without the addition of any extra fat, i.e., roasted, bdiled or broiled. Avoid canned meats, sausages, weiners, bacon and sardines. A l l meats should be lean. Trim visible fat from meat„ 3. Avoid pie, pastry, cake, cookies, candy, chocolate, candy coated gum and rich desserts„ Avoid waffles and griddle cakes. ha No preserves as jam„ marmalade, honey or peanut butter are allowed. NO sugar is allowedo 5. Avoid soft drinks, milk shakes, cocoa. - 99 DETAILED CONSTITUENTS OF l 6 0 Q CALORIB D U E -GMS C_A£S OJffl fiMfi MGS I . U . MQ-S MPS MPS MQS I . U . 1 i i « 1 • PHOT. 1 CALSo' CALC0 • PHOS. 1 IRON 0 THIA-sRIBO-iVIToA.i MIN iFLAVIN1 NIACIN 1 Milk l£ Pt. (30 0 Z o ) Butter k tsp. Bread Zk slices |" thick 7.2 Cereal J c u p " Milk Padding Fruit 2 servings \ cup each Vegetable 3 servings \ cup each 3 2 „ 3 ' 6 0 0 o * 1 . 0 8 1 . 8 5 » o 9 2 8 1 U ? 6 • o 0 3 1 l 0 5 7 1 tl 0 B B v O S 0 .92 V 5 I D ,1 ! lU?. ' . 0 0 3 1 o 0 0 3 1 oOU 660 ' — ' 3.7 k . i ' 135 1 1 9 7 . ' 1 1 9 6 . ' . 0 3 , 0 1 . 0 9 . 2 7 . 0 9 ,'4 ' 119. ' . 0 2 » „03 2 . 2 5 1 . 3 0 » 5 3 080 . 1 3 . 0 0 ' . 0 2 1 1 i . 0 8 ' 2 . U 0 1 1 — 1 . 1 6 1 .ok 1 . 3 0 I t I ? i t 2 7 8 " . 0 3 1 . 1 6 > I I 1 1 i i I t I 1 3 5 6 ' . 0 9 1 1 s . 0 7 ,82 119. 1 d i 1 .12 1 2„6l ' 6906 ' . 1 6 , 1 7 1 1 . 2 3 1 3-k per wk„ ' < J per day ' 3.3 « hf. I ! Meat •" 1 2 servings • 16.3 1 163. . 0 1 .06 .81 1 i 1 8 3^ 2 » .03 ' . 1 0 . 0 3 . 0 1 J „20 • 3o6o 1 3 ^ 5 6 1 . 1 0 ' . 6 1 ' 6 . 7 0 1 1 1 1 VIT.C. 9.2 .5 3 3 . 6 U3.5 6 . 7 VIT.D. TOTAL » 7 3 . 7 ! l 6 2 3 o J t l.iio «1066 '12.86 Ii ! rihu^h • .77 « 2.80 8 1 2 . ^ 2 1 9 3 . 5 tl t t I 1 7 6 - 100 -REDUCING DIET SUITABLE FOR A GROWING SCHOOL CHILD (Appro*. 1600 Calories) TOTAL FOOD TOR ONE DAY Heat or Substitute - 2 servings d a i l y - meat or f i s h or fowl 2" x 3" x or substitute 1 egg, \ cup cottage cheese, 2 one inch cubes Canadian cheese. Milk - l £ pints Butter - k teaspoons Bread (whole wheat)- z\ s l i c e s £-inch thick. Cereal (whole grain)- \ cup. Milk Pudding - 1 serving, l / 3 cup. Fr u i t - 2 servings, \ cup each Vegetables - 3 servings e -jjr cup each; plus one small potato. - 3 or h weekly BREAKS'AST Unsweetened f r u i t or f r u i t Juice - \ cup. Any one of the following? 1 apple, apple j u i c e , 1 orange, orange j u i c e , grapefruit Juice, prunes. P a t t e r \ cup whole grain cereal, e.g0 r o l l e d oats, or whole grain combination on market. \ s l i c e ^-inch thickness or 1 s l i c e ^ - inch thicknett. 2 teaspoons £ cup (6 o«.) At least 3 mornings per week an egg should be substituted f o r cereal i n above breakfast. LUNCH Meat or Substitute - 1 serving (meat 2" x 3" x£") (egg may be poached, .craBbled, soft or hard cooked). Vegetables Fr u i t  Bread  Butter Milk OR LUNCH BOX  SOUP  8andwlch - 1 cup (see vegetable l i s t ) or 2 servings, \ cup each. When i n season two or more vegetables may be combined to make a salad. \ cup tomato juice or tomatoes should be used often when green vegetables not i n season. Raw vegetables are p a r t i c u l a r l y good sources of minerals and vitamins. - \ cup fresh or canned (see f r u i t l i s t ) . - 1 s l i c e , \ inch thickness, or 2 s l i c e s \ inch thickness. - 2 teaspoons - £ cup (k ox.) - •£ cup canned or home-made. - 2 s l i c e s bread, inch thickness. Butter - 2 teaspoons. F i l l i n g of egg, meat, f i s h or cheese. Vegetable - -£r cup tomato Juice, or tomatoes, or any vegetable. 101 Trait Milk 2/3 cup fresh or canned (see fruit l i s t ) , cup (h 0 Z O ) Sandwich and vegetable may be interchanged. Tor example,, with tomato and lettuce sandwich 1 hard cooked egg or 1 one-inch cube of cheese may be carried. AFTER SCHOOL Milk Bread DINNER Meat Vegetable Potato Milk Padding £ cup (6 os 0) -jjs- slice s -jUinch thickness, or 1 arrowroot biscuit 0 or two Graham wafers or 1 rye krisp cracker or 1 rusk or 1 bran muffin or 1 serving unsweetened fruit 8 e 0g 0 1 apple or 1 orange. 1 serving 2" x 3" x without gravy - Liver should be served once weekly0 \ cup (see vegetable l i s t ) . 1 small,, \ cup. 1 serving,, 1/3 cupc custard,, junket9 rice B sago„ tapioca,, bread pudding,, cornstarch pudding0 Ice cream or 1 ice cream cone. \ CUp (k Q950 ) - \ cup (k oss0) - slice, -^-inch thickness8 or 1 arrowroot biscuit,, or 2 Graham wafers or 1 rye krisp cracker or 1 rusk or 1 bran muffin or 1 serving unsweetened fruit 0 VEGETABLE LIST 8 Artichoke Asparagus Beetroot Broccoli Brussels sprouts Cabbage Carrots FRUIT LIST 8 Apples Apricots Blackberries Cherries Gooseberries Cauliflower Chard Green Peas (not canned) Cucumber Endive Egg plant Kale Grapefruit Grapes Melons Oranges Peaches Lettuce Marrow Onions Parsnips Radishes Rhubarb Spinach Pears Pineapple Plums Lemons Red Currants String beans Spring onions Tomato Turnip Watercress Squash Mushrooms Strawberries Raspberries Blueberries Limes MEAT LISTg Beef Veal Lamb Chicken Liver Heart NOTESj 1. 2. DON'TSs 1. 2. 3. k. A standard measuring cup should be used to measure amounts of food0 Clear fat free broth,, oxo„ bovrll 8 bouillon or consomme add no food value to the diet and may be taken as desired 0 Avoid the use of sauces9 gravies,, salad dressings and cream. No fried foods are allowed., Meat should be cooked without the addition of any extra fat, i 0 e O 9 roasted,, boiled or broiled 0 Avoid canned meats, sausages, weiners0 bacon and sardines. A l l meats should be lean. Trim visible fat from meat„ Avoid pie, pastry,, cake,, cookies8 candy0 chocolate,, candy coated gum and rich desserts,, Avoid waffles and griddle cakesD No preserves as jam„ marmalade,, honey or peanut butter are allowed0 NO sugar is allowed. Avoid soft drinks„ milk shakes, co«oa-APPENDIX C: , D e t a i l s of Total. Children, attending C l i n i c , , showing Success, ox. F a i l u r e In. Weight, Los a SUCCESS; GROUP - those, children; showing; lo.ss. of weight Name Sex... Age in:' yrs.. Height in;' Ins., Attend-ance Weight" at f i r s t . Attendance No. of•Lbs. overweight (app-rox..); . $ o f Av.pe.r-mensum gain or. l o s s of overweight Betty; 0. E" u i 59; 3 mos. 107i l b s . 9 l b s . 30^ Tour, B- 11. 15 70? 4 u 200 + rc 17+ w. 25^ Anne- K. pi 14 5'4i 1 tt(pX) 104i «. 20- It: 25^ Bee E i , F a 4.6- 1 111 n 3.0' U 16^ Nancy 0» 5.9&. i-"£ " ( » 134. it> 30 tt I'6# Glyne P.. p.- 9; 5 l i 6. tit 94 tt! 20 IT: 10% Ron; f l * H s i 56. io: 134 ff 34 tt W?o Robert, P.. M 15 62. 3 « 236 tu- 80+ tf Daphne: S. & i 5 i 69i 4 202 rn 70: tt 6.8^ . John G.. W. 3 i 40 4. IT 58i tt. 15 tt Qfa-Wynne H. E' ioi 55i 10 11.7 II 30 H> 5;7# Sandy I£c. H; 13 6.7 5 tt; I86i; w 40 tt E i l e e n I . F 14. 62 i i 162#- m 40 If. Penny T.» E" 13 62f s 154 u 35 tt 4.7^: Lucy J» P 13 65f i i n ( p ) 218f tt. 60 tt 4^ Day P. E 15, 63 r 19 2 i u. 70. tt Lois, D. E: IS 6 i i 6. u 217- it 80) II Babs BW. E" L I 62f 5 ti 134. » 15 tt Jean P., E 1.6 6.3.$- & tt 180: tt> 55 If 1$ - See next page for- d e t a i l s of! *f.allure group r. x (P). — p o t e n t i a l eases I.e.. c h i l d r e n who; attended the c l i n i c one® or f o r a p e r i o d less- than two months. - log -lo D e t a i l s of Total. C h i l d r e n attending- C l i n i c , showing-Succesa : or.' Failure: In Weight. Loss; FAILURE' GROUP - those children: showing; g a i n of' weight Same: S:ex; Age i n yr.a. Height in; i n s . A t t e n d -ance Weight, at. f'irs.t Attendance STo-.. of Lbs . overweight, f approx.;): fp of Av. per mensuni gain or Loss, of overweight Tony G.. w 13 6 L i o;nee(P) I44 f Ihs 35"; lbs., -Mike T» m. I L 59# once(P) 123} l b s 25 » -Ina D.. F L2£ 6 X i 3 mos.. L36.£ u 35 II 3^ Don B-. 1 2 i 5.8f 121 11'. 25: n Z2%, Ezra C, It L3: 5 8 i 7 » I.35f n 35: it L4# Helen. H» F; 1.5 59-i 3 u 116 \h 15 30^" Roy M„- I£ 8 54. L * * 85 ti LO:- II 50^ B I S L I o a B A f f i Y 1. Pi&tl 0 Ain? 1. Bd.bcook. C . a . s food aad I t s isatotiooal o i g n i f i o a n o e , J o u r n a l of the Amyrloaii J i e t e t i c A s s o c i a t i o n ^ V o l , 24, 1948, page 390, 2* J a m s , and iwse&oti, i i * * * J udtperiiaeafeti. ubessity, jigerie&n J o u r n a l o f Physiology* V o l . 129, 1940, page 30 3# BrooBfcein, I .P., Hal pern, J.P. and Brown, t Obesity i n C h i l d r e n , J o u r n a l of P e d i a t r i e s . / o l * 21, 1942, pago 485* J r o n s t e i n , I*P, f Wexler, Brown, A * V # and i l a l p e r n , i».J*t Obesity i n Childhood, .fayouologie s t u d i e s , <*merloaa Jo u r n a l of Diseases e f C h i l d r e n . V o l * 63, 1942, page 238* 4 . j r u o b , u» t v j e s i ty i n Ubildnood: ** jrhyaio&l growth and development of obese o h i l d r e n , Aaerjtean J o u r n a l of  Jiaeaaea of J f t i l A r e n * V o l . 58, 1939, pages 457 « 484. 3ruoh, H*s Obesity In Childhood! I I * Basal metabolism and «>eru:a c h o l e s t e r o l of obese c h i i d i ' e n , A f r i c a a •Journal of iHaeasOs of C h i l d r e n * V o l * 58, l e v * 1939, pages 1001-isi;* tfrueh, I I * i Obesity i n Childhood* 1 1 1 * r h y s i o l o g i o a l and p s y c h o l o g i c a l aspects of the intake of obese on i i d r e n , American Journal of Jiseaaea of a a l l d r e a * V o l * 59, A p r i l 1940, page 739. Bruch, H. s Obesity i n Childhoods IV. rinergy impenditure of obese o h i l d r e n , amerioan Journal ef Jiggasea of C h i l d r e n . V o l . 60, 1940, pa^es 1032 - 1109* 3rueh, ii., and Touraine, 6* t Obesity i n Childhoods V* The Sumily ifrmae of uoeae C h i l d r e n , Psycho a otae t i p Medicine. V o l . 2, A p r i l , 1940, page 141* Bruoh, H.f F r e h l i e h Syndromei Heporfe on Case* Amorioaa Jottrnal of J i a e a s e a of C h i l d r e n * V o l * 58, 1939, page 1282* Brush, H» * Obesity i n Childhood and i n l o c r i n e rreatment, J o u r n a l of P e d i a t r i c a . V o l . 18, 1941, psgea 36-56* Jruoh, dm: i'ood and .^notional s e c u r i t y , fhe l e r r a a s C h i l d . V o l * 3, 1944, pages 165 - 173* (ii) . SruehV B** G r i d 'for -JSvaluating- P h y s i c a l • Witiiem* Joarnal.. of  : the- American Medl c a l . A i s opiat'lora* : W l o. 118? 194&* ; pages 1289'V 1293 o-" Bruch* Hv*. • l^sychologl tial. A s p e c t s o f Oo.eslty"^ ^ i l e ^ l p - ^ b f the ' ^fesr^Yorfe^Aeai-foay of 'Sedicihe Lw •'Voi.*,'24J., -iMS*"piges'"' '7'3"~ 86, Sru'eh, H%j ^ p s y c h i a t r i c Aspects .of ©feesity I n ' C h i l d r e n * . AmericanJJournal "of •ga-.»ehfra$ry:» 'v o l , f 9 , ' I f 42 9 . .;.. . page''752*' . Bracih,., H ^ t . f he-si ty In Childhood..and l ^ r s o n & l i t y • ©evelopaeat, Ji!> ' ;ifeeri&aft ''3ourn&l: of Oxih-apay ei* latry*. ?oi«'iI^ 1941, • pSge. 4.6,7'% " ' • ' 1 . §.*, Conn,.,, J . , € A :* ^ ^ l i . t y f ;S%i:©1^0gl.sal Aspects.^. '.Bhysiolo^i.cal ' \SS£lM^ *' '^Mr* B49:'^a.:n* 1944, 'page :'31$. .'"' ' '" falser, J^S.,-^ •@tt#il«&^'.S!;.J*.'asd ,i^;.il©t©ff *'• A.?.».*. •Oaskiag^s '" •Igadroise^I'a' ghildren^-' A^erloa,h Journal of B.ia eases • i ; ; ' g l l M ^ & t u T o l , ' ' * S > :19«3 9; p&ge* S#3. , ""T~' '7% f;re®v&.*'\&*'0%.S: 'PsyeMe $a&t#*;s; i a ' the Be>eib$i»eht' and 1 f'rem.tsent bf' :©besity^ ^darhaV o f the,Ataerlegn' ge d i e a l . A S S B » « V o i v 133 s '1947.r page S$3. • ' Sfce«*©V ;fbe3l;ty;'iR;-0re©hlalil' «I<,iy (case' st-edy) * O f f i c e Gyne^ol^gy*,; e<|*.'4*. psvised. 0hi,ea:gqy- the Wear Boole • P u ^ i i s h e ^ S s i - ' March 1.940*.' Si 1 • Hamburger* • %St*,s;; S w o t l o a ^ l Aspects- of .#hesi.ty a- 'Ifac .Medical - C l i n i c s : of gorth, A m e r i c a I t a g c h '19$la- p&ge: 483.*, 9> l a r r i h g t o ^ i t * 8 * t A p p e t i t e .in •Helafeloa to fei^ht t.£oargai • Af, ,the-; .&&e>.lo&ri Blfeil.t£o' ^ saoci.atieia^ V o l * '•©.»; 193C, page'101* i 0 * l l l l 9 , <3V« Ipfen't • Seeding and P ^ r a o h a l l t y D i s o r d e r s ? . a study. • O'f. l a r l y ' Fe.edi.ag> i n i t s S e l s t l o s - to.'.'laoti©;fial:'and. B l g e s t i o h M e o r d e r s * .Psychiatric' t u ^ r t e r l y * Vol* II* •-1^7,-psges 3®f — 382.*' '41%S©lle'r9.''Ai|9% -and Soil'e> s. .Adiposity with'S^raaal Sex f u n c t i o n f o l l o w i n g . E x t i r p a t i o n o f the' .Po'stef io'r l»0M'', of the '• vly-p6paysi& ia--thV .Agtericah J o u r n a l of •Physiology, To!*: 113#, :3t:93S>-'p»:ge. ; "• •: ; — ' ' t8.wSewb«JMCgbr ' ©besity «• JSnerigaf Metabolism^. Physiology •aevlewa.' fol« '24« ' Ssm* '.1.94;4.^  "ya^e''l.S^" • i3;*^ enn:fl.{%*&•.,,),»•. a • Ih-fliie.^ce of ' f& ycholsglea.!' 'fa©tors on • • the' ' l u t r i t i o n o f diiiictren^ ' -Awi-rlisgii-' J»urttal' of Pabl i c  Sealth,,. f o l . 0 ; ' 35 'lo.« 30 March 1945* page '211 0 ( i i i ) 14* S h o r t , J . J . sand,. Johnson, 'B:«,J,.,s.. The.' E f f e e t '••of '• Overweight on Vital • S a p s e i t y * . .Bro^eeai/tiga o f ' l l i e . . kiEt4:-Jgkaia«4 V o l * 1, g a r oh* . . ^ r i ; l * v|^ 3©;,>'|)a,g^ #;Y':3&;' 4|!>i;>." ''"; -' "''' ', IS^Steiner^/{$#B^).:Ji;M'»H:^ ft$$\.|ia^gemeh.t' pf'-©hebity/in'':Qhii'&h©bd-, / ' • i t e d i b a l : & l i h i b # b f ^ f b r t ^ .pate''223:.. .? •_ 16;*.$al,''obtif;: : B ie%iJ*M^i|©&0(iite/ata^dardb;'; fbr g?hiidren^: American " ' ; • Jburha;i;;sbf''#i^^^ Vol.*:.. 554 -iQ3'8'a bage 455, : T a l b o t , la/:|nf ^ nfca •and...0hlldren«, l e d i b a l : ' S i i n l e g . • ''of I b r t f c A m e r i m l : V o l 4 2J,,:.;i94;54 pag* 1.21174'. '. .<• •'• • J ' Talbot,''.B\i;3«;». i i l s o h i i&#jBu.»< an£ f b r c a a f c e r * B a s a l . M e t a f e s i i s a b . f ' : & i x l i ^ A p p l i c a t i o n o f , * S t a n d a r d s , -iae'ri'-ban yJ&ria*£<>!0?l'ifteea&ea:-'of ..-CM&d-reB* 1 Vbi*. S-^ : ^ J a h ^ / p t V " ? : ) 1937;, page: 2,73*/ - "' ' • " " I I . BOOKS 1« A l e x a n d e r , .Fran2;i-\.Sastrbi:n^.s-t'inal Jfewfco'siss ''(€.ha:p.;...V'l)4 ' i n , . P o r t i a , . '.BlBeaaeb.bf •tai.e ^ a e a t i v e : System* &ea &• I'e^iger,,'Phila.-, • ' ' i t ' * ! * , /•'' : • • ' •"'.'''•'••"•': :''.•' _'. ' 2. Gannon1,. W a i t e r .B.4.' jgh& :Histfoia- o f ; the. Body..' S 4 f f i v Her t e n & Gb., • ' !. ••:'i9^ a.v-' ••'• , , . ; : . • ' - . . ' . " ; ' * • ' -. ' . 3. •Bewburkh* '&»g8 i '#beblfey/ ; l G h a ^ : i l ^ , , f n . V f ii'Maaa.,; /ifegtbbbfe'•of • '•; ; a n d b e r i b h l b f e : l i ^ l ^ i a ^ d ^ ^ 4* fei'as.^/.Edward,.' gb^hbabm^ P h i l a d e l p h i a and', London* •f4B.,/.Safnters^Vl^P>;'r.' • '••'"•''.." ;, '• ' ' : '• 1. i d i t o r i a l , ' A s t u d y o f ' p e d i m e n t s ' f o u n d aspong 10,000 Q n s e l e s t e d •'exaajihe-ea-.,:"Artiie :'li„' Weight. P r o c e e d i n g s b f L i ' f e v i & t * ixam.. V o l . . !«, J'uly-Angust, ; 19.399 pages:,' 39 >•',93. : IV.. • BMPOHT • 1. Annual B e p o r t . .Healths Gentre f o r S h i l d r e n . The Vancouver G e n e r a l • •" • "Hospital,;fa»ebuybry June 11949.;? Say 19:50$ 1-*. Epstein,, &.-A,*,*.''€3#ttJL:eal and. biologic considerations of Obesity and certain a l l i e d condi tlons*. 3uilefein of tne Sew York • Academy of; Medicine*- Vol*. 10.9 Jaly. 1934, pages 389 ~ 414 2*..Metropolitan L i f e Insurance Company, Ideal weights for Sen* Metropolitan l i f e Insurance S t a t i s t i c a l B u l l e t i n * tol* "24.*: June 1943*'.'"pages -6 «-"8.0 ' " ~~ 

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