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Fasting for Obesity Author(s): Shirlee Ann Stokes Source: The American Journal of Nursing, Vol. 69, No. 4 (Apr., 1969), pp. 796-799 Published by: Lippincott Williams & Wilkins Stable URL: http://www.jstor.org/stable/3453826 . Accessed: 16/09/2013 18:18
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Four patients, hospitalized for the purpose,went withoutfood for periods ranging from 7 to 29 days. A nursewho workedwith them reports their reactionshere, as well as additional observationsabout the effects of fasting that have been reportedin the medical literature. SHIRLEE ANN STOKES More than 15 million personsin this countryare obese-that is, at least 20 percent over the normal weight for their body build and age.This means that they are predisposed to such conditionsas heart disease, diabetes, hypertension,and cholelithiasisand are at greater risks during surgery and childbirth. The direct cause of obesity is the consumptionof more calories than are needed to meet individual energy requirements.As one investigator has said, "If a patient claims to remain obese on only one ham sandwich a week, then the obvious reply is that this is too much for him and he should have only half a ham sandwich a week"(1). It is thus easy to say that overeating is the most common cause of obesity. But what constitutes"overeating" is determined by the individual's energy requirements,which are influenced by various factors. Thus, the person who engages in little physical activity-homo sedentarius, one investigator has called himneeds fewer calories than the more active person(2). Other factors also enter into the
(St. Luke's, Cleveland, Ohio; B.S., M.S., Ohio State University) observed the patients described in this article during her period of graduate study. She is now assistant professor of nursing at Columbia University, Department of Nursing.
MISS STOKES

Fasting
Obesity
production of obesity. Metabolic disturbances,for instance, can lower the energy requirements,as can disturbances in the digestion and utilization of foods. In addition, re-cent research suggests that stress may cause an autoimmunereaction that alters thyroid function and leads to obesity. The possibility of genetic transfer of traits that alter is also underinvesbody metabolism tigation. For practical purposes, though, overweight individuals can be classified into three groups: (1) those with normal metabolismwho overeat; (2) those with decreasedbody requirementsfor calories; and (3) those with disturbances in digestion, absorption, and/or utilization of foods. The first is consideredexogenousobesity, while the othertwo are endogenousforms of obesity. And the fact remainsthat-unless the cause is an underlying physiologic disturbance that can be corrected-the only way to lose weight is to decreasefood intakeor increase bodily energy requirements. Weight reductiondiets, however,often yield discouragingresults. One study revealed that after two years a large

percentage of the individuals who had lost weight through diet had gained back all or even more than the amount they had lost. Increased exercise, the other alternative, is often discouraged because it increases appetite; much of the immediate weight loss is perspiration. Total fasting is now being tried as a corrective measure. Bloom, in 1959, was the first one to study fasting as a measure to treat obesity (3). Since that time, other investigators have also used and explored this technique. Fasts up to 249 days have proved relatively harmless, according to one group of investigators (4). What problems, medical and nursing, do these fasting persons present? I had the opportunity of working with four such persons being treated for obesity in a university hospital. The observations that follow are based on that experience, plus information in the literature about various effects of fasting. FOUR PATIENTS The four patients, as shown on the charts at right, were between 25 to 40 years of age. They were all at least 20 percent over their ideal weight and had all tried a variety of reducing diets at home with poor results. Mrs. A., Mrs. B., and Mr. D. wanted to lose weight for personal reasons. Mrs. C. did "not mind" being fat, but her physician considered her to be an operative risk at her present weight. The reason for their obesity, all four patients said, was overeating. Mr. D. often went through a case of beer, a jar of peanut butter, and a loaf of bread during an evening of television watching. All four reported, too, that they ate more
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when they were under stress; family quarrels were the most common example. These four persons were admitted to the hospital's clinical research unit at different times during an D-1 eight-week period. At no time were there more than two fasting patients in one four-bed room, or more than two people fasting at one time. The other patients in the unit were ambulatory and in no acute distress. Before beginning the fast, each X.S Cx patient received a thorough examination, including a physical examination, blood and urine studies, and an electrocardiogram, to ascertain 'XIXxxI....... his fitness to undergo fasting and to Frain W provide a baseline of information 245 ii i!!!Height !!!!!i!!!!!!!!~iiiii~ i~i: ?!!ii against which to measure the physieight:i!i;ii!i~i! ologic effects of the fast. The patients were eager to begin the fast 5 213 and needed an explanation of the reasons for this exhaustive examilarge, OS nation. Since most of them were MRS. A i, healthy and had never been hospitalized before, they also needed to be oriented to the hospital setting and routine. M MSRAS9 6 laAe They apparently knew little about what to expect from the fast and MRS. B 2 MRSsma exhibited apprehension about their C l 25 67 . ar!!ii~i DDays of9Fms M.R..C...S. well-being. "Will I be weak?" "Will 32 69.... I be hungry-or irritable?" "Will I m,!iiiii~i be able to live without eating?" were common questions. t 5 67 0 15r3 They were reassured about the ...........~ ~ safety of the fast, and I explained a so F s that their bodies would now utilize X:::!i. the fat that had been stored away for years. They asked, too, whether they would be receiving multivitamin supplements. As a matter of fact, they were not givien any. Some investigators have reported them unnecessary, and they have been known to produce nausea when given under FASTING HISTORY of four patients hospitalized because of obesity. In addition to initial these circumstances. weight loss, the fasting proves to the patient that his overweight is due to overeating.

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FASTING

For the duration of their fasts, which ranged from seven days in the case of Mrs. A. to 29 days for Mr. D., the patients had no caloric intake. They were allowed only such noncaloric items as dietary soft drinks, bouillon, water, and unsweetened black tea or coffee. These beverages were served at meal times but, for the first few days of the fast, the patients found it easier to be out of the room while other patients were eating. Other fasting patients have been reported to sneak scraps of food from other patients' trays but, so far as we know, our four didn't cheat-even when they went home for occasional weekends. Their activity was not restricted, although strenuous exercise was not encouraged. Periods of atrial fibrillation have been noted after physical exertion in some fasting patients. HUNGER Hunger was not a problem, although a few sporadic cravings were noted. Mr. D., for example, wanted a piece of meat or "at least something tough to chew," and Mrs. C. wanted a glass of tomato juice, but these desires were transitory. The patients remained congenial and pleasant throughout their fasts and usually stated they felt well, although three of them, at times, expressed feelings of irritability. After 24 to 48 hours, the usual fasting patient has been found to experience little hunger. First, liver glycogen stores are burned, and the resultant gluconeogenesis leads to a mild keto-acidosis. The elevation of serum free fatty acid and of urine acetone were associated with anorexia in our four patients, as well as those reported in other studies. Bloom has also noted a mild euphoric state possibly due to an "accumulation of acetoacetic acid [that producedJ a mild intoxication with
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a physiologic response not dissimilar to the effects of ethanol"(3) It proved important to make clear to the patients, right from the beginning, that their weight loss would be irregular. Otherwise, they would become depressed on each day they failed to lose weight or even gained a little. During the first 24 hours, each one lost from two to three pounds; this was partially the result of diuresis. From then on, each patient lost an average of one to two pounds per day. As predicted by other studies, the extremely obese patients lost more at first and then tapered off after a week to the same weight loss rate as the others. REACTIONS Sodium as well as fluid is usually lost in the first week's diuresis. After that time, the body compensates by retaining the sodium and, consequently, water. Urine output diminishes and the patient either does not lose, or gains, weight for several days. Mr. D., on days nine and 10, and Mrs. C., on days 12 through 17, manifested this pattern. This is, of course, a depressing experience for the patient who has fasted for a long period of time. Mrs. C. stated, "I can gain weight at home and eat!" The nurse can help the patient most during this time by allowing him to express his feelings and reassuring him that this standstill period is to be expected and will not last. Encouraging the patient to try on old clothes to see how loose they are now is another way to remind him of the progress he has already made. A daily weight chart kept by the patient is another source of reassurance. If he has experienced a previous plateau in weight loss, he knows that it will eventually be followed by a rapid weight loss. After the fourth to fifth day the patients stopped having normal bowel movements and had only occasional small mucoid stools. An exception was Mrs. B. who had diar-

rhea on the tenth day. I did not follow these four patients after the cessation of their fasts, but another study reports the return of normal bowel habits upon refeeding. Changes in menstrual cycles and a sensitivity to cold have been reported in association with fasting, but neither of these reactions were noted in our four patients. Boredom was a problem, however. Playing cards, visiting, sewing, and painting helped to pass the time and divert their attention. After the first 24 to 48 hours, none of the patients were distressed by talking about food. This proved to be a perfect time to teach diet, since they would all be going home on low calorie diets. Already encouraged by their weight loss and very interested in continuing it, these four patients were a receptive audience. The length of the fast was predetermined in most instances, so I could space the teaching over the available time. The length of hospitalization also allowed time for me to learn the reactions to my teaching. It was my impression that most of the dietary teaching should be done in the first week or two. The three patients who fasted more than seven days reported intermittent bouts of dizziness. This may have been associated with postural hypotension, as reported in other fasting patients. We encouraged them to stay in bed or sit in the chair when they felt dizzy, and reminded them to rise slowly from a prone to an upright position to prevent faintness and a possible accident. Mrs. C. and Mr. D., who fasted longer than Mrs. A. and Mrs. B., experienced other reactions in addition to those already described. After the twentieth day, for instance, both of them found it more difficult to concentrate on reading; their attention span decreased. Mr. D. started to lose more often at his card games. The decreased attention span was
AMERICAN JOURNAL OF NURSING

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a problem, too, because it called for projects that could be completed or put to one side after 15 to 30 minutes. We found that projects which "helped" the nurses and made the patients feel involved, like folding bags or putting away linen, helped prevent frustration. Liberal visiting hours were allowed and passes home helped to decrease the sense of isolation. Mr. D. and Mrs. C. also complained occasionally of nausea. Mr. D. vomited one evening; after the twenty-fourth day he said his toothpaste nauseated him. Mrs. C. refused her beverages one day because of nausea. Other investigators have reported nausea following oral fluids or medications but this did not happen with our patients. Both of our "long" fasters were smokers: Mr. D., three packs a day, and Mrs. C., about six cigarettes daily. During and after the periods of nausea, however, they no longer smoked. Mr. D. also complained of nightmares and headaches near the end of his 25-day fast. The reason was not ascertained. Each patient must be helped to realize that he is going to gain as much as five to weight-often, eight pounds-once the fast is ended. When intake is begun, the body retains sodium, and water tends to reexpand the fluid compartments. A 25 percent weight gain has been noted at the end of short fasts. Sodium retention has been reported greatest with high carbohydrate diets. To prevent the weight gain, some investigators recommend low sodium diet and diuretics. COMPLICATIONS None of our four patients developed any adverse effects as a result of fasting. However, complicationsalthough rare-have been reported by other investigators, so nurses must be watchful for their signs and symptoms. Serum uric acid levels rise during a fast because of decreased glomVOLUME 69, NUMBER 4

erular filtration of uric acid. As a result, patients with gout or a familial tendency toward it may develop symptoms of gouty joint pain and swelling during fast. This possibility would seem to contraindicate fasting regimens for these patients. The development of uric acid nephritis from the high serum uric acid levels has also been reported. For this reason urine output should be carefully measured and the fast terminated if oliguria occurs. A few fasting patients have developed parotitis, attributed to a lack of salivary production as a result of decreased stimulation from food. Frequent mouthwashes and gargles might help to prevent this problem. Sodium depletion syndromes have in some instances accompanied the sodium diuresis during the first week of the fast. The symptomslizziness, weakness, skeletal muscle cramps, restlessness, and nausea on the seventh to fourteenth day-have been relieved, it is reported, by the administration of two grams of sodium chloride. At the other extreme is the sodium retention that usually develops after a week or two of fasting and could lead to congestive heart failure or pulmonary edema. Patients should be observed for sensations of "tightening," weight gain, shortness of breath, and edema. Chronic liver disease precludes fasting, because the damaged liver cannot perform glucogenesis and other functions necessary for life in the fasting patient. A history of peptic ulcers is another contraindication to fasting. On the other hand, diabetic patients-except the younger ones with uncontrolled labile diabetes-do very well during fasting. In fact, there may be a remission of symptoms in adult diabetes, since the obesity may have caused it. In relation to the long-term results of enforced starvation, Harrison and Harden have reported that of 62 chronically obese patients who fasted for 10 days, 40 percent

retained the weight loss or continued to lose weight after one year (5). These results are much better than those reported in outpatient department weight reduction clinics (6). Several reasons have been hypothesized for the positive results. To begin with, the free fatty acids reportedly remain high for about three days after refeeding and the patient continues to be anorexic. Because of this and the long deprivation of food, patients find it easy to tolerate low calorie diets. Perhaps more important is the fact that the obese individual as a result of his fast, finally realizes that his weight is due to overeating and that only a decreased intake will decrease his weight. In addition, the rapid weight loss and concomitant increase in self-esteem and sense of well-being that he has experienced spur him on to continued weight loss. Finally, it has been speculated that a subtle metabolic change may occur during fastingone that makes weight loss or weight stabilization easier than before the fast. It would seem, therefore, that fasting is a relatively safe and effective way to lose weight. It is not without its complications, however, and is therefore not a "home remedy." It should be carried out in the hospital under medical and nursing supervision.

REFERENCES
1. J. T. Obesity and slimming. Nurs.Times 62:667-669, May 20, 1966. PEASTON, M. PASSMORE, R.

2.

How Fasting

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as an introduction

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the treatment of obesity. Metabolism 8:214220, May 1959.

4. THOMSON,
T.

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AND

OTHERS.

Treatment

of obesity by total fasting up to 249 days. Lancet 2:992-996, Nov. 5, 1966.

5. HARRISON, M. T., AND HARDEN, R. M.

Long-

term value of fasting in the treatment of Dec. 17, obesity. Lancet 2:1340-1342, 1966.
6. STUNKARD, ALBERT, MAVIS. Results of
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A selective bibliography on fasting prepared by the author is available on request from the Journal, 10 Columbus Circle, N.Y.C. 10019. APRIL 1969

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