Nutritional Diseases

CASE 4: Obesity

Clinical History:

Adapted from: Sotos JG. Taft and Pickwick: sleep apnea in the White House. Chest. 2003;124:1133-1142.

In 1909, at the age of 51, William Howard Taft became President of the U.S. He was 182 cm (just under 6') tall. He had always been a "big" man, but during the presidency, his weight reached 150 kg (330 lb) and more. He became famous for exhibiting numerous periods of somnolence throughout the day. At night he snored loudly. His wife Nellie took to calling him "sleeping beauty." His blood pressure reached 210 mm Hg systolic. He developed gout. On examination he exhibited central obesity and a short, thick neck. He had hypoventilation. His complexion was "ruddy" from plethora. Though not available at the time Taft lived, nowadays laboratory testing is performed, and a serum chemistry panel would likely have revealed the following:

Cr1.4 mg/dL
BUN22 mg/dL
Glucose130 mg/dL
Total protein7.3 g/dL
Albumin5.1 g/dL
Hgb A1C 7%

Further History

He served one term as President, having been defeated for re-election in part due to his poor reputation as a bumbler who was "asleep at the wheel". Upon leaving office, he began a program of weight loss directed by the Dean of Yale Medical School, Dr. George Blumer. He lost 30 kg (over 60 lbs) and kept the weight off. He was appointed Chief Justice of the Supreme Court in 1921 and in that capacity never once exhibited somnolence, serving 9 distinguished years before his death in 1930.

  1. What is the BMI? What do the laboratory findings from similar patients nowadays suggest?

  2. His BMI reached 45, consistent with morbid obesity. Though not diagnoses made at the time he lived, nowadays the elevated glucose and the elevated Hgb A1C are indicative of diabetes mellitus. Given that he is obese, with a BMI of 45, he most likely had early type II diabetes mellitus, with glucose and Hgb A1C values that are just above normal.

  3. What condition is suggested by the somnolence and hypoventilation? Explain the plethora.

  4. He likely had obesity hypoventilation syndrome and obstructive sleep apnea. As a consequence of hypoventilation with hypoxemia, he developed secondary polycythemia with increased red blood cell mass that produced the ruddy complexion.

  5. What are possible health problems in such persons?

  6. Diabetes mellitus predisposes to accelerated, more severe atherosclerosis. Major organs affected are heart, kidneys, and brain. Peripheral vascular disease with ulcerations often occurs. He could develop visual problems.

  7. What are possible lifestyle modifications to prevent these problems?

  8. In many cases of type II diabetes mellitus, losing weight will improve the situation. This is a difficult undertaking for most middle-aged Americans. Adopting a diet that one can live with on a long-term basis, coupled with a regular program of exercise, is indicated, but difficult for most persons to accept, let alone follow. Nevertheless, it is important for the physician to inform patients of the risks and the solutions.

  9. What is the socioeconomic status of most persons with high BMI?

  10. Ironically, in developed nations, poor people are more likely to be obese than well-to-do persons. Some people have argued this is the worst-considered social policy when it comes to health in the U.S. Why do we have the highest rates of diabetes mellitus and obesity? A good argument can be that it is our eating too much fast food and junk food. All developed nations subsidize agribusinesses, not family farms, to keep commidity costs--and food costs--low. Two examples are sugar and corn (maize). Processed white sugar is cheap in modern society, while it was a luxury item before the 20th century. Feed corn for cattle subsidizes the cost of hamburgers, and corn syrup goes into soft drinks.

    If the cost of junk food increased 50% in a year, consumption would go down. Instead of satiating our appetites with calorie-dense, high glycemic index snacks, we might try eating something new to our pale palettes: fresh food, food with colors left in it instead of bleached white like our sugar and our bread. (The best way to guess the nutrition of many foods is the color: eat more red stuff, more orange stuff, more green stuff, more yellow stuff. The darker the color the better. Snack on berries and fruits. Have a salad with every meal. Avoid WHITE bread and WHITE sugar. You'll start to lose weight, and decrease your risk of cancer too.) Ask your poor patients if they like collard greens, or sweet potatoes. The ultimate irony is this: poor people at greatest risk for obesity-related diseases are least able to afford the medical care to treat them.