48 WILDER TILESTON 



to ten pounds a month being a suitable amount. This prolongs the period 

 of dieting, which is of advantage in that it accustoms the patient to a 

 small amount of food, so that he is not so likely to over-eat again after 

 the weight has been sufficiently reduced. A slow reduction also avoids 

 the danger of weakening the patient. 



In the case of the extremely obese, and when cardiac decompensation 

 complicates the picture, it is often advisable to go faster, so that from 20 

 to 30 Ibs. are lost in the first month. In such cases it is well to begin 

 with a marked reduction of the intake down to 1000 calories, and for this 

 purpose a brief milk-cure, lasting not more than one or two weeks, is 

 excellent. It is true that under these circumstances considerable body 

 protein is burnt, but this does not appear to be harmful provided little 

 exercise is taken, and the loss is quickly made up later after the diet is 

 increased. 



Since the greater part of the calories of the food is derived from fat and 

 carbohydrates, these two forms of food will be the ones most restricted. 

 In general it is better to cut the fats down to a low level and practise less 

 restrictions of carbohydrates, since bulk with low caloric value can be sup- 

 plied by the vegetables, and this satisfies the appetite, a very important 

 matter if the treatment is to be long continued. In the case of persons who 

 are very fond of fat, it may be advisable to allow more fat and less carbo- 

 hydrate. 



It is evident that weight may be reduced safely on a great variety of 

 diets, provided that sufficient protein and carbohydrate are given to pre- 

 vent loss of body protein. It is important that there should be enough 

 variety to prevent the treatment from becoming irksome. A satisfactory 

 diet will be found usually to contain a considerable amount of protein in 

 the form of lean meat and fish, a moderate amount of carbohydrate, and 

 little fat. Vegetables containing not more than ten per cent of carbo- 

 hydrate usually may be allowed ad libitum, provided those containing 

 more than this amount are excluded, while sugar is better cut down to a 

 minimum, and breadstuffs limited to one or two slices daily. Fresh fruit 

 may be taken in moderate amount. 



Under such a regime the weight can be almost always satisfactorily re- 

 duced without calculating the calories or having the patient weigh the 

 food. It is only necessary that the body weight be followed closely, 

 with careful attention to the details of diet, including the quantity 

 as well as the quality. For this purpose it is well to have the patient keep 

 a daily list of the food taken at each meal. Occasional breaking over 

 in the diet may be made up for by eating very lightly on the following day. 



In difficult cases the caloric value of the food should be estimated. For 

 this purpose Locke's (a) "Food "Values" and Atwater and Bryant's tables 

 may be consulted. 



In the case of gouty patients the weight may be reduced safely on a 



