Health & Fitness Journal of Canada Copyright 2017 The Authors. Journal Compilation Copyright 2017 Health & Fitness Society of BC Volume 10 Sept 30, 2017 Number 3

SPECIAL SERIES Have people always been fat? An historical enquiry. Roy J. Shephard1

Abstract Introduction Objective: Some investigators claim that obesity has Over the past 20 years, much attention always been a feature of human society, but others maintain that obesity was absent from traditional has been focused upon an obesity hunter-gatherer communities. Resolution of this issue is epidemic affecting not only North America, important to prevention and treatment. Can obesity be but also many other developed and avoided by the rigorous daily activity and limited availability of food found in many hunter-gatherer developing nations (GBD 2013 Obesity groups, or is the accumulation of body fat an inevitable Collaboration, 2014; World Health consequence of the human genome? Methods: A Organisation, 2014). Perhaps as a narrative review has gathered available information on eating habits, habitual daily physical activity and body fat consequence of this attention, we tend to accumulation over various historical eras, ranging from regard an excessive accumulation of body the earliest Paleolithic and Neolithic communities to fat as a modern problem, brought about by Victorian society. Results: The success of Paleolithic and Neolithic communities generally depended upon high a combination of over-eating in response levels of daily energy expenditure, and despite the to the wiles of giant commercial food discovery of some obese "Mother Goddess" figurines, distributors, intent to increase our studies of small communities that have maintained a Neolithic lifestyle still show very low levels of body fat. consumption of their products, by With the development of settled societies based upon an industrial automation with ever more agricultural economy, an economic surplus and social sedentary work, and by a progressive stratification allowed the emergence of a growing upper echelon of society that could over-eat and engaged in too reduction of daily energy expenditures in little physical activity. However, the widespread our leisure time. prevalence of obesity across developed societies is a late In exploring the lifestyle of successive 20th century phenomenon, associated with ever- decreasing needs for energy expenditure in daily life, cultures from the Paleolithic world reduced opportunities for deliberate leisure activity in through to Victorian times, this historical mega-cities, the promotion of over-eating and unhealthy review in general supports the thesis that diets by commercial interests, and possibly a greater public acceptance of obesity. Conclusions: Obesity is obesity was the exception rather than the typically an expression of over-eating and inadequate rule during most of antiquity. habitual physical activity. Although there are occasional Nevertheless, it also highlights some pathological causes, an excess of body fat is a health problem that could be resolved quite readily for most seemingly well-documented examples of people by a disciplined return to the dietary and physical gross obesity from the early history of activity patterns of earlier generations. Health & Fitness humankind, a finding that some have Journal of Canada 2017;10(3):3-53. interpreted as evidence that the ability to Keywords: Body Composition; Diet; Lifestyle; Obesity; store fat was an early adaptive feature of Physical activity human evolution (Bray, Bouchard, and James, 2003). We note further that the From 1Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada. potential for people to become obese Email: [email protected] generally seems to have followed the

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 3 Historical Perspective on Obesity transition from a hunter-gatherer society Paleolothic artifacts. Cave art and a small to settled agricultural communities, where number of carved idols have been found an economic surplus allowed social across Europe, from south-western France stratification, and an elite of wealthier to Russia. Many of these items date back to individuals could opt to over-eat and 25,000-30,000 BCE. The cave art has not engage in little physical activity. As we contributed much to arguments about the explore the phenomenon of obesity, it will prevalence of obesity during this era, but become apparent that many of the healers the unearthing of a number of pudgy and physicians of antiquity recognized miniature idols has stimulated much over-eating and a lack of physical activity discussion. The most famous of these as twin causes, and that they proposed as relics is the Venus of Willendorf, a small staples of treatment a regimen that statuette found near Krems, in Lower embraced a moderation of food intake, Austria (Stéphen-Chauvet,1936). This accompanied by regular and vigorous particular artifact is characterized by physical activity. pendulous breasts and marked abdominal obesity (Figure 1). Paleolithic and Neolithic communities Bray et al. (2003) listed a number of Paleolithic era. similar Paleolithic and Neolithic artifacts The Paleolithic era, also known as the that archeologists had discovered in digs Old Stone Age, was marked by the over at least 8 sites in Europe. The idols fashioning of tools formed from chipped were carved from ivory, limestone, stone and antlers. This phase of history serpentine or terracotta. All appeared to extended from some 2.5 million years ago represent to about 10,000 BCE. Given the lack of very obese Figure 1: The Venus of written records, inferences about the women. Bray Willendorf: a grossly obese likelihood of obesity in Paleolithic et al. (2003) historical artifact discovered communities have been limited to a cited the in Austria. Source: https://en.wikipedia.org/wiki/Paleol knowledge of the economy and a study of earlier ithic#/media/File:Wien_NHM_Venus cave art and occasional artifacts. verdict of the _von_Willendorf.jpg Paleolithic economy. The economy of French the Paleolithic people was based upon the physician hunting of wild animals and birds, fishing, Hautin and the gathering of berries, nuts and (1939): "The roots. In most habitats, this would likely women have implied a life of hard physical labour, immortalized with the sharing of what was a rather in stone age limited amount of food among members of sculpture the community. Inferences are supported were fat; by 20th century studies of communities there is no that have maintained a Neolithic lifestyle other word (below). The available resources would for it." Bray hardly have predisposed to the et al. development of obesity, an argument themselves supported by measurements of body fat concluded content in communities still following the "That obesity Neolithic way of life (below). was known in

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 4 Historical Perspective on Obesity this early period is evident from Stone Age fruits, vegetables, underground tubers, artifacts." More recently, Josza (2012) has and, in some parts of Africa, honey. In reinforced this viewpoint; in a study of general, game was scarce, and the photos or copies of 100 Paleolithic statues, traditional sharing of the proceeds of the 97 of which were of women, he noted that hunt among the whole community 24 were skinny, 15 of normal weight, and reduced the likelihood of individual over- 51 were overweight or obese. eating. Moreover, the physical energy Nevertheless, there is no good expenditures demanded by many types of evidence that either these chubby idols or hunting were extremely high, militating some of the slim athletic statues of male against obesity. deities were in any way representative of Neolithic artifacts. Caricature-like the Paleolithic population. Episodes of representations of an obese Mother starvation make obesity an unlikely Goddess continued into the Neolithic era. occurrence (Colman, 1998). The figurines One example of such idols was found at with their exaggerated female sexuality Catalhöyük, a proto-city that flourished in are more likely to have been idealized southern Anatolia, around 5500 BCE. A primordial female deities, fertility clay figurine featured a naked woman goddesses or more general symbols of the seated between two lions. Her hips, belly bounty of the earth; some authors have and breasts are exaggerated, and the even suggested that they were a form of genital areas are marked by a triangular Stone Age pornography (Beller, 1977; decoration; possibly she was in process of Gimbutas, 1991; Guthrie, 2006; Stone, giving birth at the time of the sculpture 2012). (Figure 2). Again, there is no strong reason to suppose that such representations of a Neolithic era. Mother Goddess figure were in any way The Neolithic era or New Stone Age began around 10,000 BCE, and in various Figure 2: Woman of Catalhöyük, parts of the world it continued to 4500- Turkey, from about 6000 BCE. 2000 BCE, ending with the introduction of Source: https://en.wikipedia.org/wiki/Seated_Wom copper, bronze, and iron tools. The an_of_%C3%87atalh%C3%B6y%C3%BCk Neolithic economy was generally similar to that of the Paleolithic people. A few obese artifacts have again been discovered from this period, but studies of continuing Neolithic communities provide more direct evidence on levels of habitual physical activity and the resulting accumulation of body fat. Neolithic economy. In some areas, dogs, sheep, and goats were domesticated, and groups began to experiment with the cultivation of crops. But many Neolithic communities maintained a hunter- gatherer lifestyle. Some populations had access to animal protein such as caribou or fish, but for many the diet was based upon

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 5 Historical Perspective on Obesity representative of the body build of the Alacalufe Indians, 7.9 mm; for general female population. Australian aboriginals, 7.0-9.1 mm; for Direct evidence of habitual physical Arctic Indians, 5.7-6.7 mm; for Inuit from activity and body composition. During Fort Chimo, Igloolik, and Wainwright, 5.5- the 1960s, the Human Adaptability (HA) 6.5 mm; for Scandinavian Lapps, 7.7 mm; Project of the International Biological and for Hokkaido Ainu, 5.3 mm. Programme (IBP) made detailed Daily energy expenditures. In Igloolik, examination of many hunter-gatherer energy expenditures during the specific societies that were still relatively isolated activities involved in eight different types from the modern world, and maintained of hunting were measured in the field, something closely approaching a Neolithic using a Kofranyi-Michaelis respirator. lifestyle (Weiner, 1964). Among the mass Despite the relatively small size of the of information that was collected during hunters, daily expenditures averaged as the IBP-HA project, objective data were much as 15.3 MJ. Moreover, much of these obtained for the average heights, body very high totals was accumulated by masses, and skin-fold thicknesses for prolonged periods of moderate physical many "primitive" communities. These activity, at an intensity of effort where a findings confirmed that in such maximal fraction of energy would have populations the average stores of body fat arisen from the metabolism of body fat were generally small. In some (Gmada et al., 2012). Energy expenditures communities, evidence was also obtained were lower when the hunters were of very high daily energy expenditures confined to the village by bad weather, or (Shephard, 1978). repairing their equipment, but Excess body mass. In almost all of the nevertheless the field data argue strongly populations that were examined by the against a sedentary lifestyle and an IBP-HA, the average body mass showed a accumulation of body fat. substantial deficit relative to actuarial Effects of acculturation to a "modern" ideals for white populations (Society of lifestyle. Many indigenous populations in Acuaries, 1959), for example: Bantu, -4.7 North America have shown a growing kg; Tanzanians, -2.7 kg; Easter Islanders, - prevalence of obesity as they have become 0.0 kg; Ethiopians, -10.3 kg; Jamaicans, -5.3 acculturated to a "modern" lifestyle, with kg; Nigerians, -3.9 kg; Tanzanians, -2.7 kg; changes that have included a drastic Trinidadians, -2.4 kg; and Zaireans -7.4 kg. decrease in their daily physical activity, Such findings suggest a low body fat and a shift from "country" to store- based content, although findings must be foods. interpreted cautiously because of the low This trend has been documented in average standing height and unusual limb longitudinal studies of the Inuit living in lengths in many of the populations Igloolik, Nunavut, from 1970 to 1990 examined (Shephard, 1978). (Shephard and Rode, 1996). The Skinfold thicknesses. Perhaps more government organized concentration of convincingly, an analysis of average the population into a single settlement of skinfold thicknesses for populations more than 1000 people facilitated the continuing to follow a Neolithic lifestyle provision of health-care and schooling, but has shown much lower values than would it also meant that local game resources be anticipated in a modern urban society. were no longer adequate to allow In young men, averages readings were for traditional hunting and to sustain a diet of

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 6 Historical Perspective on Obesity country foods. Dog-teams were San communities of Botswana, other abandoned, food (often of low nutritional pygmy groups (Barnard, 2007), and value) was purchased from the village the Batek people of Malaysia) in general store, and the majority of the Inuit became reflect a small and extremely thin body unemployed, dependent on governmental build. The Baka, for example, have a height welfare payments for their subsistence. of a little over 1.5 metres, but a body mass There were corresponding negative of only about 48 kg, giving them an changes in the body fat content and average body mass index of about 20.8 aerobic fitness of the Inuit people. Even in kg/m2 (Devlin, 2017). 1970, a gradient of obesity was apparent Although the rest of the body is not very between those members of the community fat, some women in hunter-gatherer who were persisting in their traditional societies [for example the Khoisan Bush- hunter-gatherer lifestyle (Table 1) and people of southern Africa (Barnard, 2007), those who had settled in the village, either the pygmies of Central Africa, and the Onge finding sedentary government employment or relying upon welfare Table 1: Average skin-fold thicknesses and maximal oxygen payment for their subsistence. Moreover, intakes of traditional male Inuit hunters, compared with their all population sub-groups showed a small transitional and acculturated peers living in the community of Igloolik, Nunavut, in 1970. Based on the data of Rode and increase of sub-cutaneous fat and a Shephard (Rode and Shephard, 1973). corresponding decrease of aerobic power Current Average skinfold Maximal oxygen intake during the winter months, when adverse Lifestyle thickness (mm) [mL/(kg.min)] Summer Winter Summer Winter weather conditions kept everyone Traditional 5.8 6.4 56.6 56.2 confined to the village for much of the hunters (n = 20) time. Transitional 6.1 6.7 54.9 54.9 The adverse effects of abandoning the (n = 22) Acculturated 6.7 7.9 51.1 50.1 hunter-gatherer lifestyle were yet more (n = 18) obvious when average data for the community were collected over the period from 1970 to 1990 (Shephard and Rode, Table 2: Changes in average skin-fold thickness, body mass 1996), as most of the Igloolik people index and maximal oxygen intake of Igloolik Inuit from 1970 underwent the transition from active to 1990, as the community underwent a rapid transition from hunting to a sedentary type of economy a hunter-gatherer to a sedentary economy (Shephard and Rode, 1996). (Table 2). Age Men Men Women Women Cross-sectional data from other parts of group (1970) (1990) (1970) (1990) North America reveal parallel trends, as (yr) Average thickness of 3 skin-folds (mm) 20-29 5.5 7.1 8.5 12.0 comparisons of body fat content are drawn 30-39 6.3 8.4 9.2 13.5 between indigenous peoples who are in 40-49 5.4 10.1 7.0 16.4 regular contact with modern civilization 50-59 7.9 8.6 19.0 11.2 Body mass index (kg/m2) and those who live in more isolated 20-29 24.4 23.8 23.2 23.1 communities where traditional patterns of 30-39 24.9 25.8 23.9 25.4 physical activity and diet have been better 40-49 25.3 26.9 23.7 27.9 50-59 2f5.8 26.4 27.5 24.0 maintained (Young, 1994). Maximal oxygen intake (mL/[kg.min]) Other evidence. Anthropometric data 20-29 58.4 51.1 48.1 41.0 for other continuing hunter-gatherers of 30-39 55.5 46.0 46.3 35.2 40-49 51.6 41.5 40.8 30.7 today (the Baka, a pygmy group living in 50-59 41.6 35.2 36.4 27.7 the tropical rain forests of Cameroon, the

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 7 Historical Perspective on Obesity in the Andaman Islands of the Bay of progressively Bengal (Sharma, 2003)] accumulate large disappeared in amounts of adipose tissue in the buttocks settled, urban and the thighs, a condition known societies. Moreover, as steatopygia (Figure 3). The condition is the introduction of thought to be of genetic origin, and may be cattle raising, and an adaptation to meet the energy demands the over-feeding of of pregnancy and lactation in an domestic animals environment where there are periodic and birds to enrich shortages of food and/or water (Cohen, banquet tables

2017; Marett, 1936). In a hot climate, profoundly changed Figure 3: The Rensch's "desert fat rule" (Coon, Garn, and nutritional patterns condition of Birdsell,1950) suggests that the for the wealthy. The steatopygia, as morphology of steatopygia allows some fat introduction of seen in a Khoisan woman. Source: storage without impeding heat loss. alcoholic beverages https://en.wikipedia.or Although the condition is seen mainly in such as wine, mead, g/wiki/Steatopygia women, it can occur to a lesser extent in and beer also set the men. The phenomenon may once have stage for drunken feasts where the nobility been more widespread, and it may have perceived consumption of food in excess of helped to inspire some of the voluptuous their immediate energy needs as a normal Paleolithic and Neolithic figurines found and pleasurable event. by archaeologists (Radmilli, 1950). At the height of its power, Mesopotamia However, its prevalence has probably was one such wealthy area, peopled firstly been over-stated through the illustration by the Sumerians (4500-1750 BCE), then of extreme cases, and Namibian rock-art by the Babylonians (1750-538 BCE), and suggests that most of the San population finally by the Assyrians. Inferences about have had a relatively normal body build obesity in this region can be drawn from a (Dowson, 1994). In any event, as a genetic knowledge of the overall economy, variant, steatopygia is not particularly archaeological excavations, historical relevant to our overall discussion of artifacts, medical records, and the obesity in Neolithic society. reported lifespan of prominent Mesopotamia individuals. The appearance of obesity in early Mesopotamian economy and society was associated with the archaeological discoveries. accumulation of sufficient wealth to allow Mesopotamia was situated in the fertile a differentiation of labour. Development of Tigris/Euphrates river system, covering an economic surplus often accompanied an area corresponding to modern Iraq and the transition from a hunter-gatherer to a Kuwait. It was the site for the first settled agricultural lifestyle (Shephard, cultivation of cereals, invention of the 2015). Opportunities for over-eating had wheel and irrigation, and also saw the been rare during the Paleolithic and introduction of writing, mathematics, and Neolithic eras. The habitat had been harsh, astronomy. In the Babylonian era, Jewish and the tradition of sharing food as well as scriptures tell of sumptuous feasts such as the very constituents of the diet militated that of Belshazzar: "Belshazzar the king against an excessive accumulation of body made a great feast for a thousand of his fat. However, the sharing of resources lords, and drank wine in the presence of the

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 8 Historical Perspective on Obesity thousand" (Daniel 5:1). Kramer (1956) Thus, the discovery of one obese Mother quotes at least 5 instances of such feasting. Goddess artifact in Susa can hardly be The "best fat and milk" was found in the considered good evidence for the "dining halls of the Gods" (Kramer, 2010) prevalence of gross obesity throughout as a part of the daily religious sacrifices, early Mesopotamia. and "feasts rich with abundance." Medical records. Much of the history of There is archaeological evidence for the medical practice in Sumeria and Babylon is construction of luxurious temples, recorded on some 600 medical tablets towering palaces and hanging gardens in from the period 1000-600 BCE, conserved the chief cities of the region such as in the royal library of Ashurbanipal (668- Babylon and Susa, and also in Nineveh (the 627 BCE) in Nineveh (Thompson, 1923). last featured on sculpture and drawings The most extensive text is the "Diagnostic held by the British Museum). Although the Handbook," prepared by the scholar majority of the population (including for a Esagil-kin-apli, and dating from ~1050 period a band of Jewish captives) BCE (Heessel, 2004). The cuneiform continued to engage in hard physical records discuss problems such as epilepsy labour as they built such wonders, other and consider various prognoses, but there people in the higher ranks of this society is no mention of obesity, excess body fat, enjoyed a relatively sedentary lifestyle. In excess weight, or arterial disease (Finkel addition to kings, princes, and warriors and Geller, 2007). (between battles), a growing group of During the Persian period, sedentary craftsmen were busy producing Zoroastrianism became the dominant artifacts for the temples and the nobility, religion, and it placed considerable and various passive leisure pursuits such emphasis upon the dignity and importance as the Royal Game of Uri and a form of of hard physical labour, reducing the backgammon were developed for this likelihood of obesity. Moreover, from an leisured class. age of 6 years, Zoroastrian boys Artifacts. One terracotta artifact from underwent around the 12th century BCE, discovered rigorous in the Elamite city of Susa, shows a physical training grotesquely obese Mother Goddess for a succession (Figure 4) reminiscent of the Paleolithic of expansionist and Neolithic artifacts, suggesting a wars. continuation of this earlier tradition. Reported However, a statuette of Sumerian King Ur- life-spans. Nammu (2047-2030 BCE) held by the Certainly, some Oriental Institute of the University of members of the Chicago shows a very trim-figured young Mesopotamian man carrying the first brick used in the nobility failed to Figure 4: Terracotta rebuilding of a temple. Other artifacts from show the short figurine from Susa, in the the adjacent Elamite (pre-Iranian) lifespan that one Elamite kingdom, probably dating from the civilization show quite slim individuals would associate 12th century BCE. Source: (Figures 5 and 6). Leonard Woolley (2009) with gross https://s-media-cache- writes of figurines unearthed at Ur and the obesity, ak0.pinimg.com/originals/82/ 32/93/823293780cbbe92dc1c Tell Al'Ubaid: "the conventional bodies, although given c7e0b8b4345fe.jpg slender as they are, are skillfully modelled..." the tendency of

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 9 Historical Perspective on Obesity people to exaggerate their age in antiquity, a few cases of obesity and dietary the ages recorded at death must be indiscretion among the elite of ancient regarded with suspicion. Shulgi of Ur Egyptian society. (2094-1999 BCE), a distance runner Egyptian economy and (Kramer, 1956), is known to have held the archaeological discoveries. The early throne of Sumeria for 48 years, and Pharaohs were generally proud to be Addagoppe of Harran, the mother of athletic, and indeed at one time the ability Nabonidus (556-539 BCE), the last king of to complete a 100 km race was seen as a the Neo-Babylonian empire, is reputed to tangible proof of their continued fitness to have lived for a total of 104 years. reign (Shephard, 2015). Early statues of Conclusions. Despite the records of notable men and women generally suggest feasting by the Mesopotamian leaders and a fit physique. Moreover, most of the the discovery of one obese "Mother general Egyptian population worked Goddess" figurine, other artifacts, medical extremely hard on the construction of records and reported life-spans offer little pyramids, massive temples and other evidence for the widespread prevalence of public works in the Nile valley. A number obesity in ancient Mesopotamia. of fat men, both the upper-class rulers and their immediate servants, are featured in Figure 5: Silver Figure 6: Another Egyptian stone reliefs. However, it is less cup, showing a example of a slim clear whether the obesity portrayed by the slenderly built Elamite statuette. Elamite individual. Source: artist is an accurate representation of the Source: https://en.wikipedia.org individual concerned (Nunn, 2002). https://en.wikipedia.org /wiki/Elam#Statuettes. Specific examples of obese images include /wiki/Elam#/media/Fil e:Elam_cool.jpg a doorman featured at the temple of Amon-Ra Khor-en-Khonsu, a cook depicted in the tomb of Ankh-ma-Hor, an obese harpist shown as playing for Prince Aki (Bray et al., 2003) and the Old Kingdom priest Ka-Aper (from around 2500 BCE) who is seen in a sycamore carving (Figure 7). From the same period, a sculpture of Hemiunu, architect of the Khufu pyramid (~2570 BCE) shows a double chin, heavy shoulders, and a fat

waistline. Queen Hatshepsut came to the throne in 1478 BCE as the second female Ancient Egypt Pharaoh. She is depicted in a sculpture on Ancient Egypt was another region of the wall of the temple that bears her name, the world where periodic flooding and and although the statue is probably irrigation schemes allowed primitive idealized, it does suggest that she also was agriculture to flourish in a large river heavily built (Figure 8). However, she is basin. Herodotus once called Egyptians the less obviously obese in the twin statues "healthiest of all men." Nevertheless, stone representing her at the entrance to her images, papyri, medical writings and post- tomb. The Queen of Punt (from the Yemen mortem examinations of mummified region), featured on the tomb of Queen royalty allow the inference that there were Hatshepsut, appears to have steatophygia

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 10 Historical Perspective on Obesity

(above). physicians saw an appropriate diet as a In the later phases of Egyptian history, means of preserving health, and they when the country came under Macedonian recognized the importance of not only the rule, the puppet King Ptolemy VIII (170- quality but also the quantity of food 163, 145-116 BCE) was nicknamed ingested. According to the Sicilian Physcōn ("fat stomach" or "sausage"). The historian Diodorus Siculus (90-20 BCE), common people of Alexandria mocked him Egyptian methods of limiting food for his obesity and his potbelly before he absorption Included "purging, vomiting or decided to flee to Cyprus. Nevertheless, he fasting every second, third or fourth day", seems to have survived his exile through to because "the greatest part of the aliment the age of 64 years, despite his we take is superfluous, which superfluity is accumulation of body fat. cause of our distempers" (Diodorus, 1721). Medical writings. The Egyptian The Greek historian Herodotus (480-429 Imhotep, sometimes described as the BCE) had earlier reached a similar Father of modern medicine, described conclusion: "Egyptians vomit and purge some 200 diseases, including 16 them- selves thrice every month, with a view conditions that affected the abdomen, but to preserve their health, which in their he did not judge obesity of sufficient opinion is chiefly injured by their aliment" importance to include in this list (Filer, (MacKenzie, 1758). 1995; Osler, 1921). Nevertheless, Darby et The Ebers papyrus (c. 1550 BCE) al. (1977) concluded that some Egyptians suggests that Egyptian physicians may regarded obesity as objectionable. The have encountered diabetes; they certainly Insinger papyrus (probably dating from described patients with excessive the second century CE but reflecting urination, and sought "a medicine to drive earlier independent Egyptian thought) away the passing of too much urine" also speaks of personal responsibility for (Stapley, 2001). the moderation of diet: "Illness befalls a During the Greek occupation of Egypt man because the food harms him. He who (from 332 BCE onwards), Alexandrian eats too much bread will suffer illness..." physicians such as Herophilus and (Lichtheim, 2006). Moreover, Egyptian Erasistratus recognized the therapeutic value of moderate exercise. They condemned "plethora," apparently meaning an accumulation of blood rather than fat. They also related increased body dimensions to an excessive intake of food and its subsequent putrefaction (Magner, 1992; Shephard, 2015), but Erasistratus was unsure the association was causal in Figure 8: Depiction of nature; in any event, the plethora was Figure 7: A sycamore the solid figure of the carving of Ka-Aper, an Egyptian Queen often local, speaking against an Old Kingdom Egyptian Hatshepsut, on the wall accumulation of fat as its cause. priest. From around of her temple. Source: Paleo-pathologic data. A variety of 2500 BCE. Source: https://www.google.ca/imgre mummified bodies, mostly dating from the http://www.globalegyptian s?imgurl=https://upload.wiki museum.org/detail.aspx?id= media.org/wikipedia/commo Old Kingdom (2663-2195 BCE) has 14910 ns/thumb/1/11/Hatshepsut.j pg/220px-Hatshepsut.jpg allowed post-mortem examination of body composition in Egyptian rulers and their

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 11 Historical Perspective on Obesity close servants. The mummies of Queen rich diet was accompanied by obesity. Hatshepsut (above), the Pharaoh Conclusions. Statues and carvings Amenhotep III (who was born in 1411 suggest that at least some members of the BCE, and died at an age between 40 and 50 Egyptian royal entourage were obese. This years) and Ramses III (1217-1155 BCE, view is supported by the practice of who was assassinated at the age of 61 fattening a variety of livestock and calls of years) are all characterized by large Alexandrian physicians for moderation in reconstructed skin-folds, suggesting that diet. Further, examination of some royal in life these rulers were very fat (Bray et mummies provides evidence of thick skin- al., 2003; Lestrel, 2015). The identity of the folds and atherosclerotic lesions in major mummies is not totally certain, and some arteries. Nevertheless, it also appears archeologists have suggested that the likely that the general population were individual identified as Hatshepsut was kept thin by a combination of hard actually the palace "wet nurse." Hatnofer, physical work and a limited availability of the royal housekeeper, was an important food. figure in the court of Hatshepsut, and in their excavation of her tomb at Thebes, Figure 9: Figure 10: Forced feeding of Radiographic evidence livestock in Ancient Egypt. Source: Lansing and Hayes (1937) suggested that of atherosclerotic http://www.gettyimages.ca/detail/news- although she had a frail build, she was lesions in an Egyptian photo/force-feeding-geese-papyrus- reconstruction-of-a-relief-from-news- "distinctly fat." The mummy of Queen mummy. Source: photo/182131940?#forcefeeding-geese- Duathathor-Henuttawy (20th dynasty, https://www.google.ca/sear papyrus-reconstruction-of-a-relief-from- ch?q=atherosclerosis+in+Eg the-of-picture-id182131940. ~1060-992 BCE) also seems very stout. yptian+mummies+photos However, it is difficult to judge a person's physique from a mummy (Dunand and Lichtenberg, 2006), and in particular to be certain how far the superficial fat has been modified by the process of mummification. Dissection (Ruffer, 1910-1911), radiography (Harris and Wente, 1980), and computed tomography (Allam,

Thompson, and Wann, 2009) of mummies has provided evidence of substantial atherosclerosis in the arteries of some Ancient Israel Egyptian royalty and their attendants such Information on obesity in ancient Israel as a nursemaid (Figure 9). This probably is drawn almost exclusively from Biblical reflects at least in part the dietary choices references. Jewish scholars of the Old of wealthy individuals, including the Testament spoke against feasting, eating of deliberately fattened livestock; as drunkenness, and obesity, in part because illustrated in the Harris papyrus (Figure such feasts were associated with their 10); the Egyptians made a practice of pagan contemporaries in Egypt and in force-feeding of cattle, lambs, goats, ducks, Babylon. Nevertheless, warnings and geese, pigeons, and cranes with milk condemnations of obesity occur with bread-dough as banquet delicacies sufficient frequency to suggest that a (Mehdawy and Hussein, 2010). It is less significant fraction of the Jewish clear how far the local accumulation of population were overweight. cholesterol plaques associated with this In the Genesis version of the great flood

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 12 Historical Perspective on Obesity story, Noah is ridiculed by his son Ham, come to poverty, and slumber will clothe because as soon as the waters had them with rags" (2320-21). "If you have subsided, he planted a vineyard and found honey, eat only enough for you, lest became disgustingly drunk (Genesis 921- you have your fill of it and vomit" (2516). 22). Moses, looking forward to a Two verses speak specifically to the prosperous Israel in a promised land of association between gluttony and heathen "milk and honey", warned that as they practices: “Do not be with heavy drinkers of became more wealthy, the people would wine, Or with gluttonous eaters of meat; For "grow fat, stout, and sleek," turning from the heavy drinker and the glutton will come their God and His precepts (Deuteronomy to poverty, And drowsiness will clothe one 3215) (note that the Jewish honey with rags" (2320-21), and "He who keeps the mentioned here was a syrup made from law is a discerning son, But he who is a sweet fruits). Gluttony was specifically companion of gluttons humiliates his condemned in the 10 Commandments. The father" (287). originator of the book of Deuteronomy By the time of the prophet Amos (possibly Moses himself) also cautions (around 760 BCE), the problem of dietary "This son of ours is stubborn and excess had spread from royalty to a rebellious. He will not obey us. He is a significant fraction of the Israeli upper glutton and a drunkard” (Deuteronomy and/or middle class, and Amos spoke 2120). plainly to his self-indulgent and wealthy During the time of the Judges, Eglon, parishioners in the northern kingdom: King of Moab, was one of the oppressors of "Listen to me, you fat cows living in the new Jewish state. One day, the Israelite Samaria, you women who oppress the poor judge Ehud called on Eglon, supposedly to and crush the needy, and who are always present him with tribute money, but Ehud calling to your husbands, "Bring us another took the opportunity to stab Eglon (Figure drink!" (Amos 41). As in other parts of the 11). According to this legend, King Eglon world, being heavy of jowl and with sides was so obese that Ehud could not bulging with fat was seen as a mark of evil subsequently withdraw his sword (Judges prosperity (Job 1527): "These wicked 312-30). people are heavy and prosperous; their The Book of Figure 11: Eglon, waists bulge with fat." Proverbs, possibly King o: Moab, was The second part of Isaiah's prophesy (~ authored by King supposedly so fat 550 BCE) is addressed to the Jewish exiles Solomon (970-930 that when he was in Babylon. The writer of this section of stabbed by Ehud, the BCE), warns latter could not Isaiah asks rhetorically: "Why do you spend repeatedly against retrieve his sword. your money for that which is not bread, and gluttony: "Put a Source: your labor for that which does not satisfy? https://en.wikipedia.org/ knife to your throat wiki/Eglon_(king) Listen diligently to me, and eat what is good, if you are given to and delight yourselves in rich food" (Isaiah appetite" (232), "Be 552). not among In the first and second centuries CE a drunkards or number of prominent Jewish rabbis, among gluttonous including Ishmael ben Jose and Simeon eaters of meat, for ben Eleazar had such gross bellies that the the drunkard and Talmud queries whether they would ever the glutton will be able to reproduce. The Talmudic

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 13 Historical Perspective on Obesity tractate "Baba Metzia" includes an account sacred and medical writings. Indian of surgery that was performed on Rabbi doctors noted an association between the Eleazar (1st century CE) for the removal of accumulation of body fat and diabetes excess fat. He apparently "underwent an mellitus and proposed specific treatments. operation to remove much of his fat" Around 600 BCE, the (Rosner, 2000). "Baskets of fat" were said physician Sushruta (Figure 12) to be ripped from his abdomen during this commented on two of the more important procedure (Gilman, 2008). adverse medical consequences of obesity, As Christianity spread across the Greek diabetes mellitus and heart disease. He and Roman world, a healthy, fit body called diabetes "Madhu‐meha," noting "a became seen as a gift of God. The New sweet taste and smell like that of honey" in Testament thus contains many passages the breath of affected patients. He further where gluttony and drunkenness are distinguished a congenital form of criticized as evidence of reversion to diabetes, where patients were emaciated, former pagan ways: "Woe to you who are showed excessive thirst and a loss of full now, for you shall be hungry" (Luke appetite, and an adult form. With 625); "watch yourselves lest your hearts be surprising accuracy, he associated the weighed down with dissipation and latter with the choice of an "injudicious" drunkenness and cares of this life" (Luke diet, and symptoms that included "obesity, 2134); "walk by the Spirit, and you will not voracity, a soporific tendency, and an gratify the desires of the flesh" (Galatians inclination for lounging in bed or on a 516); "those who belong to Christ Jesus have cushion" (Bhishagratna, 2006; Haslam, crucified the flesh with its passions and 2016). Sushruta recognized the desires" (Galatians 524);"Their end is contribution of a sedentary lifestyle. He destruction, their god is their belly, and they thus advised exercise as well as fasting and glory in their shame, with minds set on other depletory measures (Dods, 2013), earthly things" (Philippians 319)."Older replacing lounging in bed or sitting on a women likewise are to be reverent in cushion by exercise and adopting an behavior, not slanderers or slaves to much Ayurvedic diet. The therapeutic physical wine" (Titus 23). activity had to be performed daily and at Conclusions. These various writings least a moderate intensity was needed, provide evidence that obesity was present although he cautioned that the half- in a number of the more wealthy people in maximum limit for ancient Israel, although gluttony and exhaustion should Figure 12: Sushruta, excessive body weight were regarded as not be exceeded Indian physician from c. 600 BCE. manifestations of a lack of self-control and (Tipton, 1985). Source: were roundly condemned by both Jewish One of the main https://www.google.ca/s and Christian scriptures. subsequent earch?client=safari exponents of Hindu and Buddhist India Ayurvedic medicine There is a word ("medas") in the and the 3 doshas Sanskrit language that translates into was the physician excessive fatness, suggesting that obesity Charaka (c .300 was a problem for at least some people in BCE) (Figure 13). ancient India. Specific evidence of fat He underlined that a accumulation is again found mainly in poor lifestyle

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 14 Historical Perspective on Obesity shortened lifespan (Mondal, 2013). In his the available literature suggest it was an view, excessive corpulence was caused by occasional problem of the wealthy, rather "an excessive intake of heavy, sweet, cooling than a common occurrence in the average and unctuous food, want of physical citizen. An examination of the 2200-year- exercise, day sleep, uninterrupted old Terracotta Army of Chinese Emperor cheerfulness, or a lack of mental exercise." Qin reveals 8000 life-size figures, each Diabetic individuals should practice with a unique face, clothing, and body regular physical exercise, including build. Many are senior military officers, "wrestling, riding on an elephant, long but others include accountants and walks, pedestrian journeys, archery and administrators, and only one member of casting javelins." The Ayurveda also the group is obese- the Entertainer— recommended the administration of clearly a passive occupation in the Royal testicular tissue as a cure for both Court. impotence and obesity (Iason, 1946). In the Han dynasty, the mythical Yellow "The Four Tantras" (Alphen & Aris, emperor Shen Nung (3000 BCE) (Figure 1997) was for long the basic book of 14) is said to have discovered green tea, Tibetan Buddhist medicine. It was written and he urged its consumption as a method in the 12th century CE, and it incorporated to reduce obesity. In the Suwen, or Book of elements of Indian, Arabic, Chinese, and Plain Questions (Unschuld and Tessenow, Greek medical scholarship, with an 2011), Shen Nung conducted a dialogue emphasis on keeping 3 bodily humours in with his medical advisers. Chapter 28 ("A balance. The text noted that over-eating discourse thoroughly deliberating on caused illness and shortened life span. In depletion and repletion"), states "If obesity keeping with the passive and meditative occurs in the nobleman and rich people, philosophy of Buddhism, obesity was they must be over consuming heavy and discussed as a problem that required greasy foods." Associated risk factors were catabolic treatment, to be sought through said to include undesirable eating habits, massage with pea flour, the eating of wolf under exercising, body constitution and flesh, and the use of enemas and mental state. compresses (Wolin and Petrelli, 2009). By In more recent times, a general in the the 12th century, many Buddhists also Figure 13: Charaka, Figure 14: Shen Nung viewed obesity as evidence of moral Indian physician from ~ (c. 2695 BCE), failure (Stunkard, LaFleur, and Wadden, 300 BCE. Source: considered as the father 1998). https://www.google.ca/imgres? of Chinese medicine. Conclusions. Obesity was well- imgurl=http://www.brahmayur Source: ved.com/images/legendofayurv http://www.toxipedia.org/dis recognized in ancient India and Tibet, with eda/7624download.jpg play/toxipedia/Shen+Nung an understanding of some of its complications and the prescription of specific exercise and dietary treatments.

The Chinese dynasties Obesity was a problem among some of China's emperors, and it was sufficiently prevalent in ancient China that Chinese physicians and scholars proposed several remedies. On the other hand, comments in

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Tang dynasty (An Lushan, 703-757 CE) some form of toxic purgative (Kelly, 2006). suffered from gross obesity and was Obesity features regularly as a medical reputedly so fat that he caused more than disorder in the writings of physicians in one horse to collapse beneath his weight. classical Greece and Rome (Haslam, 2007). He developed diabetes and eventually The number of such references suggests became blind. And in the Ming dynasty, the that obesity was a fairly common Wanli Emperor (1572-1620 CE) also complaint, at least among aristocratic banqueted his way to gross obesity, so that patients throughout the classical Greek in his latter years he was unable to stand and Roman periods, perhaps because an without assistance. enormous number of slaves undertook The placing of sharp objects in the pinna most of the heavy physical work for the of the ear was plainly a potent aide- wealthy elite. As in other early cultures, memoire when at the dining table, and this the problem was sufficient to merit both form of acupuncture was claimed to description and the proposal of remedies. reduce appetite (Wolin and Petrelli, 2009). Hippocrates discussed the issue Other therapeutic suggestions included frequently, and even Plato expressed two ideas borrowed from the Buddhists (a concern about immoderation in food vigorous massage of the body with pea consumption, partly for ethical reasons, flour, and the eating of wolf flesh), but also because of the resulting health together with administration of an extract problems. from the Thunder-God vine (a preparation On the other hand, the emphasis for the that reduced the patient's appetite, young Greek nobleman was on perfecting apparently by enhancing the action of the body beautiful as an offering to the leptin). Gods. In Pindar's 11th Olympic Ode we Conclusions. The texts cited above read: "Strength and beauty are the gifts of point to the development of gross obesity Zeus...natural gifts imply the duty of in some of the elite in ancient China, but on developing them with God's help" the other hand the physique of the (McIntosh, 1970). In general, because of terracotta warriors suggests that this was the Greek emphasis on the balance of four an uncommon problem. body humours, for most physicians, the ideal body composition was found at the Classical Greece and Rome mid-point between fat and thin. On the island of Crete, the Minoan Spartan attitudes. Physical perfection civilization flourished from the 15th was especially prized in Sparta. The century BCE. Not much is known about the legendary law-giver Lycurgus (c. 900-800 health of this community. Evidence of BCE) oriented Spartan society, both male gallstones and gout suggest that some of and female, towards a tradition of life-long the wealthy may have indulged in over- military fitness and austerity, based on eating (Shephard, 2015). On the other guidance given by the Oracle of Apollos at hand, short average heights and periods of Delphi (Figure 15). The laws of Lycurgus growth retardation indicate the common established firm measures against people may have experienced periodic laziness, muscular weakness and obesity food shortages (Arnott, 1996). There were both in Spartan youth and in society claims of a secret that allowed wealthy generally. Shortly after their birth, the Cretans to eat as much as they wished local elders inspected infants, and those without getting fat; possibly, they used that were puny or deformed were tossed

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 16 Historical Perspective on Obesity over the cliffs at Mount Taygetus. success in prolonging life, not least his Throughout their childhood, all Spartans own. He, also, underlined the need to followed a rigid physical regimen, and at regulate diet and exercise, and indeed he the age of 18 years both men and women was censured in Plato's Republic for had to pass a rigorous physical fitness test. "keeping people with crazy constitutions Those with the misfortune to fail the test alive to old age" rather than letting them " lost both their citizenship and their die out of the way" (MacKenzie, 1758). political rights. Thereafter, the men who Herodicus advocated a systematic and passed this test were required to maintain strenuous exercise programme; many of a high level of fitness and remain in the his patients were prescribed repeated military reserve until they reached the age brisk 42 km walks from Athens to Megara of 60 years (Shephard, 2015); any who at progressively increasing speeds. became fat were banished from Sparta. However, both Hippocrates and Plato Hippocratic medicine. Even before thought he demanded too much of his the coming of Hippocrates, the Ionian patients, and Herodicus was said to have philosopher Pythagoras (570-495 BCE) caused the death of several individuals by had already recommended eating in submitting them to excessively long walks moderation. He commented adversely on and forced exercise. those of his fellow-citizens who over-ate Hippocrates of Kos (460-370 BCE) and then vomited or fasted. In a life of (Figure 16) played a central role in Pythagoras, the biographer Diogenes revolutionizing Greek medicine, Laertius (3rd century CE) noted that the establishing it as a profession that was philosopher had recommended the wiser distinct from philosophy and the alternative of moderation: "No man, who supernatural. He also seems to have been values his health, ought to trespass on the well aware of the harmful effects of bounds of moderation, either in labour, diet obesity, noting the low resistance of the or concubinage" (Paredes, 2011). To this obese to febrile disease, and their recommendation was added unction, increased risk of sudden death. Thus, he bathing and exercises to increase bodily gave strict directions for the prevention strength (MacKenzie, 1758). and treatment of obesity. His remedies The physician Iccus of Taranto (5th included severe physical labour before century BCE), himself an Olympic athlete and victor in the Games of 444 BCE, Figure 16: Hippocrates of advanced similar views. He combined Kos (460-370 BCE). Source: exercise with a frugal diet in order to https://www.google.ca/search?client =safari preserve health. The 6th century CE philosopher Stepnaus of Byzantium commented that the saying "the repast of Iccus," probably originating with Herodicus (below), had become a proverbial watchword for a plain and Figure 15: Lycurgus, the temperate meal (MacKenzie, 1758). legendary Spartan The 5th century BCE physician lawgiver. Source: Herodicus, one of the teachers of https://en.wikipedia.org /wiki/Lycurgus_of_Spart Hippocrates, and sometimes considered as a#Education_of_children the father of sports medicine, claimed

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 17 Historical Perspective on Obesity breakfast, a hard couch, a hardening of the walks" (Christopoulou‐Aletra and body in the open air, the prohibition of Papavramidou, 2004). Among the warm baths and the avoidance of wine colleagues and successors of Hippocrates unless it was largely diluted with water. there are also recommendations of He wrote: "One cause which made it emetics. Thus hellebore plants and honey necessary to study the art of restoring lost water were prescribed ‘"for the evacuation health, was the great difference to be of the nourishment two or three times a observed between the diet of the healthy month"), along with cathartics (for and that of the sick" (Rossen and Rossen, example, scammony juice (bindweed), 2011). "The men lack sexual desire because Cnidian berry and sea spurge) and of the moistness of their constitution and laxatives (donkey milk with honey, wild the softness and coldness of their bellies. ... parsley, dodder of thyme (Cuscuta In the case of the women, fatness and epithymum), honey water and sweet wine) flabbiness are also to blame... sudden death (Christopoulou‐Aletra and Papavramidou, is more common in those who are naturally 2004). fat than in the lean" (Haslam and Rigby, Polybus. In treating obesity, the 2010). "it is very injurious to health to take physician Polybus (c. 400 BCE) generally in more food than the constitution will bear, followed the treatment plans of his father- when, at the same time, one uses no exercise in-law Hippocrates: "Persons of a gross to carry off this excess" (Wells, 2009). relaxed habit of body, the flabby, and red- Moreover, Hippocrates seems to have haired, ought always to use a drying diet... recognized that android fatness was more Such as are fat, and desire to be lean, should harmful than a gynoid distribution, and use exercise fasting; should drink small that the latter might even help outcomes liquors a little warm; should eat only once a during prolonged illness: "In all maladies, day, and no more than will just satisfy their those who are fat about the belly do best; it hunger " (Haslam, 2007). is bad to be thin and wasted there" (Little Aristotle. The philosopher Aristotle and Frayn, 1986; Raisborough, 2016). (384-322 BCE) was a strong believer in Hippocrates was particularly scathing moderation: "You may not live solely about the Scythians in Persia, where he pursuing your base desires. Rather, you perceived a lack of daily activity from an must subordinate them to right reason, and early age. He commented “The male your life must be determined by the children, until they are old enough to ride, intellect, not by base desire." "both eating spend most of their time sitting in the and drinking too much or too little destroy wagons and they walk very little... The girls health, whereas the right quantity get amazingly flabby and podgy" (Haslam produces, increases or preserves it" (Engel, & Rigby, 2010). 2002). Diocles. Diocles of Carystus (240-180 Colleagues and successors of BCE), regarded by Pliny as a physician who Hippocrates. The advice of both Greek was second in wisdom only to philosophers and the medical colleagues Hippocrates, recommended that those of Hippocrates was that overweight who were obese should eat only once per individuals should "reduce food and avoid day (Sydenham, 1844). drinking to fullness," engage in regular Asclepiades. Asclepiades (120-40 exercise, "running during the night" and BCE) practiced medicine in Rome. He was take "early morning an advocate of strong friction for the obese

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(Dublin University, 1861). Like Views of Galen and his successors. It Hippocrates, he believed that strong is plain from the above comments that friction made the body harder. many Greek and Roman physicians Celsus. The Greek philosopher Celsus recognized that obesity was unhealthy. In (~ 25 BCE) was sometimes criticized as "a some instances, they also recorded and patron of gluttons and drunkards" because treated occasional cases of morbid obesity. he suggested that a person could "indulge Oribasius (325-400 CE), author of a 70- himself at feasts; . . . sometimes eat and volume Medical Encyclopaedia, believed drink more than is proper" (Haslam, 2007). that obesity reflected a combination of Nevertheless, Celsus advised an overall flabbiness and excessive moisture, and he moderation in diet, and treated obesity by argued that it arose from an inappropriate sea-bathing. He regarded a square, fit lifestyle: "Non plus par nécessité, mais par frame, neither thin nor fat, as optimal suite du régime habituel, le corps des gens (Celsus, 1935). Like Asclepiades, he doué d'un tempéremant sec est plus dur et generally rejected purges and vomiting, plus sec que celui des gens doué d'un but nevertheless he suggested that an tempéremant moyen. (Not only necessity, excess of food could become corrupted, but also due to habitual lifestyle, the body of and then treatment by the induction of people with a dry temperament is harder vomiting was indicated (Celsus, 1935). and dryer than that of people with an Dioscorides. During the first century average temperament)" (Bussemaker and CE, the De Materia Medica of the physician Daremberg, 1863). The condition required Pedanius Dioscorides (40-90 CE) listed treatment by emaciati on and fat certain foods and herbal preparations that reduction, achieved through exercise, diet, helped to reduce obesity; one particular medications, baths, massage, and recommendation included a mixture of provocation of what was termed “mental Asian meadow, cheese, and mustard anxiety.” (Dioscorides, 2003). Galen (130- ~210 CE, Figure 17) was Plutarch. The essayist Plutarch (46- physician to several Roman Emperors. He 120 CE) commented on obesity and health, classified overweight individuals as pachis remarking that “thin people are generally (fat), efsarkos (overweight, a natural the most healthy; we should not therefore condition) and polisarkos (obese, a morbid indulge our appetites with delicacies or condition, derived high living, for fear of growing corpulent... from poly (much) The body is a ship which must not be and sarka (flesh). A overloaded” (Sinclair, 1818). person with Soranus. Soranus of Ephesus (98-138 polisarkos was CE) regarded obesity as a chronic disease “exceeding fat”. In in immediate need of treatment. He De Methodo believed that obesity could narrow the Medendi, Galen Figure 17: The birth passage and cause problems in described the Greek physician Galen introduced the childbirth, and by way of treatment he typical patient with first classification of proposed a combination of diet and polisarkos as obesity. Source: exercise, baths, venesection, purging, and "unable to walk https://www.google.ca/i mgres?imgurl=http://ww a radical change in lifestyle (Soranus, without sweating w.thefamouspeople.com/ 1991). and unable to reach profiles/images/galen- 1.jpg the table when

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 19 Historical Perspective on Obesity sitting due to the size of his stomach, with Aetius. Aetius of Amida (5th century difficulty breathing, and unable to clean CE) authored a 16-volume medical text himself" (Papavramidou, Papavramidis, that was subsequently arranged as a 4- and Christopoulou‐Aletra, 2004). He volume set, the Tetrabiblos. It drew heavily regarded polisarkos as due to a on the works of Galen and Oribasius. preponderance of phlegm, one of the 4 Aetius saw the optimum body body humours in Greek medical thought, temperament as a balance between and he underlined the resulting dangers to extremes of leanness and obesity, of life, particularly an increased risk of softness and hardness, of heat and cold, sudden death. and of moisture and dryness. However, Galen gave a detailed description of his obesity could arise from a faulty lifestyle, recommendations in de Victu Attenuante. as well as by inheriting a predisposing He suggested that obesity should be temperament (Olivieri, 1935). treated by strenuous running, warm baths, Alexander. The physician and medical a light meal and more physical work; author Alexander of Tralles (~ 525-605 affected individuals should eat only once CE) suggested that obesity reflected an per day, and then in proportion to the altered balance of the temperaments, amount of exercise that they take. which he located in the stomach. Most Proposed medications included various commonly, the problem was an extremely diuretics such as seed of wild rue with its cold temperament; this led to a desperate tops, the round birthwort, the small need for food, and he recommended the centaury, gentian, poley, and Macedonian counter-treatment of feeding "warm" parsley (Bussemaker and Daremberg, foods, namely unmixed wine and very fatty 1863). Massage with oils containing these protein such as legs of pheasants and pork herbs was also thought to be helpful. meat; these caused satiation and appeased Galen claimed that he could make a the underlying hunger. However, obesity "sufficiently stout patient moderately thin could also reflect the opposite extreme, an by compelling him to do rapid running" excess of heat, with a need to correct the (Shell, 2003), and he reported in De problem by ingesting food with cooling Sanitate Tuenda (160 CE): "I reduced a properties. A further possibility was an huge fat fellow to a moderate size in a short anomaly of retentive function (Trallianus time, by making him run every morning and Goupyl, 1556). until he fell into a profuse sweat; I then had Theophilus Protospatharius. him rubbed hard, and put into a warm bath; Theophilus Protospatharius (9th century after which I ordered him a small breakfast, CE) discussed obesity in his comments on and sent him to the warm bath a second Hippocratic aphorisms (Papavramidis and time. Some hours after, I permitted him to Christopoulou‐Aletra, 2007). Obesity was eat freely of food, which afforded but little seen as an unhealthy situation, because nourishment; and lastly, set him to some the natural faculties did not “calm down.” work which he was accustomed to for the Such a situation eventually led to death. remaining part of the day" (Haslam and The body humors became jellied, causing Rigby, 2010). hypertension and problems of digestion. Later Byzantine physicians. The idea There was no adhesion of food to the of a linkage between a "moist" tissues, no assimilation and this ultimately temperament and obesity persisted brought about the death of the patient. among Byzantine physicians.

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Longevity. Although obesity was tower from which only his head emerged described by many of the ancient Greek to bark orders. In the opinion of Aelianus and Roman philosophers, and was well "By the gods, that was an absurd way to recognized amongst the aristocracy, it was cover himself: to prefer a sort of cage for often attracted negative attitudes, and its wild beasts to a dress for human beings! " prevalence in the various strata of society Nevertheless, Dionysius did not renounce remains unclear. Many Greek leaders his gluttony, and he is reputed to have said appear to have lived what would have that he wanted to die with his mouth full, been an unusually long life for an obese "rotting away in pleasure" (Shell, 2003). individual, for example Thales (78 years), Magas, King of Cyrene (317-250 BCE), Anaximenes (57 years), Heraclitus (67 was also weighed down by monstrous years), Solon (80 years), Empedocles (60 masses of fatty tissue in his final days, and years), Pythagoras (75 years), Hippocrates he is aid finally to have choked himself to (90 years), Asclepius (84 years), Aristotle death (Kryger, 1983), an incident that the (62 years), Plato (82 years), and historian Agatharchides, (2nd Century Antisthenes (80 years). BCE), cited with great relish (Africa, 1961). A census conducted by the Roman Some Greek authors satirized those Emperor Trajan (53-117 CE) claimed to who were obese. Thus, in the 5th century find 11,000 centenarians (Oswald, 1878), BCE comedy Plutus, the playwright but many of the group had probably Aristophanes described the grossly exaggerated their age because the society overweight as stupid gluttons, figures of of that era tended to venerate those who mockery and disgust: ''bloated, gross and were very old. preseniled... they are fat rogues with big References to obesity in classical bellies and dropsical legs, whose toes by the literature and art. We may cite two gout are tormented" (Allardyce, 2015). specific examples of gross obesity from the The Roman representation of classical literature of the Greco-Roman Dionysus, the God of wine and the world- Dionysius and Magas. Dionysius is personification of self-indulgence, is not described by Claudius Aelianus (170-235 particularly fat (Figure 18), but the Roman CE) in his "Historical Miscellany" (Bevegni tutor of Dionysus, the mythical horse-like and Adami, 2003) as the tyrant of Heraclea Silenus, did have a pot-belly, and obesity Pontica during the 4th century BCE. was a feature of the self-indulgent Dionysius became sufficiently fat that he Bacchus/Dionysus, as seen for instance in earned the nickname of Pompikos the paintings of Rubens. ("stately, magnificent"). He could not eat Pathological consequences of food unless it was introduced into his obesity. The recognition of a link between stomach by artificial means and had obesity and abnormal sleep patterns, as difficulty in breathing. Moreover, he described in Dionysius and Magas, dates frequently fell asleep when conducting back to Hippocrates: "Others, when their official business, to the point that his diet bears too great a proportion to their servants had to poke long needles into his exercise, not only sleep well at night, but are skin to waken him. His outer layer of fat likewise drowsy in the day; the repletion was relatively insensitive, but when the still increases, and their nights begin to needle penetrated to healthy tissue, he grow restless; their sleep afterwards was awakened. He became ashamed of his becomes disturbed with frightful dreams of condition and lived secluded in a small battles" (MacKenzie, 1758).

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By the second century CE, Greek hydrotherapy, and lifestyle changes. One physicians were also aware of the link new idea was that "prolonged thinking that between obesity and diabetes mellitus. leads to sadness slims”. The celebrated Cappadocian physician Obesity was also well known to Abu Ali Aretaeus wrote: "Diabetes is a wonderful Ibn Sina (Avicenna, 980-1037 CE, Figure affection, not very frequent among men, 19), another of the leading figures of early being a melting down of the flesh and limbs Arabic medicine (Nathan, 1992). He into urine. Its cause is of a cold and humid devoted a part of Volume 3 of the Canon of nature as in dropsy" (Aretaeus, 2010). Medicine to a Conclusions. In classical Greece, the discussion of the ideal body type was athletic, and the drawbacks of longevity of many leading thinkers excessive obesity, suggests that they conformed to this classifying it as a phenotype. Obese individuals were medical disorder, satirized by playwrights, and because of and noting public disapproval some were even associated health reluctant to show themselves in public. risks, including But at the same time, the interest of a large respiratory and number of physicians in the causes and cardiac problems, treatment of obesity, and a knowledge of infertility, and some of its complications suggests that a sudden death. He substantial number of wealthy patients was a strong carried an excess of body fat. advocate of a Figure 18: A The mediaeval Arab world positive lifestyle second century Obesity was well-known to leading (Avicenna, 1999), Roman physicians of the mediaeval Arab world arguing: "The representation of such as Al Razi, Avicenna, Ibn Hubal Al- regimen of Dionysus, the God of wine. Source: Baghdady, and Ibn el Nefis. Most of these maintaining health https://en.wikipedia.org/ scholars were well aware of the medical consists essentially in wiki/Dionysus complications attendant upon gross the regulation of 1) obesity, and they recommended treatment exercise, 2) food and by a combination of vigorous exercise and 3) sleep. Once we dietary change. direct the attention Al-Razi (854-925 CE) was a Persian towards regulating polymath who practiced medicine in exercise as to amount mediaeval Baghdad. He wrote several and time, we shall books on nutrition, including one entitled find there is no need Figure 19. "Benefits of food and the warding off of its for such medicines as Avicenna, a leading harmfulness" (Nikaein, Zargaran, and are ordinarily figure of mediaeval Mehdizadeh, 2012). In his Encyclopaedia required for Arabic medicine and of Medicine, he also reviewed existing remedying diseases." advocate of a healthy lifestyle. knowledge of obesity. He presented if obesity was Source: clinical case reports on the patients he had already established, https://www.google.ca/i mgres?imgurl=http://ww treated successfully; the therapy that he he proposed treating w.thefamouspeople.com/ had recommended for the obese included it with hard exercise profiles/images/avicenna -2.jpg diet, drugs, exercises, massage, and lean foods. On

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 22 Historical Perspective on Obesity occasion, he also prescribed an appetite obesity and its complications were well suppressant for his obese patients, based known in this part of the world during the on sweet almonds, beef suet, violets and "Arab Spring" of mediaeval learning. marshmallow (Haslam, 2016). Ibn Hubal Al-Baghdady (1121-1213 Mediaeval and Renaissance Europe CE) also practiced medicine in Baghdad. As Christianity became the dominant Like Avicenna, he commented on the belief system in Europe, the idea grew that predisposition of “hugely obese persons” to illness was a punishment of God, merited fall ill quickly. He concurred with the idea by a person's sinful behaviour. of management by heavy exercises on an Nevertheless, obesity was not uncommon empty stomach, but he also stressed the among the elite, and it was prized by some importance of a gradually increasing the as a physical manifestation of their training regimen, because an excessively wealth (Bloomgarden, 2003). obese person could put himself at risk if he Obesity among the wealthy elite. In started abruptly on a programme of heavy much of Europe, the world of the 1300s physical activities. was marked by hunger and severe food The Damascus-born Ibn al Nafis (1207– shortages. Episodes of famine seemed to 1288 CE) practiced medicine in Cairo recur at least once every five years. (Abdel-Halim, 2005)(Figure 20). He Throughout this era, degraded soils, reported further on the association inadequate storage of food products, slow between excessive obesity and and difficult transportation networks, and cardiovascular and cerebro-vascular vulnerability to inclement weather accidents, respiratory, and endocrine contributed to an inadequate diet for most disorders in his of the world population. Obesity thus book Al Mujaz became a visible sign of wealth and Fit-Tibb (The personal success. Rulers such as Charles Concise Book of III, Louis VI, and Henry VIII all became Medicine), greatly overweight, as did many of their noting senior officials (Bloomgarden, 2003). that "Excessive Charles III. Charles III, the Carolingian obesity is a Emperor from 881-888 CE, was constraint on the nicknamed "Charles the fat" (Figure 21). human being He is reputed to have shown an limiting his accompanying lethargy, although the freedom of cause of his death, at the age of 56 years is actions." He Figure 20: The Cairo- unknown. distinguished a based physician Ibn al Louis VI. Louis VI (1081-1137 CE) was Nafis (107-1288 CE) special type of noted the association king of France. He was nicknamed "Le obesity in that between excessive Gros," and by the age of 40 he had become some children obesity and so obese that he had difficulty leading his were “obese by cardiovascular and army into battle. He died suddenly, birth.” cerebro-vascular supposedly of dysentery, but it seems accidents, respiratory Conclusions. problems and endocrine likely the infection was complicated by his The writings of disorders. Source: obesity. Persian doctors https://en.wikipedia.org/wiki/ Henry VIII. Henry VIII of England Ibn_al-Nafis show that (1491-1547 CE) was very athletic as a

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 23 Historical Perspective on Obesity young man, and he built elaborate exercise garden of her convent... her eyes fell on a facilities into many of his palaces. lettuce, and... she was tempted to the sin of However, he abandoned exercise gluttony. She yielded to the sin, plucked the following a serious jousting injury, lettuce, and ate it greedily. But ...as she was without curbing what was reputed to be a eating, a devil entered into her, and she prodigious appetite. A study of his suits of became possessed, with torments." "A monk armour shows a progressive increase in who gave up himself to the sin of waist girth from 81 cm to 140 cm over gluttony...lived in a monastery of Lycaonia, adult life, with the body mass rising and was held in great esteem ... But the eventually to 178 kg (corresponding to a unhappy monk was a slave to gluttony; so BMI of 52 kg/m2) (Figure 22). In his final that, whilst others fasted, he took secret years, 4 strong men were needed to carry opportunities for eating. At length he was Henry from room to room on a padded overtaken with a serious illness, which chair known as "the King's tram" proved to be his last. As the hour of his (Shephard, 2015). departure drew near, the monks flocked Attitudes of the mediaeval church. around his bed, thinking to hear ... The mediaeval Catholic church voiced something for their soul's edification." strong public disapproval of obesity, "Brethren... when you fasted, I feasted in viewing gluttony as one of the "seven secret: for which cause I am given over to deadly sins" (Shipley, 1875). Pope Gregory the infernal (6th century CE) noted five potential enemy, who manifestations of gluttony: has already 1. Sin in the matter of time, eating before coiled himself the appointed time. around my 2. Sin on a question of quality, seeking out feet and delicacies. knees, and is 3. Sin by the use of stimulant sauces and now reaching condiments. my heart." Figure 21: Charles the Fat, 4. Sin in relation to the quantity of food With these Carolingian Emperor from ingested. words he 881-888 CE. Source: 5. Sin from eating with undue eagerness expired." "A https://www.quora.com/Why-is- Charles-the-Fat-called-Charles-the- (Shipley, 1875). saintly old Fat-and-not-some-more- Other mediaeval church leaders saw monk, while appropriate-or-kingly-title-such- as-the-great expressions of gluttony in: sitting at • Praeopere (eating too soon); table with • Laute (eating too expensively); other monks, Figure 22: Henry VIII. Source: • Nimis (eating too much); was favoured https://www.google.ca/search?q= • Ardenter (eating too eagerly); by GOD with Henry+VIII

• Studiose (eating too daintily); an inward • Forente (eating wildly) (Wolin & vision, in Petrelli, 2009). which it was Shipley (1875) relates several revealed to anecdotes that illustrate the stern him that some attitudes of the mediaeval church towards of his any hint of gluttony: "A nun, walking in the brethren were eating sweet

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 24 Historical Perspective on Obesity honey, others were eating plain bread, and that agreed Figure 23: Louis others, again, were eating uncleanness... with his Cornaro's Four Those who were eating for the sake of constitution. He discourses on a sober life. eating only, who gave up themselves to the claimed not Source: https://www.google.ca/search? sensual gratification and could think of only to have q=Luigi+Cornaro nothing but their food, were they who fed on lived for uncleanness." somewhere Medical attitudes to obesity during between 98 and the Renaissance. Renaissance physicians 102 years, but and other scholars in Britain, including also to have Elyot, Cogan, Boorde, and Moffett, all retained full advocated moderation and frugality of diet mental clarity, in both scholarly and popular writing. good eyesight Thomas Elyot. The diplomat and and robust scholar Sir Thomas Elyot (1490-1546 CE) health until his was one of the first Britons to promote the death. He is said primary prevention of disease. In his to have eaten treatise The Castel of Health, he offered about 340 g of food per day, supplemented simple rules for a healthy diet and overall with a little wine. At one point, his relatives lifestyle in a text that was accessible to all persuaded him to increase his daily intake who could read Greek (Elyot, 2005). He to 400 g/day, but he found: "This increase, warned specifically of the dangers to had, in eight days’ time, such an effect upon health from over-eating: "abuse is heere in me, that, from being cheerful and brisk, I this realme in the continual gourmandise began to be peevish and melancholy, so that and dailye féeding on sundrie meats at one nothing could please me. On the twelfth day, meale, the spirit of gluttony triumphing I was attacked with a violent pain in my among vs, in his glorious chariot called side, which lasted twenty-two hours and welfare, driving vs from him, as his was followed by a fever, which continued prisoners into his dungeon of surfet, where thirty-five days without any respite, we are tormented with catars, fevers, gouts, insomuch that all looked upon me as a dead pluresies, fretting of the guttes, and many man" (Cornari, 1993). other sicknesses, and finally put to death by Thomas Cogan. The Tudor physician them, oftentimes in youth, or in the most Thomas Cogan (1545-1607 CE) recounted pleasant time of our life." the adages of Hippocrates and Galen, Luigi Cornaro. Luigi Cornaro (1464- adding his own shrewd analogies. On 1566 CE) was a long-lived Venetian exercise, he wrote: "Flowing water does not nobleman. He devised a personal diet and corrupt, but that which standeth still; even lifestyle at a relatively young age, when he so animal bodies exercised, are for the was informed by doctors that his life of greatest part healthful; and such as be idle excess was killing him. He turned to are subject to sickness" (Cogan, 1596). temperance and frugality in order to treat Andrew Boorde. The cleric and his ill-health and laid down rules for good physician to Henry VIII Andrew Boorde health in his "Four Discourses on a Sober (1490-1549 CE) wrote the "Breviary of Life" (Figure 23). His basic plan was a health." This blamed obesity upon an restriction of food intake to the minimum excessive consumption of alcohol (Boorde, needed for survival, and to eat only food 1552): "All sweet wines and grass wines

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 25 Historical Perspective on Obesity doth make a man fat" Abstinence is "the associated with slowness, laziness, and most perfectest medicine that can bee." He ignorance about things and people, and also stated that repletion shortened a this was reflected in the literature of the man's life, and two meals a day should period (Haslam and Haslam, 2009). suffice, except for a labourer. By the time William Langland. In the 14th century of the publication of his book, he had allegory Piers Plowman, William Langland abandoned the priesthood, and was living (1332-1386 CE) has the sin of gluttony on Fleet Street in London, making a excite visceral horror (Levy-Navarro, handsome living as a jocular purveyor of 2008). health foods that were nicknamed "Merry Giovanni Boccaccio. The Decameron Andrew". offers 100 tales written by the Italian Thomas Moffett. The English novelist Giovanni Boccaccio (1313–1375 naturalist and Paracelsian physician CE). St. Thomas Aquinas (1225-1274 CE), Thomas Moffett (1553-1604 CE) wrote the a brilliant Italian theologian and popular book "Health's Improvement" Dominican friar, was reputed to have been (Moffett, James, and Oldys, 1746). In this colossally fat and hugely fond of his food; text, he noted that "to sleep and sit too perhaps for this reason, he wrote strongly much... of itself procureth fatness." "in a against gluttony. He may also have Man too much fatness is both a causes of provided the inspiration for Friar Rinaldo, diseases and a disease itself." one of the stereotypically fat clerical William Vaughan. William Vaughan characters in the Decameron. (1575-1641) a doctor of Civil Laws and an Giovanni de Medici. Giovanni de early promoter of settlement in Medici (1421-1463 CE), Cosimo de Newfoundland, first published his health Medici's libidinous, cultured and favourite education text ("Directions for Health, son was a typical child of the Renaissance. Naturall and Artificiall") in 1600 He cared for art, music and beautiful (Vaughan, 1607). He wrote: "They that views. However, he is also known for being observe a good diet, neede no artificiall grossly overweight. Physicke." "For how is it possible, that the Geoffrey Chaucer. The English story- smoaky vapours which breathe from a fat teller Geoffrey Chaucer (1343-1400) and full paunch, should not interpose a thick reiterated the advice of Hippocrates: mist of dullness between the body, and the ''Agonys glotonye, the remedie is body’s light!’ He criticized 17th century abstinence." However, he recognized that gourmandises, suggesting that health was for some of his contemporaries, being "full better before Noah's flood, when food was fat" was a status symbol. The church had much simpler. "They were ignorant of our relaxed some of its dietary restrictions delicate inventions and multiplied during the 14th century, and in the Monk's compounds. They knew not of our dainty tale, Chaucer highlights the obesity, the cates [delicacies], our marchpanes [fancy sweating faces, and the rich food and wine cakes], nor our superfluous flibber [flighty] that were being enjoyed by many of the sauces." clergy. "Steaming like a furnace, " the monk Literary criticism of the obese “stood in goodly case. His bulging during the Renaissance. Criticism of the eyes he rolled about, and hot. They gleamed fat and sedentary person was becoming and red, like fire beneath a pot...He was not increasingly prevalent in the fifteenth and as pale as some tormented ghost, a fat swan sixteenth centuries. Obesity had become loved he as best as any roast."

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Marguerite of Navarre. The huge baby, calling for ale immediately Heptaméron is a collection of 72 short after his birth, and drinking the milk of stories, written by Marguerite, Queen of 17,913 cows. As an adult, he had 18 chins Navarre (1492-1549 CE). One tells the tale (Figure 25), and when mocked by a crowd of a fat cleric, a Grey Friar. When he tried in Paris, he drowned many of them in a to run from the perceived danger of flood of urine. It looked as though the poor slaughter by a butcher "who... would think man might burst. "Why don't you swaddle no more of slaughtering him than if he were him round with good girths, or secure his an ox or any other beast." Listening to the natural tub with strong sorb apple tree conversation of his hosts, he heard the hoop? Nay, why don't you iron-bind him, if words: "I must rise betimes in the morning, need be? This would keep the man from sweetheart, and see after our Grey Friars. flying out and bursting." One of them is Martin Luther. As a young man, Luther Figure 24: The obese very fat and fought stubbornly against the temptations Grey Friar imploring the butcher to save his life, must be killed; of the flesh, and became haggard from from the Heptaméron. we will salt him studying and worrying about many Source: forthwith and supposed transgressions, but later he https://ebooks.adelaide.edu.au /m/marguerite_de_navarre/h make a good became quite obese. Catholics ridiculed eptameron/chapter35.html profit off him." Luther (1483-1556 CE), with images of An attempt to Bibles crushed under a stomach so huge jump from the that a wheelbarrow was needed for him to window led to a get around (Figure 26). Several days fall and before his death, Luther joked to his impeded his friends that he would shortly return to escape; the Wittenberg and "give the worms a fat butcher doctor to feast on" (Wright, 1864). discovered him William Shakespeare. Shakespeare hiding in a pig makes numerous references to obesity in sty, and the friar his plays. We may cite from the Merchant begged for his of Venice (Act 1, Sc. II): "They are as sick life (Figure that surfeit with too much as they are that 24). starve with nothing;" from the Comedy of Figure 25: Gragantua, Gargantua. Errors (Act 3. Scene 2): "How dost thou from François Rabelais. François mean a fat marriage? Marry, sir, she's the

Source: Rabelais (c. kitchen wench and all grease; and I know https://www.google.ca/imgres ?imgurl=https://images-na.ssl- 1483-1553 CE) not what use to put her to but to make a images- was the author lamp of her and run from her by her own amazon.com/images/I/81o27B XYIoL.jpg of the Life of light;" from Henry IV (Part 1, Act Ii, Scene 4: Gargantua and "There is a devil that haunts thee in the Pantagruel, a likeness of an old fat man, a tun of man is pentalogy of thy companion;" from Julius Caesar, Act I, satiric novels Scene 2: "Upon what meat doth this our (Rabelais, Caesar feed, That he is grown so great?" and 2005). from "As You Like it" (Act II, Scene 7): "then Gargantua was the justice, In fair round belly with good pictured as a capon lin'd."

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Historical Perspective on Obesity

healthy life-span. Little new was Figure 26: Cartoon of Martin discovered about the pathogenesis or Luther and wheelbarrow. Source: treatment of obesity, but some surgeons https://www.google.ca/search?q=Cartoon +of+Luther+and+wheelbarrow made heroic efforts to excise the excess fat. One Parisian surgeon reported excising 4.5 kg of fat from the abdomen of a woman in 1718 CE, with at least temporary relief of her obesity, but often such operations had fatal consequences. Edward Baynard. Edward Baynard (1641-1719 CE) practiced medicine in

London and in Bath. His "‘Health, a Poem. Shewing how to procure, preserve, and Conclusions. During the mediaeval period restore it. To which is annex'd The Doctor's and the Renaissance, both the church and Decade" (Baynard, 1719) contained much physicians spoke strongly against practical advice on dietary moderation, for gluttony, and much of the literature from example: "Fly all excess and first take care this era satirized those who were obese. of wine and women to beware." "A little Nevertheless, they did not themselves breakfast you may eat, but not so as to always heed these injunctions, and various satiate." "Accustom early in your youth to examples of extreme obesity can be found lay embargo on your mouth." among rulers and senior prelates. Tobias Venner. Tobias Venner (1577- 1660 CE)(Figure 27) was a medical The enlightenment practitioner who attended some of the By the 17th century, the tide of public socialites who were flocking to the thermal opinion had turned even more strongly springs and Pump Rooms in Bath. He against the obese. The physician Thomas himself lived to the age of 83 years. He Short wrote: “I believe no Age did ever subscribed to Galen's theory of the four afford more Instances of Corpulency than body humours but argued that these could our own” (Short, 1727). He argued strongly be thrown out of balance by six non- the need for exercise in the fight against natural factors (environment, diet, sleep, corpulency, but also had some bizarre exercise, excretion, and the passions of the ideas about environmental risk factors, mind). advising against living near "Marshes, fens, He was the first physician to use the ponds or stagnant waters" and warning word "obesity" in a medical context, and he against the dangers of flannel shirts; the called specifically for its treatment in his latter were "exceedingly injurious to weak Treatise, published in 1620. He underlined people" because they increased sweating. that obesity was a condition of the elite, Medical attitudes. Enlightenment and that it could be cured by the physicians in general continued to treat combination of an exercise regimen and a their patients within the constraints of the balanced diet with regular use of the classical Greek understanding of mineral waters of Bath (Venner, 1620): "to physiology, although many recognized make slender such bodies as are too grosse . that an adverse lifestyle could contribute . . let those that feare obesity, that is, would to obesity, and that its treatment was not wax grosse, be careful to come often to important in the quest for a long and our Baths: for by the use of them, according

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 28 Historical Perspective on Obesity as the learned Physician shall direct, they the Joints will stiffen, the Nerves will relax, may not only preserve their health, but also and on these Disorders, Chronical keep their bodies from being unseemly Distempers, and a crazy old Age must corpulent." ensue" (Cheyne, 1724). Thomas Sydenham. Thomas Personal experience had taught Cheyne Sydenham (1624-1689 CE) was a about the associated depression: "a disgust physician who practiced in the city of or disrelish of Worldly Amusements and Westminster. He wrote a textbook of Creature Comforts . . . tumultuous, medicine ("Observationes Medicae") which overbearing hurricanes in the mind" became a reference standard for two (Guerrini, 2000). Cheyne also suffered centuries. He acknowledged the from a skin disorder that he termed multifactorial nature of obesity, but also "skorubtick ulcers" – and linked his obesity recognized that its origins had a strong with a poor circulation; his blood had lifestyle component: He emphasized become "one impenetrable Mass of Glew’," "moderation in eating and drinking is to be with "every vein and artery like so many observed, so as on the one hand to avoid black puddings" (Haslam, 2007). taking in more aliment than the stomach The poet Alexander Pope (1688-1744 can conveniently digest, and of course CE) was one patient that Cheyne treated increasing the disease thereby, and on the for obesity during the 1730s, and Pope other hand defrauding the parts by was persuaded to follow a regimen of light immoderate abstinence" (Rush, 1809). wine, few suppers and much water. George Cheyne. George Cheyne James Mackenize. In 1758, the (1671–1743 CE)(Figure 28) was born in Scottish physician James Mackenzie Aberdeen, and became one of the leading wrote: "I determined to prevent [illness], by physicians of his day. He himself suffered acquainting those that will restrain their from gross obesity. A self-indulgent youth appetites, and hearken to reason, with the had left him "excessively fat, short-breath’d, most effectual rules to preserve health: For lethargick and listless," and despite some certain it is, that from men’s ignorance, or weight reduction during two periods of contempt of such rules, adherence to a milk and vegetable diet, he returned to meat-eating and regained the Figure 27: Tobias Venner Figure 28: George (1577-1660 CE), a physician lost pounds. Seeking to build up his Cheyne (1671-1743), a in Bath, was the first person physician who reached a medical practice, he was constantly to use the term obesity in a weight of 203 kg. Source: "Dineing and Supping in Taverns, and in the medical context. Source: https://en.wikipedia.org/wiki/ Houses of my Acquaintances of Taste and https://en.wikipedia.org/wiki/Tobia George_Cheyne_(physician) s_Venner Delicacy." The consequences were a peak weight of 32 stone (203 kg), taking refuge in the "poison of opiates," and finding a servant who walked behind him, carrying a stool on which he could recover his breath every few paces (Porter, 2005). Cheyne wrote of "The fat, unwieldy and overgrown," noting "tis easier to preserve Health than to recover it, and to prevent Diseases than to cure them . . . without due Labour and Exercise, the Juices will thicken,

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 29 Historical Perspective on Obesity thousands never arrive at that period of life distribution of body fat: "There is one kind which their strength of constitution would of obesity that centres round the belly; I have reached with proper care." have never noticed it in women: since they William Cullen. William Cullen (1710- are generally made up of softer tissues, no 1790) was a physician who later became part of their body is spared when obesity professor of chemistry in Edinburgh. He is attacks them. I call this type of fatness well known for his classification of Gastrophoria, and its victims Gastrophores. diseases. He termed obesity "polysarcia," I myself am in their company; but although from the Greek for much flesh, placing the I carry around with me a fairly prominent condition in his "Order II" of diseases stomach, I still have well-formed lower legs, ("Intumescentiae', or swellings"). Cullen and calves as sinewy as the muscles of an proposed treating obesity by creating a Arabian steed" (Brillat-Savarin, 1854). saline and acid state of the blood, although William Wadd. William Wadd (1776- Wadd (below) questioned whether such 1829 CE) was a British surgeon and an initiative might have "worse physician practicing in central London. He consequences than the corpulency it was unequivocally considered obesity as a intended to cure, and that no person should disease: "corpulency may be ranked hazard these while he may have recourse to amongst the diseases arising from original the more certain means of abstinence and imperfections in the functions of some of the exercise " (Wadd, 1816). organs, yet it must be admitted also, to be François Boissier de Sauvages. most intimately connected with our habits François Boissier de Sauvages (1706-1767 of life" (Wadd, 1816)(Figure 29). He wrote CE) was a physician and a botanist who scathingly of "some poor victim, too served as professor of physiology and ponderous to be brought down the pathology at the University of Montpellier, staircase." of a brewmaster who "became in southern France. He also developed a too big to pass up the brewhouse staircase," classification of diseases, listing polysarcia of Tunisian maidens fattened for marriage, (Young, 1813). of a girl who weighed eleven stones (69.5 John Armstrong. In 1744, the London- kg) by the age of eleven, and of a child who based physician and poet John Armstrong was so fat at (1709-1797 CE) wrote a lengthy poem the age of six Figure 29: One of the patients of William Wadd where he engagingly discussed "The Art of that the (1776-1829 CE). Source: Preserving Health." He stated: "Unless with public were https://www.google.ca/search?q= exercise and manly toil You brace your willing to pay William+Wadd nerves, and spur the lagging blood. The a shilling to fat’ning clime let all the sons of ease Avoid; view her... He if indolence would wish to live" (Armstrong, speculated 1744). He contributed material to James that some of Thomsen's the "Castle of Indolence." these people Jean Anthelme Brillat-Savarin. The might even Parisian author Anthelme Brillat-Savarin be at risk of (1755-1826 CE) wrote a notable book on spontaneous Gastronomy (Physiologie du goût; “The combustion. Physiology of Taste”). Although a lawyer Sometimes rather than a physician, Brillat-Savarin obesity also distinguished an android from a gynoid caused fatal

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 30 Historical Perspective on Obesity difficulties in breathing. Further, he made palliatives, such as opium, hyoscyamus, and valuable post-mortem observations on the hemlock." obese (below). Shadrach Ricketson. In 1806, the William Buchan In 1795, the Scottish Quaker physician Shadrach Ricketson physician William Buchan (1729-1805 CE) (1768-1839 CE) produced the first wrote the very successful "Domestic American book on hygiene and preventive medicine, or a treatise on the prevention medicine, entitled "Means of preserving and cure of disease," at the modest price of health and preventing diseases" (Ricketson, six shillings (Buchan, 1776). A total of 19 1806). This text emphasized the hidden editions were published. In this popular acquired diseases and eventual death that work, he stressed the link between healthy resulted from over-eating: "Let not the eating, body mass, and health. He warned drunkard, the epicure, or the voluptuary "such girls as lead an indolent life, and eat say, that because he feels no immediate bad great quantities of trash, are not only effects from his excesses, none are ever to subject to obstructions of the menses, but follow: he may be assured, that if he likewise glandular obstructions; as the persevere, weakness, disease, and, perhaps scrophula or king’s evil." For "women of a death, will, sooner or later, be the inevitable gross or full habit," "a spare thin diet" was consequence . . . Fullness of blood, and required, with only a small beer to enliven corpulency, are the disagreeable effects of it. gluttony, which progressively relaxes the Robert Thomas. Robert Thomas, an stomach, and punishes the offender with Enlightenment physician practicing in headache, fever, pain in the bowels, Salisbury, Wiltshire, wrote "The Modern diarrhoea, and other disorders." Practice of Physic" (Thomas, 1802). He Public attitudes and Enlightenment linked "paralysis" or stroke with a “full authors. The popular denunciation of plethoric habit." He commented: "It is corpulence was particularly marked in found to attack men much more frequently Enlightenment France (Gilman, 2017), than women, particularly those who have where there was a vigorous social critique short necks, who are inclinable to of those who were judged to be corpulency, and who at the same time lead “profiteering” for themselves and an inactive or sedentary life . . . he should “starving” others. This condemnation even endeavour to counteract any disposition to had a negative effect upon employment obesity, which has been considered a opportunities. Although examples of gross predisposing cause." Robert Thomas obesity were recorded, among the nobility, described the link between obesity and authors, actors and even physicians, its endometrial cancer; writing of menstrual prevalence seems to have remained discharges, he noted "When they happen to sufficiently low that the public was willing disappear suddenly in women of a full to spend substantial sums at fairgrounds plethoric habit, such persons should be in order to view individuals who were careful to confine themselves to a more excessively fat. spare diet than usual; they should likewise Francis Bacon. Sir Francis Bacon take regular exercise, and keep their body (1561-1626 CE), the Lord High Chancellor open by a use of some mild laxative . . . of England, recounts the visit of his father Should any scirrhous or cancerous affection Nicolas Bacon (the Lord Keeper) to his of the uterus take place...all that can be barber, with attendant sleepiness (Bacon, done in such a case is to have recourse to 1803). He "ordered a window before him to

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 31 Historical Perspective on Obesity be thrown open. As he was become very with a "mountain belly" and a plagiarist corpulent, he presently fell asleep in the (Dryden, 1709 ). current of fresh air, " Sir Francis developed William Congreve. The satirical a theory that strict moderation in diet was playwright William Congreve (1670-1729 necessary to keep "the vital spirits of a CE) is said to have been crippled by a person's intelligence aflame" (Sanders, combination of gout and obesity, to the 2010). point where he could no longer engage in de Vauban. The military engineer and stage management (Gosse, 1888). Marshal of France (Sebastian Le Prestre de Jonathan Swift. The satirist Jonathan Vauban, 1633-1707 CE) refused to give Swift (1667-1745 CE) wrote derogatively appointments to big eaters and fat people about the wordiness of a fellow author: (Vigarello, 2013). Such individuals were "after this you are presented with a foot- judged as incapable of good service and race of mountains and woods, where the not to be trusted with important affairs. woods distance the mountains, that, This criticism of the bourgeoisie persisted like corpulent pursy fellows, come puffing during the Restoration (1815–1830) and and panting a vast way behind them" the July Monarchy (1830–1848). (Macbeth, 1876 ). Queen Anne. The last of the Stuart Samuel Johnson. James Boswell monarchs, Queen Anne (1665-1714 CE) described a conversation between himself had 18 pregnancies between 1684 and and the writer Samuel Johnson (1709- 1700, with only one child surviving 1784 CE) on the subject of obesity: beyond infancy. The “ seventeen BOSWELL: “I don't know, Sir; you will see pregnancies – all resulting in miscarriages one man fat who eats moderately, and or young deaths – took a heavy toll” and her another lean who eats a great deal.” “anxieties grew in proportion to JOHNSON: “Nay, Sir, whatever may be the her corpulence" (Stubbs, 2017 ). From her quantity that a man eats, it is plain that if mid-thirties, Anne became so obese that he is too fat, he has eaten more than he she could walk only a short distance should have done” (Boswell, 1847). without help. David Hume. The Scottish Ben Jonson. The English actor and philosopher, historian and empiricist playwright Ben Jonson (1572-1637 CE) David Hume (1711-1776 CE)(Figure 30) was obese, and on one occasion he tried to was a favourite with duchesses and correct this by walking from London to countesses, but it is said that his Edinburgh (Sanders, 2010). corpulence and weakness for port and George Herbert. George Herbert cheese left him ridiculed by their swains (1593-1633 CE) was the Anglican priest of (Finch, 2018). His corpulence was already the small parish of Bemerton, in Wiltshire. evident in a portrait by Ramsay dating He translated Luigi Cornaro's "A treatise of from 1754, and Diderot also commented temperance and sobriety." advocating a on the roundness of his face in a letter from reduction of food consumption as the key 1769. to a long and happy life (Sanders, 2010). David Garrick. By mid-century, like John Dryden. In the mock heroic other London celebrities, the actor and satirical poem Mac Flecknoe, John Dryden theatre impressario David Garrick (1717- (1631-1700 CE) presented the British poet 1779 CE) was euphemistically using laureate Thomas Shadwell (1642-1692 Hogarth's "Line of Beauty" to describe his CE) as a dull poetaster, a corpulent man own corpulence (Goggin and Hassler-

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Forest, 2010). point, Byron ate only potatoes dipped in Niccolò Jommelli. The Italian musician vinegar, with some disastrously Niccolò Jommelli (1714-1774 CE)(Figure unpleasant side effects. He also tried 31) retired to his native Aversa, and is said programmes that involved obsessively to have spent there his weighing himself, of subsisting on biscuits "opulent corpulence" (Durant and Durant, and soda water, and of wearing heavy 2011). clothes to induce excess sweating. James Thomsen. The Scottish 18th Moreover, he advocated these dangerous century poet James Thomsen, author of the lifestyles to his wealthy friends. "Castle of Indolence" was a bulky man. Anatomical study of obesity. The Whether his bulkiness was the result of Restoration and enlightenment saw the indolence, or indolence resulted from first anatomical dissections of obese his corpulence, it matters not; but at any individuals by Bonet, Morgagni, Haller, rate it seems that Thomson was rather Wadd and Haller. lazy. Lyttleton described him as "more fat Théophile Bonet. Théophile Bonet than bard" (Hawick Archaeological (1620-1689 CE) (Figure 32), a Geneva- Society, 1863). based physician (Bonet and Manget, 1679) Lord Byron. George Gordon Byron described the post-mortem findings on (1788-1824 CE) called obesity "an oily obese individuals in his text dropsy." He himself seems to have been a "Sepulchretum, sive anatomia practica, ex weight cycler, with his body mass cadaveribus morbo denatis, proponens swinging between 60 and 89 kg over his historias omnium humani corporis adult life. Occasionally, he would eat huge affectuum" ("Practical anatomy from dead meals and then purge himself or engage in bodies relative to all conditions affecting violent bouts of exercise (Baron, 1997). In the human body")(Bonet and Manget, 1811, Byron bought a copy of Wadd's book 1679).This monograph included the on corpulence. accumulated findings from some 3000 Byron is famous for his promotion of a autopsies performed by Bonet and his vinegar diet (Bijlefeld and Zoumbaris, contemporaries, including Harvey's report 2014). Reports of his nutritional advice on Thomas Parr, a man who was alleged to range from “Drink some vinegar with have died at the age of 152 years meals” to “Drink some vinegar as your (Shephard, 2015). meal,” with associated claims about how Bonet's vinegar could help with weight loss. At one insights into the pathological Figure 30: David Hume Figure 31: Niccolò anatomy of many (1711-1776 CE). Source: Jommelli. (1714- clinical conditions https://www.google.ca/search? 1774 CE). Source: are widely q=David+Hume https://en.wikipedia.or g/wiki/Niccol%C3%B2 acknowledged to _Jommelli Figure 32: Théophile have laid the Bonet performed the groundwork for first post-mortems on studies by the the pathologically Italian pathological obese. Source: http://hardluckasthma.blo anatomist gspot.ca/2011/11/brief- Giambaptista history-of-copd.html Morgagni (below).

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Historical Perspective on Obesity

Giambaptista Battista Morgagni. In on corpulence: Lineaments of leanness" 1765, Giambaptista Battista Morgagni (Wadd, 1829), Wadd presented details on (1682-1771 CE) gave some extended case 12 cases of obesity; two had been descriptions of patients with severe examined at post-mortem, and their obesity. He recognized that the bodies were found to contain enormous accumulation of substantial amounts of fat accumulations of fat. On microscopic was linked to an increased risk of disease, examination: "The first striking and by anatomical dissection he appearance was the degree to which the demonstrated that the location of this fat cellular membrane was loaded with fat." In was a crucial issue. In his Epistola anatoma our present context, perhaps the most clinica XXI, he describes one female with interesting of Wadd's cases was a "Fat severe abdominal obesity ("virili aspectu" sportsman." This particular patient – a manly, distribution). "The limbs were claimed to have gone through great not lean, but they did not correspond in exertion every morning, but to have fatness with the extreme obesity of the rewarded this virtue by eating, drinking abdomen and thorax." "Her abdomen was and sleeping throughout the afternoon. prominent, and a large amount of fat had The morning's exertions waned as obesity accumulated. Her abdomen was prominent, began to impede his movements, and the and a large amount of fat had accumulated "sportsman's" weight at examination was in the intra-abdominal spaces and at the 121 kg. A country practitioner had mediastinal level, with a raised diaphragm" referred another case of gross obesity to (Morgagni, 1761). Wadd; with a height of only 1.52 m, but an Morgagni also commented on a initial body mass of 146 kg, this person had hardening of the arteries in the post- a BMI of 63.2 kg/m2. mortem examination of a severely obese Albrecht Haller. Albrecht Haller 1708- male. 1777 CE), the Swiss anatomist and William Wadd. William Wadd (1776- physiologist, is himself reported to have 1829 CE) was a British doctor practicing in suffered from obesity associated with London, who was appointed as Surgeon- bipolar disorder (Kretschmner, 1948); in extraordinary to King George IV. Wadd later life he became addicted to opium. He became celebrated for his Cursory provides further post-mortem Remarks on Corpulence or Obesity descriptions of obesity in his book Considered as a Disease (Figure 33) (Wadd, Elementa physiologiae corporis humani 1816), a publication that went to four (Physiological elements of the human editions. The text included a graphic body)(Haller, 1757). He linked obesity to description of one post-mortem gastric disorders: "Among the diseases examination: “The heart itself was a mass of which are discovered by frequent fat. The omentum was a thick fat apron. The dissections, I have found some very terrible whole of the intestinal canal was embedded ones of the stomach, of which I shall give a in fat, as if melted tallow had been poured concise account" (Haller, 1756), into the cavity of the abdomen...So great Studies in energy balance. The was the mechanical obstruction to the Venetian physiologist Santorio Santorio functions of an organ essential to life, that (1531-1636 CE) was an interesting if the wonder is, not that he should die, but somewhat eccentric character from the that he should live.” early part of this era. He added to our In a second book entitled "Comments understanding of metabolic balance by

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 34 Historical Perspective on Obesity constructing a weighing chair on which he Adolphe Quételet. Adolphe Quételet sat for much of the day, recording changes (1796-1874 CE) (Figure 35) was a Belgian in his body mass relative to his food intake statistician who founded and directed the and excretory losses (Figure 34). He noted Brussels observatory. In our present that for every eight pounds of food that he context, he developed the concept of the ate, only 3 pounds of waste were excreted, "average man" characterized by the mean with at least a part of the difference in the of height and weight values that follow a two weights being due to insensible statistically normal distribution, and he perspiration (Eknoyan, 1999). argued that the normal variation in Conclusions. By the end of the anthropometric characteristics provided Enlightenment, gross obesity was still one basis for the operation of natural sufficiently rare as to prove a fairground selection (Quetelet, 1835). attraction. At the same time, there was Quetelet suggested that a person's public disapproval, satire, and in some weight divided by the square of his or her cases denial of employment to those who height provided a were fat. Nevertheless, a growing number Figure 33: measure of fatness that of wealthy people, including physicians, Frontispiece to corrected for inter- authors and actors, showed substantial Wadd's book individual differences accumulations of body fat. Physicians still "Comments on in height. This corpulence: had a limited knowledge base, although Lineaments of measure, although their understanding of obesity was now leanness." now termed the Body helped by post-mortem studies of the Mass Index (BMI) in grossly obese. A growing number of complications were recognized, and Figure 34: Santorio moderation in diet and regular exercise Santorio (1531-1636 CE) remained the most common studied energy balance recommendations to affected individuals. by spending much of his time in a chair where he could weigh changes in The Victorian era body mass with ingestion Quantification of obesity. At the of food and excretion. Source: beginning of the Victorian era, there were Figure 35: Adolphe https://www.google.ca/search? many shady insurance companies, and Quételet (1796- q=Santorio+Santorio little understanding of weight for height 1874 CE) was a norms even by the more reliable concerns. Belgian statistician Charles Dickens featured an unscrupulous who developed early weight for height company (the "Anglo-Bengalee tables. Source: Disinterested Loan and Life Assurance https://en.wikipedia.org/ wiki/Adolphe_Quetelet Company" in his novel "The Life and Adventures of Martin Chuzzlewit." However, attempts to quantify an individual's excess weight in ways that were appropriate to clinical and pathological practice developed in Victorian times, with Adolphe Quételet, John Hutchinson, Cesare Lombroso, and

Louis Dublin leading in this research.

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North America, is still recognized as the William Banting. William Banting 'Quételet Index' (QI) in some European (1798- 1878 CE) was a notable British countries. undertaker of the period (Figure 36). He John Hutchinson John Hutchinson was initially very obese himself and knew (1811-1861 CE) is perhaps best known as of the breathlessness that this obesity inventor of the clinical spirometer. In caused. He also described associated joint 1836, he was appointed as physician to the pains, often described by his medical Britannia Life Assurance Society, and in contemporaries as "gout." The co- this role he developed a keen interest in morbidity of deafness led him to consult relationships between body mass and life the surgeon William Harvey, who expectancy (Spriggs, 1977). His published identified Banting's hearing loss as arising an early population survey of vital from the fat around his neck compressing capacity, height, and body mass, based on the airways. Banting became slim through a relatively representative sample of adherence to a low carbohydrate diet, as British society (Hutchinson, 1846). prescribed by Harvey, and he wrote the Cesare Lombroso. In Italy, the first commercially available diet criminologist Cesare Lombroso (1835- programme, a low "farinaceous" diet that 1909 CE) accumulated statistics on the was the forerunner to the Atkins diet height and body mass of a large sample of (Banting, 1964). An article in the London the Italian population ("Sulla statura degli Daily Telegraph recounts his story: "On the Italiani" 1873), and he used this data in his August morning that he began his diet, 26 attempt to substantiate the hypothesis years into the reign of Queen Victoria, the that prostitutes and other criminals were short and very fat William Banting heaved more obese than their honest peers himself out of bed at 8 a.m., hoisted a corset (below). around his bulging stomach and struggled Louis Dublin. Louis Dublin (1882– into his three-piece suit. Unable to reach his 1969 CE), a statistician and vice president laces, he gingerly eased his feet into his of the Metropolitan Life Insurance shoes with a boot-hook - taking care as he Company in New York, built on this earlier stooped not to stress the angry boils on his work to develop tables of normal weights, buttocks. As he negotiated the stairs in based on the average weight for a given reverse (a method, he found, that eased the height reported by American applicants crushing pressure on his knees), he was for life insurance (Eknoyan, 2008). looking forward to the cooked breakfast Medical attitudes. Efforts to provide awaiting in the dining room below - but appropriate clinical care for the fat person were intensified during the Victorian era, Figure 36: A case for William Banting. Source: https://www.google.ca/search?q=William+Banting often with recommendations to supplement exercise and dietary restrictions by physical constraints such as belts and corsets. Many doctors began to apply the new understanding of physiology to rational forms of treatment, although surprisingly the lead was taken by an undertaker named William Banting, who proposed what was essentially a forerunner of the Atkins diet.

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 36 Historical Perspective on Obesity dreading the effect it would have on his lose its power." "more can be done by ever-ballooning bulk. Twelve months later, diminishing the quantity of food than by any the 5ft 5in Mr Banting had shed more than other method." three stone, to be a slightly portly 11 stone" Wilhelm Ebstein. Wilhelm Ebstein (Edwardes, 2003). Finally, Banting (1836-1912 CE) discussed a rational believed that he had reached "the standard physiological basis for the treatment of natural at my age (10 stone 10 or 150 lbs), obesity in an address to the Lower Saxon as my weight now varies only to extent of Medical Association (Ebstein, 2015). He one lb, more or less, in the course of a month. was initially critical of Banting's ideas on According to Dr.Hutchinson's tables, I ought diet, suggesting that such a regimen led to to lose still more, but cannot do so without inanition, but he later became a strong resorting to medicine." supporter of the a high fat, low Banting’s name entered into the carbohydrate diet, contending that popular culture of his day, beloved of Mr albuminous and fatty matter checked the Punch, and even becoming the subject of a deposition of fat in the body. theatrical comedy and music hall songs Max Joseph Oertel. MaxJoseph Oertel (Haslam and Rigby, 2010). (1835-1897) was a physician who William Harvey. William Harvey was operated a sanatorium in Munich. He the Ear, Nose, and Throat surgeon who advocated a diet of lean beef, veal or advised Banting; he praises the Banting mutton and eggs in the treatment of method of weight reduction in his book: obesity. He was also a proponent of the "On corpulence in relation to disease with terrain cure (Oertel, 1886), arguing the some remarks on diet" (Harvey, 1872). need to strengthen the weakened Harvey regretted that people viewed muscular substance of the heart by a obesity as a curiosity, rather than as a limitation of the amount of fluid in food condition requiring treatment: and drink, and by graduated exercise for "Corpulence is an abnormal body condition the muscles. Spa trails were marked in that has been ... observed and described, numbers and colors on a scale of mainly as being a curious phenomenon; increasing difficulty, depending on their ...nobody had studied this constitution with length and slope. The 244-pound Prince the inconveniences, the accidents, the Otto von Bismark responded to this infirmities and the diseases which it regimen by the loss of 60 pounds over the produces or maintains." course of a year. Julian Watson Bradshaw. The English William Osler. Sir William Osler naval surgeon Julian Watson Bradshaw (1849-1919 CE)– the Canadian physician (1824-1907 CE) offered many insights into who became one of the four founding Victorian medical practice. In his pamphlet fathers of Johns Hopkins Hospital, saw "On Corpulence" (Bradshaw, 1864) he over-eating and a lack of exercise as wrote: "to carry a certain amount of flesh, dominant causes of obesity. In the 1882 as it is termed, is by many considered not monograph “Obesity and its Treatment” necessarily a standard of beauty, but an Osler wrote: “With few exceptions, persons indication of health. This is a grave mistake. over forty eat too much." He recommended Augmentation of fatty tissues leads to very treatment with a diet that was low in alarming results." "fat to an immoderate refined carbohydrate, and where meat and extent...is a disease." "the diaphragm cannot eggs predominated (Osler, 1892); he act with natural ease and the heart may insisted that fatty foods were crucial in

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 37 Historical Perspective on Obesity counteracting obesity, because they Figure 37: Advertisement for the increased feelings of satiety. slimming preparation "Figuroids" Harvey Cushing. Shortly before his from the Windsor magazine of 1908. retirement, the brain surgeon Harvey an illustrated magazine for men and Cushing (1869-1939 CE) developed an women. Note the progressive interest in the neuro-endocrinology of decrease in dimensions of the woman. obesity, with a particular focus upon Cushing' s syndrome (Bray, 1994). Quack Remedies. The prosperity of the Victorian middle class and growing opportunities for popular advertising allowed a wide range of unscrupulous quacks, commercial organizations, and even less well-informed doctors to offer an arsenal of quack remedies supposed to correct obesity and fortify the flesh. Many had catchy names, such as Figuroids, Gordon's Elegant Pills, Bile Beans, Corpulean, and Slim. As examples, we will comment briefly on several "slimming" pills, deliberate tapeworm infection, prolonged mastication of food, temperate food tartaric acid, sodium choices, magnetic and electroconvulsive hexamethylinetetramine, talc, and gum, therapy, hydrotherapy, spa treatment, none of which would have had any effect acupuncture, and homeopathy. Many of on obesity. the drugs that were marketed contained F.C. Russell's Cure. A self-published substantial quantities of laxatives and book by F.C. Russell, a London Chemist were relatively harmless although (Russell, 1894), made extravagant claims , ineffective. Others were quite dangerous supposedly based upon the reports of to health. Dinitrophenol raised body users, concerning the weight losses temperature and sometimes caused achieved by his regimen. This was said to blindness, and although thyroid extract include a "purely vegetable" treatment, increased metabolic rate, it could cause with no noxious drugs and no drastic heart problems. dietary restrictions. Figuroids. The advertisement for Dr. Grey's Fat Reducing Pills. A Figuroids (Figure 37) promises "If you are magazine advertisement from 1894 like the STOUT girl—you will become like offered Dr.Grey's fat-reducing pills. These the MEDIUM girl—and finally like the apparently contained a substantial DAINTY girl—by taking Figuroids." amount of sulphur (Corless, 2011), and Release of this advertisement in various were said to be an "Absolutely safe, magazines and newspapers coincided with permanent and rapid cure for obesity. A the 1908 introduction of the sheath dress special preparation for hunting men, (Rance, 2013). An analysis of the pills by jockeys, and stubborn cases (either sex) the British Medical Association found which have resisted other treatment. them to consist of bicarbonate of soda, Abdominal obesity a speciality...plain

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 38 Historical Perspective on Obesity wrapper, post free to any part of the world." mastication even extended to the ingestion Trilene Tablets. Trilene tablets of liquids, ensuring that they were well contained small amounts of seaweed and mixed with the saliva. In Fletcher's view, starch, but in order to appeal to those with food should ideally be chewed until it a sweet tooth their main constituent was disappeared entirely. Thus, he wrote: sugar (Corless, 2011). Quotes from “One-fifth of an ounce of the midway section satisfied customers included Mr. Gillespie of the young garden onion, sometimes of Forest Gate: "I have just lost 3 stone," and called ‘challot,’ has required 722 Mr. William Usher: "A sister of mine, who mastications before disappearing through was 17 stone, was greatly reduced by your involuntary swallowing” (Chrichton- Tablets to 15 stone." Browne, 1910). Fletcher claimed that with The Tapeworm Diet. The tapeworm such thorough chewing, a person could treatment involved ingesting a pill that subsist on half as much food. Some public contained a beef tapeworm egg (Figure institutions saw Fletcherism as a way of 38). Once hatched, the parasite grew in the reducing food consumption and thus of gut, consuming a part of whatever food the saving money. Like the Grahamites individual ate, and thus (in theory) it (below), Fleucher favoured a low protein brought about weight loss without the diet, and he saw mastication as a cure for patient worrying about the amount of food his own obesity (Wolin and Petrelli, 2009), that he or she was ingesting. The opera claiming that he could subsist on 45 g/day singer Maria Callas is one person reputed of food by using this approach. to have followed this regimen. However, it Temperate food choices. Sylvester is a dangerous approach to weight Graham (1794-1851 CE) was a reduction, with many potential Connecticut Presbyterian minister, health complications (Boese, 2006). reformer and temperance lecturer, best Prolonged mastication. Horace known for the "Graham Cracker." He Fletcher (1849-1919), nicknamed "the probably formed his ideas in close contact great masticator," was an American health with two other strong advocates of a food proponent. He argued that food must vegetarian diet: the divine William be chewed at least 100 times before Metcalfe (1788-1862 CE) and the swallowing; and composed special songs physician and educator William Alcott to accompany his chewing. The process of (1798-1859 CE). The group believed that a vegetarian diet would, in essence, restore Figure 38: Advertisement the idyll of the Garden of Eden (Graham, for a "sanitized" tapeworms. 1872). Graham condemned not only alcohol and beverages other than water, but also spices, condiments and meat, and also a sedentary life, as well as "unnatural things" such as "white" flour. As a fellow Grahamite, Alcott published a short satirical prayer (Wolin & Petrelli, 2009): “Give us this day our daily bread and cakes and pies besides, To load the stomach, pain the head, And choke the vital tides." Graham specifically condemned the

obesity of the Leicester jail-keeper Daniel Source: https://www.google.ca/search?q= William+Banting Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 39

Historical Perspective on Obesity

Lambert (1770-1809 CE), who finally Wesley ((1703-1794 CE). attained a weight of 355 kg (Figure 39): 'In There have been occasional attempts some rare instances... the body continues to to exploit exposure to strong magnetic grow in bulk till it becomes an enormous fields, but there is no conclusive evidence and shapeless mass, as in the case of Daniel that such exposure influences the course Lambert"..."all obesity or corpulence is a of obesity (Braschi, 2017). John Wesley form of disease, and denotes a want of used electroconvulsive therapy in an integrity in some functions of the system" attempt to treat various medical disorders (Graham, 1872). among his parishioners; however, they Graham gained fame when followers of were mostly physical labourers, and there his diet seemed to be spared during a is no mention of treating obesity by this cholera epidemic. However, this support means. Nevertheless, there has been some faltered when Graham himself died at the subsequent evidence that relatively young age of 57 years. electroconvulsive shock may help patients Nevertheless, his ideas were perpetuated where obesity was secondary to a by the Battle Creek corn-flakes depressed mood state (Moss and Vaidya, manufacturer William Keith Kellogg 2006 ). (1860-1951 CE) and his family. Acupuncture. The Chinese practice of acupuncture became popular in the Figure 39: Daniel Graham Western world during the 20th century, (1770-1809 CE, keeper of and it has found its advocates for the Leicester jail, who ultimately treatment of obesity. Postulated attained a weight of 335 kg. Source: mechanisms of action include a serotonin- https://en.wikipedia.org/wiki/Daniel_ induced enhancement of intestinal Lambert motility, a reduction of stress and depression via an increased secretion of endorphin and dopamine, and an endorphin-induced mobilization of body fat depots (Cabýoglu, Ergene, andTan, 2006). Sweat treatments. Daniel G. Brinton, author of "Personal Beauty" developed a treatment for the morbidly obese based on the popular 19th century belief that fat was “only water” and thus could be driven out of the system by perspiration (Brinton and Napheys, 1870). Electromagnetism and Miraculous bath powders. The makers electroconvulsive therapy. The of "Healthone-obesity Bath Powder" discoveries of Benjamin Franklin led to a claimed that a twice daily hot soak with vogue for the electrical treatment of a their perfumed sodium carbonate bath variety of disorders, including obesity, powder quickly washed away obesity. Among the exponents of Hydrotherapy and spa treatment. A electrotherapeutic fads we may include visit to a spa town such as Bath or Vichy James Graham (1745-1794 CE), Franz was a common practice for over-weight Anton Mesmer (1734-1815 CE) and John Victorians. This typically involved periods

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 40 Historical Perspective on Obesity of immersion in hot or cold springs, and were indulgent towards those who were the drinking of the mineral-rich water. overweight, and despised those who were Often, the spa provided sumptuous meals, very lean (Brinton and Napheys, 1870). which militated against any weight loss, Brinton wrote: a “scrawny bony figure” is but if facilities for strenuous exercise were “intolerable to gods and men." “The only also included, benefit was sometimes seen. lady who we ever heard derived advantage The warm spa waters themselves from such an appearance (leanness) was commonly increased metabolism a little, Madame Ida Pfeiffer. She relates that and there was a little evidence that this somewhere in her African travels the had a positive effect upon obesity (Hazim natives had a mind to kill and eat her, but et al., 2015; Mooventham and Nivethitha, she looked so unpalatably lean and tough 2014). Some authors have claimed that that the temptation was not strong enough, similar benefits can be obtained by and thus her life was saved.” wrapping a person in hot hay. An unidentified correspondent of the Homeopathy. The idea of homeopathy Washington Post described politician was introduced by Samuel Hahnemann Daniel Webster (1782-1852 CE) as "broad (1756-1843 CE) of Meissen, Germany. A in body as well as in mind," and noted that homeopathic hospital opened at Leipzig in former President Grover Cleveland and 1833, treating a variety of chronic Secretary William Taft both had ailments. Any benefits observed in obese "corpulence and brains" (Segrave, 2008). patients were probably due to "gravel Charles Dickens (1812-1870 CE) pathways and spaces...where the patients created one of the most well-known of might procure sufficient exercise and fresh obese characters, the fat boy in the air" (Shephard, 2015) "Pickwick Papers," a character who Public attitudes. In early Victorian consumed great quantities of food and was times, many people took an indulgent substantially affected by sleep apnoea, attitude towards those who were continually dozing off throughout the day somewhat overweight, and sometimes (Figure 40). But in the same book Tony they even despised those who very lean. Weller, the cockney father of Mr. Because chronic tuberculosis was widely Pickwick's man-servant opined present, plumpness was seen as evidence approvingly: "Vidth and Visdom go of good health. But perhaps in part as an together." expression of "muscular Christianity" Louisa Alcott (1833-1888 CE) (Shephard, 2015), during the latter part of apparently had no problem with the the Victorian era, many people became plumpness of young women. In “Little strident in their condemnation of the Women," Margaret, the eldest of the four obese; there was fierce satire, and some girls, was said to be "sixteen and very claimed associations between obesity and pretty, being plump and fair, with large a low level of intellect or a propensity for eyes, plenty of soft brown hair, a sweet prostitution and other types of criminal mouth, and white hands, of which she was activity. Nevertheless, plumpness rather vain. …" (Alcott, 1880) remained better tolerated among a Later disapproval of obesity. Later "Bohemian" coterie of authors and actors. during the nineteenth century, many Early tolerance of obesity. Health and people no longer saw plumpness as beauty authors such as the American synonymous with health and writer Daniel Brinton (1837-1899 CE) beauty. Indeed, they began to view excess

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 41 Historical Perspective on Obesity weight as a sign that a woman was the rights of others. The woman who makes inconsiderate, stupid, lazy, and—in some a god of her stomach is incorrigible, and I cases—even promiscuous or insane. The fear no word of mine will avail to induce her stereotype was reinforced by some to reform. She is the innately selfish woman overweight characters who were featured who makes her very existence an offense.” as dim-witted and lazy in popular plays At one point, Fletcher acknowledged that and novels. An 1893 edition of Charles “corpulency” was a disease. However, this Dickens’ weekly literary magazine "All the did not stop her from accusing obese Year Round" addressed this issue women of “indolence of mind” and (Dickens, 1893), with the brief categorizing overeaters as a lower order of commentary accompanied by an beast. advertisement for F.C. Russell's remedy Satirical comment on the obese is well for obesity (above). In a section headed exemplified by Victor Géruzez (1840-1906 "Home Notes," the magazine stated: CE) a French author and illustrator who “People have rather an erroneous idea, worked under the pseudonym of "Crafty"). probably gathered from Dickens’s Fat Boy His drawings mocked the pear-shaped in ‘Pickwick,’ that corpulent people have bellies of authority figures. An illustration none of the finer feelings and are of a in Paris à Cheval from 1884 (Géruzez, lethargic and dull comprehension. This is 1884) shows a heavy female rider being altogether a mistake, as many a poor lifted with difficulty into the saddle. The corpulent lady can tell you. When she helper has his hands full, literally, and the ascends a crowded omnibus on a hot caption reads, “One of the thousand reasons summer’s day every one of the indignant why women over fifty kilos should give up glances levelled at her by her more horseback riding” (Figure 41). Géruzez fortunate sisters are as so many little further argued that it was unreasonable to dagger thrusts of mortification, though her expect a 14-15 kg bicycle to support a ruddy complexion and defiant stentorian person who weighed more than 70 kg breathing may seem to belie the truth of these words.” Figure 40: The fat On the other hand, bitingly adverse boy from the Pickwick Papers. comments on the obese appeared in books Source: such as "The Body Beautiful" (Fletcher, https://www.google.ca/se arch?q=Fat+boy+from+Pic 1901). “All defects are in the nature of kwick ugliness, but certain ones are more degrading than others; and of these obesity, which is a deformity, is signally ignoble.” “Wherever the fat woman finds herself in a crowd—and where can she avoid it in the metropolis? —she is in effect an Figure 41: A intruder. For, she occupies twice the space mocking Parisian to which she is entitled, and inflicts upon her illustration by Crafty companions, through every one of her shows a heavy woman being helped excessive pounds, just so much additional onto her horse. Source: fatigue and discomfort. Too often, this so http://www.biodiversityli brary.org/bibliography/29 redundant flesh seems to serve as a bullet- 409#/summary proof armor, repelling all consciousness of

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(Vigarello, 2013). greater weight among prostitutes is Numerous Victorians looked for confirmed by the notorious fact of the abnormalities in the anthropometry of obesity of those who grow old in their vile prostitutes, including du Chatelet (1836), trade, and who gradually become positive Salsotto (1889) and Tarnowsky (1889), monsters of adipose tissue." He claimed often claiming a linkage between obesity that 59% of prostitutes were above and immoral living. du Chatelet (1836) average weight, and some reached values commented on prostitutes: it "strikes those in the range 90-130 kg. Taking his analysis who look at them en masse..." "this obesity a step further, Lombroso looked for only begins at the age of 25 to 30 years" "a similar traits among women committed to simple explanation lies in the great number insane asylums, writing: “In conclusion, I of hot baths to which these women are would remark that in prisons and asylums accustomed to take throughout the year, for the insane, the female lunatics are far and above all to their inactive lives and more often exaggeratedly fat than the men.” abundant nourishment." However, the data However, the actual data cited by supporting these ideas is suspect. Body Lombroso do not bear out his claims mass indices calculated from the height (Table 3). Calculating the body mass index and weight data of Salsotto (1889) yield for prostitutes and "moral women," the averages of 22.9 kg/m2 for prostitutes and respective averages are 22.3 and 22.1 23.8 k/m2 for "moral" women. Tarnowsky kg/m2. Moreover, only one woman in each commented further that although 19% of of the two categories is slightly prostitutes were below normal weight, overweight. Further, any search for they were also shorter than "moral" systematic differences in body mass would women (Tarnowsky, 1889). The forensic have been complicated by the large doses pathologist Cesare Lombroso was of mercury that many prostitutes of the particularly vociferous in his viewpoint Victorian period ingested as a prophylactic concerning the body build of miscreants. against venereal diseases. The book "The Female Offender" Probably in response to these theories, (Lombroso & Ferrero, 1895) compared the Guy de Maupassant (1850-1893 CE) published anthropometric data of entitled a prostitute in his first story about Fornasari for prostitutes and slimmer the Franco-Prussian war "Boule de Suif "moral" women, arguing that: “This "("Ball of Fat")(Maupassant, 2014).

Table 3: A comparison of heights and weights between prostitutes and "moral" women published by Cesare Lonroso (Lombroso & Ferrero, 1895).The body mass indices for the two categories of women have been calculated by the present author. Prostitutes "Moral" women Age (yr) Height (m) Weight (kg), Age (yr) Height (m) Weight (kg), BMI (kg/m2) BMI (kg/m2) 27 1.445 44.3 (21.2) 15 1.445 42.0 (20.1) 22 1.415 45.0 (22.4) 31 1.50 43.0 (19.1) 24 1.523 48.15 (20.8) 25 1.54 47.5 (20.0) 24 1.510 48.2 (21.1) 26 1.45 48.0 (22.8) 22 1.604 52 (20.2) 30 1.544 51.5 (21.6) 24 1.58 52 (20.8) 22 1.40 52.4 (26.7) 26 1.50 58 (25.8) 19 1.50 55.2 (24.5) 20 1.584 59 (23.5) 30 1.690 67 (23.5)

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The idea that obesity was incompatible jolly, wicked, intellectual, with no end of go" with intelligence and mental acuity also (James, 2008). became widespread in late Victorian Emile Zola (1840-1902 CE) is said to times. As the 1900 edition of the Dietetic have written best when he was very fat, and Hygienic Gazette reported: “Obesity and when his bulk diminished, so did his always carries with it physical and often talents. mental weakness, and is in excess always a The Russian novelist Ivan Turgenev disease…” (Keatinge, 1900) (1818-1883 CE) wrote of "strong men and The Bohemian contingent. In a book monsters of obesity...the deacon who ate no entitled "Modern Paris," originally less than thirty-three herrings for a published in 1923, Robert Sherard (2009) wager...Ezyedinov, renowned for his suggested a link between obesity and corpulence... a peasant woman who at her literary genius, listing Balzac, Dumas, death weighed half a ton and some Rossini, Victor Hugo, and Sainte Beuve pounds..." (Turgenev, 2013). among a long list of fat and jolly authors. Gioachino Rossini (1792-1868 CE) Honoré de Balzac (1799-1850 CE) was had a love of food shown not only by his particularly interested in the impact of ever-expanding waistline (Figure 42), but obesity upon gait, as can be seen in many also by the number of dishes that were of his books. In "The Vicar of Tours," he named after him. Other musicians also described the walk of an old maid: “…her were quite obese, including Handel, movements were not equally distributed Sibelius, and Stravinsky. over her whole person, as they are in other The American actress and singer women, producing those graceful Lillian Russell (1860-1922 CE) was one of undulations which are so attractive. She the reigning sex symbols of Victorian moved, so to speak, in a single block, se England, and her photos were prominent eming to advance at each step like the in many newspapers. By the turn of the statue of the Commendatore.” “While it is 20th century, her weight was reputed to be true that dignity, in the sense of majesty, in excess of 90 kg (Figure 43), but her requires a certain fullness of flesh, it is nonetheless impossible to claim this to be Figure 42: Rossini. true of a man walking, since his belly throws Source: the rest of his body off balance. Walking https://sites.psu.edu/mckenzie/20 16/05/25/composer-profile- ability disappears with obesity. An obese gioachino-rossini-2/ man finds himself forced to surrender to the ungainly movements imposed on him by his rotund belly… ” Alexandre Dumas (1802-1870 CE) seemed to blame his obesity on the heavens. He had Chicot complain in "Chicot the Jester": "Because the Lord in His anger has struck me with obesity, and I could not Figure 43: The Victorian pass where the others did." The physician actress Lillian Russell, and philosopher William James (1842- who attained a weight of over 90 kg. Source: 1910 CE) once described a female https://en.wikipedia.org/wiki acquaintance: "We found the old girl /Lillian_Russell#Later_years herself, a type for Alexandre Dumas, obese,

Health & Fitness Journal of Canada, ISSN 1920-6216, Vol. 10, No. 3 September 30, 2017 44 Historical Perspective on Obesity popularity continued, and she remained rulers and a few of their relatively busy writing articles on health and beauty. sedentary servants, but obesity has spread Conclusions. During the Victorian era, progressively throughout the various the quantification of obesity began, with strata of society, with this trend speeded the calculation of weight to height ratios, by emergence of a middle class boasting and physicians advocated increasingly leisure time, surplus income, and a desire rational treatments of fat accumulation. to demonstrate their good health and But at the same time, the public was prosperity through a large paunch. attracted to a multiplicity of widely The epidemic of obesity affecting all advertised but ineffective and sometimes social classes has been a new feature of the dangerous remedies. Early in Victorian late twentieth century (Deurenberg-Yap & times, many of the public saw plumpness Sediell, 2003; Flegal, Carroll, & as a manifestation of good health, but later Kuczmarski, 1998; World Health, 2014). opinion shifted to satirical and moral Various factors have probably contributed condemnation, with obesity linked to a low to this phenomenon (McAlister, level of intelligence and various Dhurandhar, & Keith, 2009); correlates manifestations of immoral behaviour, include an ever-decreasing need for including prostitution. Nevertheless, a physical activity in daily life (Brownson, tolerance of overweight persisted among Boehmer, & Luke, 2005; Church, Thomas, the Bohemian company of actors, authors & Tudor-Locke, 2011), a growing and musicians. limitation of opportunities for voluntary physical activity as mega-cities have Discussion grown in size and population density (Fan The answer to the question posed at et al., 2017; Lake & Townshend, 2006), and the beginning of this historical review deliberate attempts by some food seems that in fact there have always been manufacturers to encourage the over- at least a few obese individuals in settled eating of unhealthy pre-packaged food communities from the earliest points in (Ledikwe et al., 2005; Livingstone and the history of humankind. This suggests Pourshahldi, 2014). that the body's capacity to store nutrients It is interesting to speculate how far a in excess of immediate metabolic needs change in public attitudes may have been a may have been a factor in evolutionary further contributing factor. Obesity has selection (Kopelman, Caterson, and Dietz, apparently evolved from a condition that 2005; Prum, 2017). When facilities for in the Victorian era provoked public external food storage were limited, stores disapproval, satire, and even denial of of body fat could have offered a valuable employment, to become almost an protection against times of famine, and accepted feature of modern life in North provided the added energy needed to America. U.S. surveys by the consumer sustain pregnancy and lactation. research firm NPD found that over a 20- The prevalence of obesity seems to year period, the proportion of people have increased steadily over the millennia, finding overweight individuals as despite edicts of the church against unattractive dropped from 55% to 24% gluttony, health warnings from physicians, (Associated Press, 2006). In some public criticism, employment sanctions, countries, commercial airlines are now and biting satire. Initially, the problem of required by law to provide obese clients excess body weight was limited to the with a second seat at no additional charge.

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Many people fail to recognize that they are history. The growing prevalence of overweight and have only a limited excessive accumulations of body fat, and knowledge of the health risks that their public acceptance of this phenomenon excess body fat imposes. Moreover, seem new features of the late twentieth obesity is regarded as a problem for century. Potential causes include an ever- physicians and affected individuals rather decreasing necessity for physical activity than society as a whole (Curtice, 2016). In during daily life, limited opportunities for all, an excessive body mass is now active leisure in mega-cities, deliberate regarded as an unfortunate medical attempts by food manufacturers to condition for which the affected individual promote over-eating, and (particularly in bears no personal responsibility. the U.S.) a growing public acceptance of Admittedly, there are rare instances where obesity. some hormonal abnormality is Acknowledgements responsible for an excessive body weight, The author acknowledges no funding but for most people the causes are over- relationships or conflicts of interest. The eating and a lack of adequate habitual author acknowledges that all images were physical activity; sympathetic obtained via open sources within the medicalization rather than a challenge to public domain. greater self-discipline could well have played a role in encouraging the obesity Author's qualifications epidemic. The author's qualifications are as follows: Roy J. Shephard, C.M.; Ph.D., General Conclusions M.B.B.S., M.D. [Lond.], D.P.E. L.L.D., D.Sc., With the probable exception of hunter- FACSM, FFIMS. gatherer communities, there is evidence that at least a few obese individuals were References living in most settled communities from Abdel-Halim, R.E. (2005 ). Obesity: 1000 years ago. early in the story of humankind. This brief Lancet 366 (9481), 204 (letter). Africa, T. (1961). Phyllarchus and the Spartan historical survey points towards a growing Revolution. University of California prevalence of obesity as an economic Publications in History, Vol. 68-69. Berkeley, surplus allowed emergence of a ruling CA: University of California Press, pp.1-92. class with no imperative to engage in Alcott, L.M. (1880). Little Women: Or, Meg, Jo, Beth vigorous physical activity, a body of and Amy, Volume 1. Boston, MA: Roberts Brothers, pp. 1-341. artisans who engaged in sedentary work Allam, A.,Thompson, R.C., Wann, S., Miyamoto, M.T., to manufacture the luxury trinkets and Thomas, G.S. (2009). Computed demanded by high society, and the growth tomographic assessment of atherosclerosis of a middle class with the means to in Egyptian mummies. JAMA. purchase food in excess of their immediate 302(19), 2091-2094. https://doi.org/10.1001/jama.2009.1641 survival needs. Almost all of the available Allardyce, C.S. (2015). Fat chemistry: The science evidence points to causation by a level of behind obesity. Cambridge, U.K.: RSC habitual physical activity that is Publishing, pp.1-330. inadequate to match the individual's food Alphen, J.A., and Aris, A. (1997). Oriental medicine: intake. Moreover, the adoption of regular An illustrated guide to the Asian arts of healing. London, U.K.: Serindia Publications, vigorous exercise and a moderation of diet pp 1-272. have been recognized as effective Aretaeus. (2010). De causis et signis acutorum remedies for obesity throughout most of morborum (lib. 2)

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