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Good results were obtained treating 49 obese patients with an elaborated selfcontrol behavior modification program. This program was an addition to the normal program of the obesity clinic of the 2. Medizinische Klinik der Universität Düsseldorf. The normal program contains some principles of behavior modification but less accentuated. After the initial 12 weeks of controlled training patients tried to reduce weight further decreasing external control. Only few patients were able to loose additional pounds during this period of 8 weeks. At the end of the initial 12 weeks patients had asked for another control before the vacational season, but only 10 out of 49 appeared at the control sessions 9 months after the program's start. If an additional behavior modification program is considered for incorporation into an already existing weight reduction clinic, additional costs and expected results have to be checked. Durative success of behavior modification techniques in weight loss programs has still to be submitted to proof.

The classification of obesity into a hypertrophic and a hyperplastic type is apparently becoming less accepted since preadipocytes are not covered by investigation of adipose tissue cellularity. Obesity-associated insulin resistance is probably due to a decrease in number of insulin receptors, induced by hyperinsulinemia. Metabolic factors may contribute to insulin resistance. Long-standing hypersecretion of insulin may exhaust the B-cell, resulting in glucose intolerance and diabetes. There is increasing interest in the (possibly) disturbed energy metabolism in obesity, though clearcut conclusions are not yet possible. For the management of obesity an integrated treatment schedule is recommended including a 1000 calorie mixed diet, intensive nutritional education, motivation, group and individual psychotherapy, physical exercise and physiotherapy. Drastic methods for the treatment of obesity are critically reviewed.

Epidemiological studies on the relationship of obesity, morbidity and mortality revealed the following results: In life insurance studies, excess mortality of obese people was found with more than 30 percent overweight. Mortality was caused by cardiovascular disease and diabetes mellitus. Obesity at issue of the policy in younger age was a greater risk than in the older age group. In prospective studies with long follow-up periods (greater than 16 years) it could be shown that obesity alone was a risk factor for coronary heart disease, the risk being greatest for men and middle aged women. However, the prevalence of accepted risk factors in an obese population is so high that the question whether obesity alone is a risk factor for coronary heart disease is of little interest. The correlations between obesity and risk factors were of minor magnitude; therefore other factors, such as age or HDL-cholesterol, should be considered in the elucidation of the relationship between obesity and coronary heart disease. HDL-cholesterol appears to be a powerful independent protective factor which is diminished in obesity. Despite the fact that studies proving a prolongation of life by treating obesity are not available, the treatment of obesity may be beneficial for the patient by diminishing risk factors.

Plasma glucagon levels were measured in 129 grossly obese patients with 77 +/- 29% excess weight according to Broca. A significantly raised basal glucagon level (179 +/- 7 pg/ml) was found when compared with normal weight controls (109 +/- 7 pg/ml). Weight reduction of 9.1 +/- 3.8 kg with reduction of glucose-stimulated hyperinsulinaemia from 97 +/- 12 microU/ml to 62 +/- 6 microU/ml had no influence on hyperglucagonaemia. A subgroup of obese patients with hypertriglyceridaemia (270 +/- 24 mg/dl) and glucose intolerance had particularly high plasma glucagon levels (198 +/- 12 pg/ml). It seems that these patients have a resistance to glucagon in addition to a marked insulin resistance.

The MMPI was administered to 209 obese women and 72 obese men before onset of a weight reduction regime. Obese subjects differ in a variety of MMPI-standard-scales from the standard population as well as from a control group of healthy women: 1. Scales Hypochondriasis (Hs) and Hysteria (Hy) have significant higher values for the obese. This somatic impairment grows in the group of obese women with increasing age and obesity. In men, scale Hs corresponds to the degree of overweight but the youngest male age group (up to 19 years) has a Hs-peak as well as men above 35 years of age. 2. Higher than normal values for obese men and women in scales Depression (D) and Psychasthenia (Pt) in the obese point towards emotional upset. 3. Obesity does not decrease Hypomania (Ma) values for men or women; to the contrary: obese men felt more active than the standard population. With growing age women had a decrease in Ma-values.

In 1332 patients with different degrees of obesity (344 men, mean age 36 +/- 13 years, Broca Index 1.46 +/- 0.23; 988 women, mean age 37 +/- 13 years, Broca Index 1.67 +/- 0.30), cardiovascular risk factors (RF), serum HDL-cholesterol, and insulin levels were investigated. The most frequent RF was diastolic hypertension (68 per cent), followed by systolic hypertension (56 per cent), glucose intolerance (55 per cent), hypertriglyceridemia (31 per cent), hyperuricemia (19 per cent) and hypercholesterolemia (18 per cent). Only 9.4 per cent of the patients were without RF, and these patients were younger and less obese than patients with RF. Compared with controls, HDL-cholesterol levels were decreased in obese patients, however, the negative linear correlation between relative body weight and HDL-cholesterol levels was only significant in women, not in men. HDL-cholesterol levels were higher in women than in men. Serum insulin levels were correlated positively with relative body weight and negatively with age. Partial correlation analysis revealed a stronger influence of age than body weight on blood pressure, serum levels of total cholesterol, LDL-cholesterol, triglycerides and blood glucose levels. Uric acid levels correlated positively, and HDL-cholesterol levels negatively with relative body weight alone and not with age. On the basis of prevalence of RF, low serum HDL-cholesterol and high insulin levels, obese patients must be considered at high risk with respect to the development of cardiovascular disease.

Analysis of 31 686 patient records for obesity among hospitalised patients in the Second Medical Clinic of Düsseldorf University between 1952 and 1972 demonstrated a steep rise to a plateau of 24 +/- 2% in 1956-1972. Adding a corresponding analysis from the Bonn Medical University Clinic some 66 000 hospitalised patients could be included for a period of 40 years. Socio-economic conditions in the war and post-war period produced a marked fall in obesity to a minimum of 2% in 1946. The mean incidence before 1935 was 10%, by 1958 it had increased two-and-a-half fold. It is thought that this had been due not to a corresponding higher calorie intake by the population but rather a general reduction in physical activity. The increase in obesity among the population, reflected in these hospital statistics, is likely to lead to a parallel increase in cardiovascular risk factors and with it the ever-rising curve of death from cardiovascular disease in the Federal Republic of Germany.

Because of conflicting reports on plasma levels of total immunoreactive glucagon (IRG) in obesity, we investigated, by gel filtration, the individual IRG fractions in grossly obese patients (N = 16; BMI 40 +/- 2) as compared with normal weight subjects (N = 18). Mean total IRG was 142 +/- 12 pg/ml in normal subjects and 190 +/- 15 pg/ml (P less than 0.02) in obese subjects. IRG3500 was 16 +/- 2 pg/ml in normal subjects and 34 +/- 5 pg/ml (P less than 0.005) in the obese subjects. Obese patients with normal glucose tolerance demonstrated 30 +/- 5 pg/ml IRG3500 (N = 11; P less than 0.01) as compared with those who were obese with impaired glucose tolerance (42 +/- 12 pg/ml, N = 5; P less than 0.0025), although the total IRG of the latter group (173 +/- 31 pg/ml) was not different from that of normal subjects. IRG90000 was of comparable magnitude in the entire groups of obese and normal subjects. A wide variability of big plasma glucagon levels was found in all three groups, mean levels not being significantly different. These data suggest that plasma IRG3500 levels are elevated in grossly obese patients, particularly in those patients with impaired glucose tolerance, a finding that may be masked by mere measurements of total plasma IRG.

In 500 obese patients (146 men, mean age 37 +/- 13 years, Broca index 147 +/- 24; 354 women, mean age 36 +/- 14 years, Broca index 151 +/- 28) cardiovascular risk factors (RF) were investigated. The most frequent RF was hypertension (71 per cent), followed by glucose intolerance (49 per cent), hypertriglyceridemia (31 per cent), hypercholesterolemia (22 per cent) and hyperuricemia (22 per cent). Only 12 per cent of the patients were without RF. These patients were younger and less obese than the patients with RF. The prevalence of RF increased with increasing age and overweight. Analysis revealed significant correlations between overweight and blood pressure, blood glucose, insulin and age. Significant correlations between age and hypertension, blood glucose cholesterol, triglycerides and overweight were detected. The correlation between overweight and the sum of all RF was higher (r = 0.35) than the one between age and the sum of all (r = 0.23). Obese patients had a high prevalence of RF. Increasing overweight and (to a lesser extent) age are both associated with increased prevalence of RF. On the basis of the prevalence of RF, patients with gross obesity (Broca index greater than around 150) were considered to be at a high risk in respect of coronary heart disease.

The long-term results of total fasting during hospitalisation were evaluated an average of 21 months after the end of the hospital stay in 42 patients treated for obesity between 1971 and 1975. Further weight reduction occurred in 14, while the remainder had regained some weight. Nine of the latter had, in fact, surpassed their prehospitalisation weight. Neither age not sex, social status, time interval since fasting had any influence on the long-term results of total fasting. It is concluded that, in view of the poor correlation between cost and long-term result of such total-fasting regimen, it should be undertaken in this form only exceptionally.