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William Howard Taft was America’s heaviest president. He would have preferred being seen and remembered for something else, and took steps to lose weight. Taft’s story of weight loss and regain, described in today’s Annals of Internal Medicine, sounds completely familiar today, more than 100 years later.

Using correspondence and archival sources, Deborah Levine, an assistant professor at Providence College in Rhode Island, tells the story of Taft’s struggles with his weight.

In 1905, while serving as Secretary of War, Taft weighed 314 pounds. That’s a body-mass index of 40, which today would indicate someone who is severely obese. He knew his weight wasn’t healthy, causing an “acid stomach,” shortness of breath, problems sleeping, and daytime fatigue. A recommendation from his sister led Taft to Nathaniel Yorke-Davies, a British physician specializing in the medical management of obesity. It was an unusual move, since there were several highly popular diet gurus in the United States at the time, including John Harvey Kellogg.

At the time, Yorke-Davies was sounding an alarm about the dangers of obesity. He identified it as a cause of lung and heart problems, and premature death. One of his books, Foods for the Fat: A Treatise on Corpulency and a Dietary for its Cure, became quite popular.

The “treatment” was conducted by mail. Yorke-Davies sent Taft letters of advice, customized eating plans, and lists of permitted and prohibited foods. The diet Yorke-prescribed specified lean meats, a little fish, vegetables, plain salad, avoidance of sugar, and minimal carbohydrates. Taft sent back progress reports, including daily weights.

At first, things went well. Taft lost 59 pounds between the beginning of December 1905 and April 1906. Taft was proud of his progress but seemed aware that it would be long struggle. According to one letter reviewed by Deborah Levine, Taft wrote his brother that “Everybody says I am looking very well, which indicates I suppose that I have a good color … but I am pretty continuously hungry.”

The success didn’t last. Three years later, when Taft was inaugurated as the nation’s 27th President, he tipped the scales at 354 pounds (a BMI of 45).

Despite his obesity, President Taft lived to age 73. By comparison, the average man born the same year as Taft (1857) was less than 45 years.
Lessons from losers

I suspect that President Taft had what we now call metabolically healthy obesity. People with this form of obesity don’t type 2 diabetes and have no greater risk of heart and blood vessel disease than people who aren’t obese.

His story and struggle with weight are much the same as the stories I hear from my patients today. They decide to lose weight, and find a diet that feels right. There’s an initial period of weight loss. But at some point, the pounds become harder and harder to shed. That’s often followed by a period of weight gain. Many people end up heavier than they were before dieting.

It’s a frustrating cycle that makes some people give up trying.

But it is possible to lose weight and keep it off. Since 1994, the National Weight Control Registry has been gathering information from more than 10,000 men and women who have lost weight and kept it off for years. One thing Registry researchers have learned is that everyone is different, and there’s no single sure-fire road to weight loss. But here are a few of the things they ‘ve learned from participants:

    45% lost weight on their own and 55% lost weight with the help of some type of program
    98% report that they modified their food intake in some way to lose weight
    94% increased their physical activity
    78% eat breakfast every day
    75% weigh themselves at least once a week
    62% watch less than 10 hours of TV per week
    90% exercise, on average, about 1 hour per day

To these sensible changes, I’d add one more

    Get enough sleep but not too much. People who sleep too little (less than six hours a day) or too much (more than nine hours a day) are more likely to gain weight.

One thing that has changed between 1909 and today is the number of Americans who are obese. During Taft’s time, obesity was relatively uncommon. Today, 36% of Americans are obese, including an alarming number of children. To reverse this unhealthy trend, we as a nation need to choose healthier diets and get more physical activity. And this should start in early childhood. Men worry about erectile dysfunction after radical prostatectomy, the operation that involves removing the prostate gland as a way to treat prostate cancer. It’s a legitimate concern. Men, their spouses and partners, and their surgeons should talk about erectile dysfunction before and after the surgery. Almost all men will experience erectile dysfunction for several months to a year after a radical prostatectomy, although today’s nerve-sparing operation has decreased the number of cases when it’s permanent.

But orgasm after radical prostatectomy? It’s often even not on the radar screen. Dr. Ravi Kacker thinks that should change.

“Sometimes orgasm gets forgotten because everyone is so focused on erectile dysfunction,” says Dr. Kacker, a urologist and fellow in male sexual medicine at Harvard-affiliated BethIsraelDeaconessMedical Center. “But for some—maybe most—men and their partners, achieving orgasm can be as important as erections—or even more so —for having a healthy sex life.”

And, says Dr. Kacker, there’s good news. “Orgasms after radical prostatectomy may feel qualitatively different for most men, but they don’t need to be any less pleasurable or satisfying.”
The three parts of male orgasm

Kacker starts by pointing out a common misconception that erections are necessary for male orgasm. They aren’t. Men can have experience orgasm without an erection. The converse is also true, of course: men can have an erection without having an orgasm.

When discussing orgasm and radical prostatectomy, it’s useful to think of the male orgasm as having three separate parts, says Dr. Kacker.

First, secretions from the testicles, the prostate, and the seminal vesicles—small, slender glands near the prostate—flow into the urethra, the tube-like structure that carries semen through the penis and out the body. The emission of those fluids creates a feeling of fullness and a sensation of inevitability.

Second, there’s ejaculation, which is accompanied by contractions of the pelvic floor muscles, the group of muscles used to hold in intestinal gas and urine.

And third is the mental component—all of the processing the brain does of incoming sensory signals from penis and pelvis that contribute to the mental experience of “build up and release.”
How radical prostatectomy affects orgasm

The first two parts of orgasm are affected by radical prostatectomy, explains Dr. Kacker. Removal of the seminal vesicles and prostate gland during the operation means no fluid can come in from the testicles or the prostate. With the gland or the vesicles gone, there’s no fluid buildup in the urethra and the sense of fullness and inevitability, which may have been a familiar part of your orgasm prior to surgery, is now missing.

And there’s no ejaculate after radical prostatectomy. Some men also report that the operation affects their pelvic floor and its contractions.

But the third part of orgasm occurs in the brain and can be just as intense as before surgery.
Steps men can take to improve or recover orgasms

This doesn’t mean that some men don’t have difficulty experiencing orgasm after radical prostatectomy. The missing sensation of fullness and the lack of ejaculate are big changes. But there are some things you can do to correct the problem, according to Dr. Kacker.

Men can achieve an orgasm on their own with manual stimulation or with a partner through manual or oral stimulation. Just remember that an erection is not needed. Using a vibrator on the head of penis is often helpful. Vibration can stimulate the nerves in the penis and increase the signals being sent to the brain.
Hormone adjustments can help with orgasm

Sometimes hormone levels contribute to orgasmic problem. Many men with low testosterone have problems with orgasm, but treating prostate cancer patients with testosterone is still very controversial. Other hormones can also play a role. For example, a low thyroid hormone level or a high prolactin level can make it more difficult to reach orgasm. Even if you have a normal hormone levels, there are a few hormonal medications that may be able to help.

Another hormone that plays a role in orgasm is oxytocin. (Don’t confuse it with OxyContin, the narcotic pain reliever.) The level of oxytocin increases in both men and women during sexual arousal. Taking an under-the-tongue (sublingual) formulation of oxytocin five to 10 minutes before sexual activity can help some men achieve orgasm. It’s safe and no side effects have been reported, says Dr. Kacker. You need a prescription for oxytocin, and it’s available only through special compounding pharmacies, not through retail pharmacies.

Cabergoline is another medication that can help with orgasm problems. It blocks the release of prolactin, a hormone that appears to play an important role in the refractory period after orgasm when men can’t have another orgasm for a while.
Cut back or change antidepressants

Another thing to think about is any other medications you’re taking, notes Dr. Kacker. Many men are, unknowingly, taking medications that suppress orgasm. By far the number one offender is the SSRI class of antidepressants, which include fluoxetine (Prozac) and Paxil (paroxetine). By reducing the dose of these drugs or eliminating them entirely, or switching to a non-SSRI like bupropion (Wellbutrin), many men see an improvement in their ability to orgasm.
Talking about orgasm problems is important

Men and their partners have become much more open about talking erectile dysfunction, in general and as a consequence of prostate cancer treatment, notes Dr. Kacker.

Whatever you think about all those ads for Viagra and Cialis, they have made it easier to talk about ED and helped remove some of the stigma around the condition.

“We should be having the same frank, open discussions about orgasm,” says Dr. Kacker. “Orgasms can bring a couple together and allow them to maintain sexual intimacy in the difficult period around diagnosis and treatment of prostate cancer.” I’m always amazed to see just how many problems a slowdown in the output of the thyroid gland can cause: extreme fatigue, intolerance to cold, weight gain, dry skin, and dry hair, to name a few. Millions of Americans have an underactive thyroid, a condition known as hypothyroidism. That means this butterfly-shaped gland doesn’t produce enough thyroid hormone to regulate metabolism, causing many body functions to become sluggish. The resulting symptoms are no picnic, but they’re usually ones that can be controlled with a daily dose of synthetic thyroid hormone called levothyroxine (generic, Synthroid, Tirosint, others).

Who actually benefits from taking levothyroxine is being called into question. New evidence suggests that many people may be taking this medication unnecessarily, to the point of overtreatment. In a study published a couple years ago in JAMA Internal Medicine, researchers in the United Kingdom determined that levothyroxine is widely prescribed for people with borderline hypothyroidism, and often without much benefit. The researchers point out that the overtreatment may be due to inadequate monitoring of thyroid hormone levels, as well as physicians prescribing the drug to treat symptoms that aren’t actually due to hypothyroidism.

Endocrinologist Dr. Jeffrey Garber, an associate professor of medicine at Harvard Medical School, agrees with the findings. He’s an internationally respected authority on thyroid disease, and author of The Harvard Medical School Guide to Overcoming Thyroid Problems. He says a number of factors may be contributing to the increase in treatment of mild hypothyroidism. “Greater patient and physician attention to thyroid status may be prompting more testing and leading to more diagnoses,” he says. Plus, he points out, the threshold of what’s considered a normal thyroid range was lowered in 2002, and that lower number is what labs use today when they look at thyroid hormones in the blood.

Maybe that’s why prescriptions of levothyroxine increased in the U.S. from about 50 million in 2006 to about 70 million in 2010. Researchers found a similar increase in England and Wales, with prescriptions jumping from 17 million in 2006 to 23 million in 2010.

What’s wrong with giving people who have a borderline underactive thyroid a little something to make them feel better? Well, it’s a pretty risky business. They run the risk of experiencing side effects from taking levothyroxine, which include irregular heart rhythms, insomnia, and loss of bone density, without reaping any benefit from it.

Dr. Garber is hoping that clinical practice guidelines will make a difference in diagnosis. The guidelines come from a task force representing the American Thyroid Association and the American Association of Clinical Endocrinologists.

There are many nuances to the guidelines, but here are two of the most important recommendations for diagnosis that warrants treatment:

Best test. The best way to check for hypothyroidism is to look at the level of thyroid stimulating hormone (TSH) in the blood. That’s the hormone the pituitary gland sends out to tell the thyroid how much thyroid hormone to release. If the thyroid is underactive, the pituitary gland will tell the thyroid to work harder, and it does that by sending out more TSH. So the higher the TSH level, the lower the thyroid activity. A normal TSH value is under 4.0 milli-international units per liter (mIU/L). When the TSH level is above 10 mIU/L, there’s uniform agreement that treatment with levothyroxine is appropriate.

Borderline results. If the TSH level is between 4mIU/L and 10mIU/L, treatment may still be warranted in various situations:

    if the levels of actual thyroid hormones in the blood—known as thyroxine (T4) and triiodothyronine (T3)—are abnormal
    if the bloodstream contains anti-thyroid antibodies that attack the thyroid. These antibodies would indicate a hypothyroid condition called Hashimoto’s disease, in which the immune system mistakenly attacks the thyroid.
    if there is evidence of heart disease or risk for it.

What should you do if you have borderline low thyroid levels that cause uncomfortable symptoms but don’t meet the guidelines for treatment? “Use thyroid hormone for a brief period of time,” recommends Dr. Gerber. “If you feel better, you can continue with treatment. If not, then stop.”

All treatment for hypothyroidism, even borderline cases, must be individualized and monitored carefully by a physician. That requires measuring TSH four to eight weeks after starting treatment or changing a dose, another TSH test after six months, then every 12 months.


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