Download The Disease That Caused Weight Loss in King David the Great

Journal of Gerontology: MEDICAL SCIENCES
2004, Vol. 59A, No. 2, 143–145
Copyright 2004 by The Gerontological Society of America
Special Article
The Disease That Caused Weight Loss in
King David the Great
Liubov (Louba) Ben-Noun
Department of Family Medicine, Faculty for Health Sciences, Soroka University Medical Center,
Ben-Gurion University of the Negev, Israel.
Background. Older people have suffered from loss of weight since the dawn of history. This research is unique in
character, as it combines contemporary medical knowledge with the presentation of a case taken from Ancient History.
Objective. To analyze from a modern perspective the biblical description of a geriatric patient who suffered from
weight loss.
Methods. Biblical texts associated with the aged were examined and passages relating to geriatric patients who suffered
from loss of weight were closely studied. This study is based on the evaluation of the biblical passages, and not on the
interpretations of various rabbis and scholars.
Results. Passages such as: ‘‘. . . I forget to eat my bread’’ and ‘‘My knees are weak through fasting; and my flesh failed
of fatness’’ and ‘‘. . . my bones cleave to my skin’’ indicate anorexia, fasting, extreme loss of weight, and subsequent
cachexia. Among the numerous causes associated with weight loss, malignancy, social problems such as loneliness, social
isolation and neglect by others, and psychological causes including depressed mood were most likely responsible. With
regard to malignancy, it seems that the King was affected by primary carcinoma of the prostate or kidney with subsequent
metastases to bones.
Conclusion. This report demonstrates that the roots of geriatric medicine can be traced to biblical times.
‘‘My knees are weak through fasting, . . . my flesh
failed of fatness, . . . my bones cleave to my skin.’’
(Psalm, Bible)
E
LDERLY patients have suffered from decrease in
weight that may be associated with various diseases for
thousand of years. By studying the causes of weight loss in
geriatric persons from ancient history, modern physicians
can expand their knowledge thereby improving their
professional skills. Who suffered from loss of weight in
biblical times? What is the most likely diagnosis? What are
the characteristics of the diseases that caused weight loss?
This article aims to answer these questions by evaluating
weight loss in a geriatric patient as described in the Bible.
WEIGHT LOSS AS DESCRIBED IN THE BIBLE
King David, the second and greatest of Israel’s Kings
who ruled that country 3526 years ago, suffered from an
eating disorder. A passage in Psalm CII: 4 ‘‘. . . I [the King]
forget to eat my bread’’ tells us about lack of food intake.
This condition indicates anorexia [from Gk, a þ orexis, no
appetite]. Anorexia is defined as lack or loss of appetite,
resulting in the inability to eat (1). A subsequent passage
‘‘My knees are weak through fasting; and my flesh failed of
fatness’’ (Psalm CIX: 24) shows that David’s anorexia led to
fasting and consequently to unintentional weight loss. The
weight loss was so extreme that ‘‘. . . my bones (the King’s)
cleave to my skin’’ (Psalm CII: 6). The condition is
compatible with cachexia. Cachexia (Gk, kakos, bad, and
hexis, state) indicates general ill health and malnutrition,
marked by weakness and emaciation, usually associated
with a severe disease such as tuberculosis or cancer (1).
What was the disease responsible for anorexia, fasting,
extreme loss of weight, and subsequent cachexia in this
particular geriatric patient, who was a member of the highest
socioeconomic stratum?
Unintentional weight loss is a relatively common problem
in clinical practice (2). Low body weight and unintentional
loss of weight predict increased morbidity and mortality,
especially in the elderly population (3–6). A retrospective
review of 8428 hospital admissions shows that underweight
is a strong predictor of in-hospital mortality in patients aged
older than 60 years (7). The Framingham Heart Study
demonstrates that the relative risk of death in persons aged
older than 65 years who are at the lower extreme of body
mass index is twice that of other individuals (8). Data for
persons in their seventies and eighties also suggest that
higher mortality rates occur in those with low body weights
(9). Thus, it is very likely that cachexia damaged the old
King’s health and even accelerated his death.
PHYSIOLOGICAL ANOREXIA oF AGING
Most men reach maximum body weight in their forties
and most women in their early fifties. Beyond these ages,
declining lean body mass normally accounts for the majority
of weight lost. Weight distribution shifts from muscle mass
in the extremities to fat stores in the trunk (10). Despite the
143
144
BEN-NOUN
increase in body fat and obesity that occurs with aging, there
is a linear decrease in food intake over the life span. This
conundrum is explained by decreased physical activity and
altered metabolism with aging (11). Since older persons fail
to regulate food intake adequately, they develop a physiological anorexia of aging (11,12).
Physiological anorexia is related to the decreased hedonic
qualities of feeding, altered hormonal and neurotransmitter
regulation of food intake (11), alterations in energy
metabolism, loss of calories in the urine or stools (10), poor
absorption from the gastrointestinal tract (13), abnormal
gastrointestinal contraction and secretion, altered perceptions of taste or smell, satiety, nausea (10,14), poor oral
hygiene, ill-fitting dentures (15), and aversion to specific
foods because these foods no longer seem palatable (10).
Was King David afflicted by physiological anorexia of
aging? The subsequent words ‘‘. . . I forget to eat my bread’’
indicate lack of appetite, absence of caloric intake, and
altered perceptions of taste, smell, and satiety or, alternatively, the onset of anorexia associated with dementia (16).
All these factors can be attributed to physiological anorexia
of aging. However, the diagnosis of physiological anorexia
of aging seems very unlikely in this case because the King’s
anorexia led to fasting and subsequent cachexia. An
excessive loss of weight may point to a serious or fatal
disease (17). What was the disease that caused cachexia in
King’s David case?
PATHOLOGICAL CAUSES oF WEIGHT LOSS
Weight loss in older persons can be ascribed to one or
more of three major sets of causes: 1) social, 2)
psychological, and 3) medical (11). Social causes include
poverty, functional impairment limiting the ability to
perform activities of daily living, social isolation, poor
nutritional knowledge, and institutional factors such as
ethnic food preferences, inability to tolerate other residents’
behavior, the monotony of institutionalized food, loss of
mate, fear of old age and changing roles, feelings of
rejection, all resulting in emotional stress, strain, and
deprivation (11,18,19).
Were any of the above social causes responsible for loss
of weight in King’s David case? Subsequent passages in
Psalm XXII: 7,12 ‘‘. . . I am a worm, and not a man;
a reproach of men, and despised of the people’’. . . and ‘‘. . .
trouble is near; for there is none to help’’ indicate
loneliness, social isolation, and neglect by others. It seems,
therefore, that these social problems were associated with
the loss of appetite that led to subsequent loss of weight.
Psychological causes of weight loss include depression,
bereavement, alcoholism, late-life mania, late-life paranoia,
anorexia tardive or nervosa, sociopathy, excessive life
burden, cholesterol phobia, choking phobia, and globus
hystericus (11,20). Was any psychological cause responsible
for the King’s weight loss? The subsequent passages ‘‘. . .
a broken and depressed heart’’ (the King’s) and ‘‘I am
feeble and depressed. . .’’ (Psalms LI: 19; XXXVIII: 9)
indicate a depressed mood. In older persons, depression is
associated with anorexia and weight loss more than in
younger individuals (21). Thus, depression probably also
contributed to King David’s anorexia, fasting, and sub-
sequent loss of weight. It seems very unlikely that other
psychological conditions played a role in his loss of weight.
There are many medical conditions that cause weight
loss. Patients with hyperthyroidism may experience increased appetite that leads to increased food consumption.
However, hyperthyroidism, especially in elderly individuals,
may present without obvious change in appetite, and
anorexia as well as loss of weight may be the predominant
symptoms (10,22,23). Hypothyroidism may cause weight
gain. However, this disorder may also lead to anorexia and
apathy resulting in weight loss, especially in elderly
people (10).
Was King David afflicted by hyperthyroidism or
hypothyroidism? As previously shown, the King was
afflicted by mild hypothyroidism (24). It is very unlikely
that this condition led to extreme weight loss. Other
endocrine and metabolic diseases such as diabetes mellitus,
Addison’s disease, pheochromocytoma, panhypopituitarism, and hypercalcemia (10,11) can be excluded, since
there are no data to prove their existence. For the same
reason, various infections such as tuberculosis, fungal
disease, amebic abscess, and subacute bacterial endocarditis
(10) can be removed from the list. The use of medications
that can interfere with appetite by causing abdominal
discomfort, anorexia, nausea, diarrhea, and inhibition of
gastric emptying seems very unlikely (10). Although
various gastrointestinal diseases such as peptic ulcer,
gastroesophageal reflux, cholelithiasis, inflammatory bowel
disease, hepatitis, pancreatitis, gluten enteropathy, pancreas
insufficiency, Helicobacter pylori infection, cardiac disease
(congestive heart failure), respiratory diseases (end-stage
lung disease, chronic bronchitis), renal disease (uremia),
connective tissue diseases (rheumatoid arthritis, systemic
lupus erythematosus), and neurological diseases (Parkinson’s disease, stroke) (10,11) may cause anorexia and
subsequent loss of weight, there are no data to prove their
presence.
Malignancy is probably the most common cause of
weight loss, especially when major signs and symptoms are
absent (2,23,25). The sentences ‘‘My strength failed . . . and
my bones are consumed’’ and ‘‘My bones wasted away
through my anguished roaring all day long’’ (Psalm XXXI:
11, XXXII:3), analyzed in a previous article (26), indicate
that King David suffered from osteoporosis, which afflicted
his bones. Among the various diseases that may be
associated with osteoporosis, the most likely are senile
osteoporosis, hyperparathyroidism, or malignant disease,
and the diagnosis of malignancy is the most acceptable. A
combination of two factors, cachexia and intractable bone
pains, reinforces a previous conclusion that the King was
indeed afflicted by a neoplastic disease.
Tumor infiltration of bones is cited as the most common
cause of cancer pain, and is most often secondary to the
primary disease in the prostate, breast, thyroid, lung, or
kidney (27,28). Was King David afflicted by thyroid
cancer? As previously reported, the King suffered from
mild hypothyroidism (24). It would be very ironic if the
King had been affected by carcinoma of the thyroid. The
diagnosis of lung cancer is very unlikely because there are
no signs to indicate the presence of chronic lung disease.
DISEASE THAT CAUSED WEIGHT LOSS IN KING DAVID
Similarly, there are no reasons to suspect breast cancer.
It follows that the King was affected by primary carcinoma
of the prostate or kidney with subsequent metastases to
the bones.
SUMMARY
This article analyzes the most likely diseases associated
with loss of weight in King David. The passages ‘‘. . . I
forget to eat my bread’’ and ‘‘My knees are weak through
fasting; and my flesh failed of fatness’’ and ‘‘. . . my bones
cleave to my skin’’ indicate that the King suffered from
anorexia, fasting, and extreme loss of weight leading to
cachexia. Multiple causes may be responsible for weight
loss in a single patient (17). For King David, a combination
of multivariate causes, such as neoplastic, social, and
psychological, played a role in the development of cachexia.
It is most likely that the King was affected by primary
carcinoma of the prostate or kidney with subsequent
metastases to bones. His social problems can be associated
with social isolation, loneliness, and neglect by other
people, while his psychosocial problems included his
depressed mood.
ACKNOWLEDGMENTS
Address correspondence to Liubov (Louba) Ben-Noun, MD, Makheisrael, 138 Street, POB 572, Kiryat-Gat 82104, Israel. E-mail: L-bennun@
zahav.net.il
REFERENCES
1. Hamerman D. Molecular-based therapeutic approaches in treatment of
anorexia of aging and cancer cachexia. J Gerontol Med Sci. 2002;57A:
M511–518.
2. Rabinovitz M, Pitlik SD, Leifer M, Garty M, Rosenfeld JB.
Unintentional weight loss. A retrospective analysis of 154 cases. Arch
Intern Med. 1986;146:186–187.
3. Hardy C, Wallace C, Khansur T, Thigpen JT, Balducci L. Nutrition,
cancer and aging. An annotated review. J Am Geriatr Soc. 1986;24:
219–225.
4. Schiffman S, Pasternak M. Decreased discrimination of food odors in
the elderly. J Gerontol. 1979;34:73–79.
5. Liu LJ, Bopp MM, Roberson PK, Sulivan DH. Undernutrition and risk
of mortality in elderly patients within 1 year of hospital discharge.
J Gerontol Med Sci. 2002;57A:M741–746.
6. Lee IB, Blair SN, Allison DB, et al. Epidemiologic data on the
relationships of caloric intake, energy balance, and weight gain over the
life span with longevity and morbidity. J Gerontol Med Sci. 2001;
56A(Special Issue SI):7–19.
145
7. Potter JF, Schafer DF, Bohi RL. In-hospital mortality as a function of
body mass index: An age-dependent variable. J Gerontol. 1988;43:
M59–M63.
8. Harris T, Cook EF, Garrison R, Higgins M, Kannel W, Goldman L.
Body mass index and mortality among nonsmoking older persons: the
Framingham Heart Study. JAMA. 1988;259:1520–1524.
9. Fischer DW. Low body weight and weight loss in the aged. J Am Diet
Assoc. 1990;90:1697–1705.
10. Reife C. Involuntary weight loss. Med Clin North Am. 1995;79:
299–313.
11. Morley J. Decreased food intake with aging. J Gerontol Med Sci. 2001;
56(Special Issue 2):81–88.
12. Roberts SB, Fuss P, Heyman MB, et al. Control of food intake in older
men. JAMA. 1994;272:1601–1606.
13. Geokas MC, Haverback BJ. The aging gastrointestinal tract. Am J Surg.
1969;117:881–892.
14. Mathey MFAM, Siebelink E, de Graaf C, Van Staveren WA. Flavor
enhancement of food improves dietary intake and nutritional status
of elderly nursing home residents. J Gerontol Med Sci. 2001;56A:
M200–M205.
15. Langan MJ, Yaerick ES. The effect of improved oral hygiene on taste
perception and nutrition of the elderly. J Gerontol. 1976;31:413–418.
16. Reynish W, Andrieu S, Nourhashemi F, Vellas B. Nutritional factors
and Alzheimer’s disease. J Gerontol Med Sci. 2001;56A:M675–M680.
17. Gazewood JD, Mehr DR. Diagnosis and management of weight loss in
the elderly. J Family Pract. 1998;47:19–25.
18. Kamath SK. Taste acuity and aging. Am J Clin Nutr. 1982;36:766–775.
19. McIintosh WA, Shifflett PA, Picou JS. Social support, stressful events,
strain, dietary intake, and the elderly. Med Care. 1989;27:140–153.
20. Morley JE. Anorexia and weight loss in older persons. J Gerontol Med
Sci. 2003;58A:131–137.
21. Fitten LJ, Morley JE, Gross PL, Petry SD, Cole KD. Depression. J Am
Geriatr Soc. 1989;40:365–369.
22. Morley JE, Slag MF, Elson MK, Shafer RB. The interpretation of
thyroid function tests in hospitalized patients. JAMA. 1983;249:2377–
2379.
23. Foster DW. Gain and loss in weight. In: Isselbacher KJ, Braunwald E,
Winson JD, et al., eds. Harrison’s Principles of Internal Medicine, Ed.
13. New York: McGraw-Hill; 1994:221–223.
24. Ben-Noun L. Was the biblical King David affected by hypothermia?
J Gerontol Med Sci. 2002;57A:M364–M367.
25. Marton KI, Sox HC, Krupp JR, Alto P. Involuntary weight loss:
diagnostic and prognostic significance. Ann Intern Med. 1981;95:
568–574.
26. Ben-Noun L. What was the disease of the bones that affected King
David? J Gerontol Med Sci. 2002;57A:M152–M154.
27. Galasko CSB. Skeletal Metastases. London: Butterworths; 1986:99.
28. Enneking WF, Conrad EU III. Common bone tumors. Clin Symptom.
1989;41:1–5.
Received February 17, 2003
Accepted February 21, 2003