If Teens Eat According to Their Own Internal Clock, Maybe They Will Eat Better

Do any teens eat breakfast? Do they eat it at breakfast time? Possibly there are a few who manage to wake up on school days early enough to get breakfast, but given the choice of sleeping longer or facing a bowl of cereal and milk and toast, it would be the rare adolescent who opts for feeding over sleeping. Conversely, late in the evening, when their homework and/or social networking is complete and everyone else in the house is asleep, the teen may prowl the kitchen for something to eat, even the cereal or toast that was ignored that morning.

That the food intake of the contemporary American teen may be lacking in many nutrients considered essential for life is well known. And that their diet may leave them too thin or too fat, this is also well known. Studies have been done to see how parents cope with the resistance of their adolescent offspring to consuming a nutritionally balanced diet, one which when they were a few years younger, they willingly ate. They, the parents, are not very successful.

Nagging, bribery, coercion, feigning lack of concern or interest, and controlling the foods coming into the household have some effect; but the pushback from the teens can be strong. And once the adolescent can buy food from vending machines, convenience stores, or fast-food franchises? Parental control over food intake is weakened considerably. Parents may not even know what their teens are eating.  A 16-year-old relative told me that she ate only white bread, peanut butter, and honey for a month before her parents noticed. A friend’s daughter used to eat dinner in her room during school nights so she wasn’t wasting time eating dinner with her family, but could start on her homework. She prepared her own dinner, usually microwaved chicken nuggets, and never ate what her mother prepared.

Teens are like the proverbial horse: they can be led to water but can’t be forced to drink or…in the case of the teens, eat. However, when they are hungry, they will eat what is available.   Perhaps one solution to improving their nutrient intake is to only make available at home foods with some nutritional value. This means eliminating junk foods, e.g. chips, cookies, sugary drinks, candy, batter-coated fried foods, cheese dips, and fatty cold cuts.  At night when the teen is looking for something to eat, he or she will just have to settle for what is in the kitchen. If no sugary beverages are in the refrigerator, then the thirsty teen will have to settle for something that is healthful, e.g. milk, juice or water.

Their hunger will have to be satisfied with sandwiches made from lean proteins such as turkey breast, cold chicken, or tuna. It is possible that the desire to crunch on something will lead the teen to baby carrots rather than nacho chips. Even breakfast foods, so soundly rejected at breakfast, will seem tempting before bedtime. Cereal & milk, yogurt, fruit, or whole grain toast or waffles topped with peanut butter will seem satisfying to the hungry teen at 10 or 11pm, and they can claim that they did indeed eat breakfast that day.

Another solution, which does not yet exist, is to invent a food or beverage containing the nutrients teens should be consuming. Surveys among adolescent populations indicate that vitamin and mineral intake is below required levels due, no doubt, to an avoidance of the vegetables and fruits that contain these nutrients. To be sure, if all teens suddenly started to eat kale salads, grapefruit segments, and low-fat cottage cheese as consistently as they eat nachos, pizza and subs, they would not need any vitamin/mineral pills or nutrient-laden beverages. And, as the saying goes, “If pigs had wings, they would fly.“

But when I asked my 16-year-old relative whether teens would consume a food or beverage that contained most of the daily nutrient requirements, she was skeptical. “Most kids would not consider it cool. And besides, it would have to be really tasty.”

However, we have seen the power of marketing on changing almost every aspect of our lifestyle, and indeed the negative power it has on generating nutritionally poor food choices. Images of older teens enjoying life in some magical environment while drinking popular carbonated beverages are so enticing that one is tempted to believe that such beverages even erase credit card debt.

What will convince teens, and indeed adults, to consume formulated beverages or foods is the belief that doing so enhances athletic power, improves complexion and hair texture, increases cognition, or even removes stress. The effects must be more or less immediate, not something that will be of benefit 40 years in the future like improved bone strength or decreased cardiovascular disease. And if the beverage or food is available when the teen decides that now is the time to eat, then there is a chance that it will be consumed.

Will Preventing Male Baldness Cause Depression?

The symptoms sounded like a case of a male PMS: swelling in the hands or feet, swelling or tenderness in the breasts, dizziness, weakness, fatigue, cravings for carbohydrates, weight gain, depression, confusion, cold sweats, and sexual dysfunction. These are some of the side effects of a medication used to treat male pattern baldness. Finasteride, the generic name of the drug, was originally used to treat benign prostatic enlargement. During early clinical trials, however, researchers noticed that the volunteers were growing hair. It seemed too good to be true: finally, a solution to reverse age-related male baldness. The drug, known by the trade names Propecia and Proscar, seemed to be an effective treatment for the restoration of hair among men suffering from male baldness.

Finasteride’s effect on decreasing hair loss is related to its effect on a testosterone-like compound, dihydrotestosterone (DHT). DHT is an active form of testosterone and is responsible for prostate enlargement and the destruction of hair follicles on the top (but not the sides) of the scalp. Finasteride belongs to a group of compounds that inhibits, or slows this conversion of testosterone to DHT, thus making it an effective drug to slow prostate growth and, happily for many men, slow hair loss.

But unfortunately, getting a full head of hair comes with potential physiological and emotional costs. Soon after it was introduced to prevent male-patterned baldness, especially among young men (it works better among a younger population), anecdotal reports of depression and even suicidal thinking began to circulate. Even more disturbing, these critical changes in mood seem persistent even after the drug was discontinued. A small study to investigate the validity of these side effects was carried out by Dr. Michael Irwig of the George Washington University in Washington D.C.  He measured the moods of young men, average age 31, who had been treating their baldness with Propecia for an average of slightly more than two years. These men had developed persistent sexual dysfunction that continued for at least three months after they stopped taking the drug. He found 75 percent of those who had used the drug had symptoms of depression compared with 10 percent of controls who never took the drug. Over 30 percent reported having suicidal thoughts compared to only one from a control group. Were these young men depressed because they were experiencing sexual dysfunction or the converse? The study did not answer that question.

An increase in appetite, especially for sugary carbohydrates, and weight gain were two additional side effects that lasted well beyond discontinuing the drug. This was also unexpected, but reported as a side effect often enough to make the FDA add them to the list of side effects. And according to stories by men who used Finasteride, the weight does not come off after they stop using the drug. As one disgruntled user said,”I would rather be thin and bald than the way I am now, fat and hairy.”

What seems to be the link between Finasteride and depression? By altering the synthesis of the testosterone-like substance, it might be affecting two possible neurotransmitters in the brain involved with depression and anxiety. One is gamma-aminobutyric acid, commonly known as GABA, and the other is serotonin. Interestingly, serotonin activity also decreases when estrogen levels decline at the end of the menstrual cycle, and the resulting depression, anxiety, fatigue and overeating characterize PMS.

Evidence that the Finasteride-associated depression may be related to a change in serotonin activity comes mainly from animal studies looking at the effect of testosterone on certain serotonin receptors. But a hint that serotonin may be involved can also be found in reports of intense carbohydrate craving from men who have used the drug. PMS and Seasonal Affective Disorder (severe winter depression) are each characterized by carbohydrate cravings, depression, and decreased serotonin activity. And the consumption of carbohydrate by these groups seems to relieve their depression, anxiety and fatigue because of the resulting increase in brain serotonin synthesis.

Might men suffering from Finasteride-related mood changes also benefit from eating carbohydrates? Were they to consume 25-30 grams of a starchy, very low-protein carbohydrate snack two or three times a day, on an empty stomach, they will be increasing serotonin synthesis. The resulting improvement in mood may not dispel their depression entirely (after all, a cup of oatmeal is not an antidepressant), but at least will make it easier to cope with their negative moods and the possibility that they will now lose their hair.

Darkness In The Morning, Depression In The Afternoon

It is getting to be that time of year again. Suddenly, or at least it seems that way, the sun is rising later and setting earlier. Of course, this has been going on since the first day of summer, but it is noticeable now, in these early days of fall.

This decrease in light causes many of us to feel melancholy and makes it harder to wake up in the morning. We experience difficulty controlling our appetite, our grumpiness, our interest in being with other people, even our motivation to be engaged in work. Soon, these subtle changes will coalesce into a seasonal-type depression known as Seasonal Affective Disorder (“SAD”) or the Winter Blues.  Often the symptoms are bearable until late afternoon when moods darken along with an early sunset.

It is no surprise that the general population who suffer from SAD live in the northern tier of states. For example, it is estimated that 10% of people in northern New England suffer from SAD whereas only 2% of the population of Southern California or Florida experience these symptoms.

About 3/4 of SAD sufferers are women, but SAD affects men and children as well. Typically, people start to experience symptoms in their twenties, but they can occur at any age. Fibromyalgia patients and women who suffer from premenstrual symptoms may find their symptoms worsening during the months when they are experiencing SAD.

How daylight, or its absence, affects mood is understood in a general way, but specific mechanisms are still being explored. It is thought that a decrease in the intensity of sunlight affects signals in the brain that ultimately decrease the activity of the brain neurotransmitter serotonin. The excessive sleepiness associated with SAD may be associated with the sleep hormone melatonin, which normally disappears from the bloodstream with sunrise.

The first, and still the most common, therapy recommended for SAD is exposure to light delivered by a fluorescent light box. These boxes, called light or sun boxes, emit so-called full spectrum light minus UV emissions.  The light intensity ranges from 2,500 to 10,000 lux and one is supposed to sit about 1–2 feet away from the box for about 30 minutes early in the morning.

How bright is the light? The following chart compares the light emitted from the dimmest natural light source, i.e., bright moonlight, to daylight when the sky is cloudless. Sitting in front of the light box is like being outside on a cloudless day, but not exposed directly to bright sunlight.

Here’s a chart to provide an easy to understand illustration:

  • Bright moonlight = 1 lux
  • Candle light at 20 cm = 10-15 lux
  • Street light = 10-20 lux
  • Normal living room lighting = 100 lux
  • Office fluorescent light = 300-500 lux
  • Sunlight, 1 hour before sunset = 1000 lux
  • Daylight, cloudy sky = 5000 lux
  • Daylight, clear sky = 10,000-20.000 lux
  • Bright sunlight = > 20,000-100,000 lux
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It might be possible to achieve the same ‘lightening of the mood’ by walking or jogging outside in the morning, if one’s schedule and weather permit this. But the light boxes are not affected by weather, and for those whose work schedules make it impossible to spend 30 minutes outside when the sun is fully up, an indoor light box may be the only light therapy option.

But other therapies are also available: antidepressants, talk therapy, or a combination of both. Antidepressants work by increasing serotonin activity to compensate for the decreased activity of this brain chemical; an activity decrease attributed to decreased daylight. It is not clear how talk therapy can compensate for a late sunrise, but talk therapy’s benefit is that patients learn coping mechanisms so their family, work, and social relationships are not impaired by this seasonal depression.

Dietary interventions also assist in bringing mood, eating, sleep, and social activities back to normal. The persistent urge to eat carbohydrates, a diagnostic feature of SAD, is a clue that serotonin levels are low. Indeed, sometimes the need to eat carbohydrates is so overwhelming that other food groups are ignored, and junk carbohydrates are eaten instead. Unfortunately, many of these high-carbohydrate foods, e.g. cookies, ice cream, chips, french-fries, chocolate, piecrust, biscuits, etc., are also very high in fat, so satisfying the carbohydrate craving by eating these foods has negative consequences. Because of the high fat content, it takes a long time for the carbohydrate to be digested and which commences the body on the process of making new serotonin. In the meanwhile, the SAD carbohydrate craver continues to eat, and eat as well as feel depressed and angry and grouchy and tired.

The optimal way of increasing serotonin, decreasing the SAD moods, and preventing weight gain is to choose very low or non-fat carbohydrate foods, and eat them only in the amount necessary to increase serotonin. This amount is small, about 25 to 30 grams of carbohydrate. A cup of instant oatmeal or an English muffin with a teaspoon of jelly provides enough carbohydrate. The carbohydrate must be eaten before, or at least 2 hours after, protein is eaten. Eating protein prevents serotonin from being made. By the way, forget about eating dessert after a protein meal to make new serotonin. It won’t happen.

Physical activity of any kind is important to remove the sluggish, blah feeling of the winter blues. Blood flow to the brain and muscles is increased, body temperature increases and energy is renewed. Exercising outside in full sunlight when possible adds an extra boost to getting back a summer-like mood.

Like squirrels laying up a good supply of acorns for the winter, those of us who suffer from SAD or the winter blues must now make plans to combat this seasonal change in our mood and activity. Life is too short to put it on hold until the spring.

Using Up Calories By Being Inefficient

The App that records my walking distance read 3 miles, but I had not left our apartment except for a quick trip to a nearby grocery store.

How could I have walked three miles inside?

I knew how. We had just moved, and the aftermath of unpacking had left me with only a vague idea of where anything was now stored. Back and forth I walked, searching for laundry detergent, trash bags, my cell phone, and my cell phone charger. Accustomed as I had been to a kitchen small enough to have everything I needed available without moving more than a few inches, now the larger and poorly laid out kitchen had me roaming around substantial distances to bring pots, plates, silverware, and salt shakers to the same place. I felt like a laboratory rat in a maze, figuring out, with many failures, how to set a path that would get me whatever stuff I was looking for.

But, on the positive side, all this wandering was burning up calories. Simply searching for my cell phone (which I stopped doing when I finally stuffed it into a fanny pack that did not leave my waist) was probably using up a few hundred calories, and searching for stuff that I thought I had unpacked (where was it?) used up considerably more. If one thing marked this week, it was efficiently using up calories by being helplessly inefficient.

Efficiency is essential in our overcommitted, insufficient time world.  We expect contemporary technology to ensure that what has to be done is done in a timely fashion, without too many errors. We are annoyed and often angry when others who are inefficient slow us down. Think of how impatient we get in a supermarket checkout line when the person in front of us can’t figure out how to use the credit card machine.

But perhaps an overlooked cause among many, for the unfortunate fattening of our nation, is that we have fewer and fewer ways of using calories by being inefficient. We shop online; it saves time and is very efficient, but then we spend less time walking to and in stores. We go to big box food stores with gigantic shopping carts and buy enough staples, from paper towels to toothbrushes, so we don’t have to ‘waste time’ running off to the local drug store or supermarket when we run out. Everything that can be delivered is: who wants to spend time even getting in and out of a car to pick up dry cleaning or a pizza?

Children are also delivered, to school, to home, and to various activities by bus or car. Do children walk anywhere these days? It would take too long, and maybe even reduce the time they spend sitting in front of their computer screens. We drive to our health club or yoga or Pilates classes. Walking there is out of the question. It’s just too inefficient.

A few years ago a middle management positioned woman told me that her company abolished cubicles and assigned desks. “See this,” she said pointing to an overstuffed computer bag/brief case. “This contains everything I need. I just carry it to any available desk when I come into work.“ She never has to get up from her chair to find anything. She never walks to someone else’s desk to talk, since no one is ever in the same place from day to day. Instead, she texts or emails messages to her colleagues. She never walks to the copy machine since everything that has to be copied is sent electronically to the copy ‘worker.’ It’s very efficient. It is also a little fattening? Perhaps.

It is too late to build inefficiency into our work situation, and anyway who would want the frustration, delays, and extra costs associated with this?  But maybe we can rejoice, rather than grumble when we forget something in the car and have to go back to get it. Maybe we can look positively on our inefficiency when we have to go back to the supermarket because we have a year’s supply of toothpaste, but forgot to buy milk. Maybe we can lose our cell phones more often, and praise ourselves for using up some extra calories when we finally find it. And maybe that will help, a little, to avoid gaining weight.

Why Is It So Hard To Lose Weight After Antidepressants?

Side effects from medications are common, although usually not severe enough to halt treatment. Anyone who has listened, perhaps unwillingly, to a recital of side effects associated with a television advertisement for a medication is aware of the number of health problems that might arise while taking that particular drug.  But unless the side effect is death (the announcer always seems to mumble at this point), one assumes most of these adverse events go away when the medication is no longer taken.

Weight gain is a common side effect associated with most medications prescribed for depression, and/or anxiety, or the pain of fibromyalgia. We know that the weight is gained for the same reason weight is usually gained: more calories are consumed than needed by the body for energy. But even though most of the people gaining weight as a side effect of antidepressants and related medications may become overweight or even obese, they differ from the typical overweight or obese individual. The latter group struggle with their weight, often because of a lifestyle of eating too much, exercising too little, and in many cases using food to deflect emotional issues. But people whose obesity is a side effect of their medication never had a problem maintaining a normal weight and fit body prior to treatment.  To them gaining weight was as much of a shock and disruption to their body as losing hair is to a patient on chemotherapy.

They’d never dieted. Why would they? They never needed to.

Antidepressants, mood stabilizers, and atypical antipsychotic drugs seem to alter appetite by inhibiting serotonin-based regulation of the appetite function.  A persistent need to eat remains after the stomach is full of food, along with cravings for carbohydrate snacks. Sometimes the ravenous need to eat interferes with sleep, and leads to waking up in the middle of the night to eat.  Medication-associated fatigue frequently accompanies the overeating side effects, so the motivation, and indeed the ability, to exercise off the extra calories becomes difficult or impossible.

All this is well known, and even if a prescribing physician may not mention weight gain as a side effect, countless studies have confirmed it to be so.

So if weight gain is caused by the medication, then weight loss should follow its discontinuation.

And it does for most people. Once the medication is out of the body, normal appetite returns, fatigue diminishes, and the patient returns to eating and exercising normally. Increasing serotonin level and activity prior to meals diminishes any lingering inability to feel full after eating or an inability to control snacking.  Consuming small amounts of fat-free, low-protein carbohydrate foods such as oatmeal an hour before mealtime or as an afternoon snack increases serotonin sufficiently to resume normal appetite control. Returning to a vigorous workout schedule once the side effect of fatigue disappears accelerates weight loss.

But not everyone is able to lose the weight even months after the medication is stopped.

And no one knows why.

Formerly pre-treatment, thin/fit individuals are horrified to find that the 15 or 25 or 50 pounds they gained on their medication is hanging around like a relative who won’t leave the guest room.  Diets are tried and discarded for lack of success. Aerobic and strength-training workouts are increased in frequency and duration.  Yet the pounds stay on.

The result is a feeling of despair and desperation: “No matter what I do I cannot lose weight.” It is as if someone who loses her hair while undergoing chemotherapy learns that she will be bald the rest of her life. Patients who have become obese due to their medication believe their bodies will be permanently changed. They believe they will never return to the slim bodies they had before their medications, and grudgingly and often angrily resign themselves to accept being overweight or obese.

Some suggest that water retention may be responsible for the increased weight, but once the medication is out of the body, the excess water should be lost. Others point to some muscle loss before and during the early stages of treatment when depression has led to weeks of inactivity. However, rebuilding muscle mass doesn’t seem to produce any significant weight loss. It is possible that metabolic rate decreased as a result of treatment, and therefore is slowing weight loss. But studies on thyroid function with patients who were treated with Zoloft or Prozac did not show any functional change in thyroid hormones. So at this point, there is little to offer someone who has tried to lose the medication-associated weight by dieting and exercising, and is failing.

Is the weight finally lost, many months or even years after the antidepressants or related drugs are out of the body?  Are the extra pounds still attached to the body five or ten years later?

No one knows. There are no long-term studies following patients after they discontinue treatment to see if weight is lost and, if so, what produced the weight loss. Interestingly, there are many studies showing that after a weight-loss diet is over, people’s weight eventually returns to the heavier pre-diet weight or ‘set-point’.  Perhaps it is time to see whether people whose weight is a consequence of antidepressant treatment will also return to their weight ‘set-point’. If this turns out to be the case, it will certainly lessen the depressed feeling so many patients experience when they don’t believe their weight will ever come off.

Too Little Potassium May Lead To Big Problems

My friend, who is undergoing chemotherapy, was admitted to the hospital because of an infection but blood tests revealed another very serious problem. Her potassium levels were extremely low and, despite getting potassium intravenously, the unfortunate effects became apparent very quickly. Her heart began beating abnormally, her blood pressure shot up, and even though she was given a drug to prevent blood clots, one found its way to her brain. Consequently, she suffered a stroke. The infection was soon gone, but the effects of her low potassium remained many days later.

Potassium is one of those minerals that we usually don’t think about. If one eats a healthy diet with lots of vegetables and fruit, then potassium levels are usually within the range of what the body needs, about 4700 mg a day. But surveys of potassium intake in the U.S. population indicate that as whole, we don’t get enough of this mineral. Indeed, the average intake is 2640 mg a day, and that level has remained unchanged for decades.

“So what?” might be one’s response to this data. “I feel fine!”

Perhaps we should not be so complacent about whether we are getting enough of this mineral. Most of us, I hope, will not have to endure the toll of chemotherapy on the body and experience the side effects that can reduce potassium levels. My friend had mouth sores that prevented her from eating for days, along with gastrointestinal side effects, thus causing a significant loss of potassium from her body.

But also consider these other factors:

• A gastro-intestinal infection that causes prolonged dehydration may reduce potassium levels so much that it is necessary to get medical attention and potassium supplementation;

• Going on a high protein, low or carbohydrate-free diet can also drastically lower potassium levels because, as the body loses water due to diminished stores of carbohydrate, the body is also losing potassium. And it is almost impossible for such a diet to restore potassium because foods rich in this mineral — i.e. potatoes and bananas — contain carbohydrate and cannot be eaten. The effects of potassium loss on these so-called ketogenic diets is known as keto-flu. Followers of such diets feel ‘wasted’ and totally exhausted with flu-like symptoms. Since potassium is needed for normal muscle function including the heart (a muscle) experiencing such fatigue should be a sign to balance eating critically important nutrients with weight loss on an extreme diet;

• Prolonged fasting or cleanses and extremely limited food intake after bariatric surgery may also lead to low potassium. Post-surgery, bariatric patients are usually given potassium supplements;

• Alcoholics may have dangerously low potassium levels;

• Athletes engaging in prolonged strenuous exercise associated with excessive sweating also lose significant amounts of potassium;

• Medicines such as diuretics cause potassium loss (as does laxative abuse);

If potassium levels are marginally low to begin with, a further decrease may, as with my friend, generate potentially dangerous side effects. (Hypokalaemia, the term for low potassium, is defined as potassium blood levels below 3.5 mmol/L. If potassium is among the items measured when you have a blood test, the computer will list the potassium level as mmol/L and note if your level is below normal. ) However, an adequate potassium intake and blood levels are important for all of us, even if we are not strenuous athletes, recovering from bariatric surgery, following a carbohydrate-free diet or receiving chemotherapy. Too little potassium may lead to elevated blood pressure, kidney stones, and/or bone loss. Conversely, obtaining enough potassium in the diet may reduce the risk and severity of these conditions.

Consuming enough potassium is not hard, or at least should not be hard, if one is willing to eat vegetables and fruit every day. Bananas are high in potassium (everyone seems to know this). But for banana haters, there are many more options, some with considerably more potassium than bananas.

Here are a few high potassium foods: sweet and white potatoes, white beans, plain yogurt, milk, halibut, cod and tuna, winter squash, spinach, peaches, papaya, raisins, prunes, oranges, soybeans, tomatoes, melon, beef, peanut butter, and turkey (dark meat). There are many more foods with moderate potassium contents, mostly vegetables like mushrooms, Brussels sprouts, cooked zucchini, avocado, carrots, asparagus, and broccoli.

Let’s face it. Conversations about potassium are boring. People might boast about their good and bad cholesterol levels but I, for one, have never heard anyone boast about his or her potassium levels. In fact, potassium is usually only mentioned when someone needs to take a supplement and complains about the size of the pill, which is enormous. But, as the saga of my friend’s many medical problems indicate, we cannot be blasé and disinterested in our potassium levels. The potential health risks are too high. Eating enough of the foods on the list (and the list was not at all comprehensive) to meet the daily requirement should be given a high priority when planning meals or choosing what to eat at a restaurant.

When your mother told you to eat your vegetables, she was right.

Dividing a Daschund: Cementing a Friendship

This blog is for all caretakers and friends who look out for one another.

Simon, our long-haired dachshund, runs to Mary Lou’s apartment and makes low, moaning sounds of anticipation as we wait for her to come to the door. Once in her arms, he licks every inch of her face and then runs to her kitchen.

 “Simon, you know there won’t be any treats!” I call after him. Mary Lou, slender herself, is strict about getting Simon’s weight under control, but it’s a hopeless goal.

 Mary Lou and I hug. We have not seen each other since she left for Palm Beach and we, South Beach last fall. Now it is May, and Mary Lou’s turn to have the dog.  I hand her Simon’s heartworm and tick prevention pills, his leash and harness, and take the elevator to our apartment. I miss the dog already. He won’t return to our bed (literally) until next fall. 

 It is right and fitting that Mary Lou and her husband have Simon for six months. They own half of him, although which half it is, after almost 14 years, is still contested.  We bought Simon together, not long after Frieda, my wire-haired dachshund, died.

 Mary Lou and I became friends almost 30 years ago when we moved the same month into a new condominium building in Boston.  My husband and I were traveling frequently for work, and she offered to care for Frieda. Their condo became the dog’s second home, and Frieda spent so time at their medical supply company that her picture appeared on the cover of the company catalogue.

Frieda died at 16, and after we stopped grieving, Mary Lou and I agreed that it hurt too much to get another dog. Six weeks later we bought Simon. The breeder, named Jenn, was so fussy that she interviewed me on the phone before allowing us to visit. So we decided not to tell her that we were going to buy and share the dog. Our story was that I wanted a dog and Mary Lou was helping me find one.  It was a wise decision. I doubt that Jenn would have tolerated the dog being shared like a lawn mower. The puppy, whom we named Simon, seemed unconcerned. 

Sharing the puppy was the only way we managed to live through the two years it took to housebreak him. Like many of his breed, it mattered little to him that our carpets were not grass. “You take him; I am out of pee cleaner!” became a common refrain during the frequent hand-overs.  

Our somewhat erratic sharing of Simon eventually became fixed by season.  Mary Lou and her husband became snowbirds, and as their Florida apartment did not allow dogs, Simon lived with us from November to early May. We followed the snowbird migration a few years later living in a building littered with dogs.  

Dividing two dogs has cemented our friendship. Like an old married couple, we kvetch over the same things, share private details about our lives, comfort  each other, gossip ( too much),  and occasionally go hiking.  

We also get lost. Often.

There was the time we hiked with Simon on Blue Hill, a nearby 630 foot nano-mountain, and could not find our way back to our car.  Using an out of date map, (we didn’t know) and following a trail marked with barely visible dots (the trail had been abandoned) we were certain that the three of us would become a newspaper headline when our bodies were discovered. We were rescued by a hiker who pointed out our stupidity as she pointed us in the right direction.  

That was our last hike. But the reason was not our phobia about getting lost again. Simon is almost blind. He has a genetic disease similar to macronnuclear disintegration.  He walks slowly, his nose acting as a built in white cane, scanning the space around him for obstacles. He manages well enough in familiarly scented areas but rock strewn hiking paths, typical of those on Blue Hill, are no longer possible.

And the other reason is that Mary Lou has cancer. The double whammy of her treatment protocol, radiation and chemotherapy, is stilling her normally active life.  So the three of sit together in the library of our building, which is a social space for residents. Our armchairs are close enough so that Simon’s head is on one lap and his tail on the other. (He is a very long dog). We each rub him and talk and laugh and gossip and sometimes cry because that is what friends do. And our love for Simon and our love for each other passes through his furry body to each of our hands and our hearts and our memories. 

Will Sugar Take Away the New Baby Blues?

Eleanor, the daughter of a close friend, apologized for still wearing her maternity clothes when her mother and I went to her home to ooh and ahh over her adorable newborn.

“It’s crazy!” she said, pointing to her baggy pants and shirt. “In the two weeks since giving birth, I think I have gained 12 pounds. I can’t stop eating and I know it is not just because I am breast feeding. I don’t want any good stuff to eat, just doughnuts, cookies, ice cream and waffles drenched in syrup.”

When she left the room, her mother confided that her daughter had been very moody and complained of exhaustion, feeling overwhelmed, and worried that she would not be a good mother. “She is also so irritable…When I offered to take care of the baby so she could get out of the house, she told me to stop giving her advice!”

The mother then whispered, since she heard the daughter returning, “She must have the Baby Blues.”

Postpartum blues, or baby blues, are not the same as postpartum depression, although some of the symptoms are identical. The ‘blues’ affect about 80% of mothers during the first week after giving birth, and the symptoms peak between days three to five. The mood swings, food cravings, fatigue, and depression are blamed on a decrease in serotonin activity due to the new mother’s estrogen and progesterone levels readjusting. In some ways, the symptoms are similar to PMS, which occurs at the end of the menstrual cycle when hormone levels are shifting. The postpartum blues disappear about two weeks after childbirth, but the exhaustion and fogginess may continue much longer until the mom and baby sleep through the night.

Postpartum depression, in contrast to these postpartum blues, can last for months; the symptoms are much more severe and require medical/ psychiatric interventions. Women with postpartum depression are usually treated with SSRIs, the antidepressants that increase serotonin activity, along with talk therapy and assistance in taking care of the baby and the household.

Postpartum blues are not treated with antidepressants because of their temporary nature. But this doesn’t mean that the new mother has to suffer the unwelcome feelings of sadness, fatigue, lack of focus, not feeling like herself, anxiety, or irritability even for a few days. Sleep helps with all of these symptoms.  One does not have to be a nursing mom to feel the effects of too little sleep and when it goes on for days? The confusion and mood swings that follow can be very distressing.  Waking every two hours to nurse during the night, and then getting up in the morning to carry on the tasks of taking care of the rest of the family is sufficient reason to exacerbate these ‘ blues’.

Women in our culture are given little or no time off to rest from childbirth and the demands of a family and even work. Other cultures, such as the Chinese, insist that a woman be secluded for 30 days with little to do except keep warm, eating high fat, nourishing soups and stews to sustain nursing, and sleep when not feeding the baby. In our culture, the postpartum blues can be minimized by helping the new mom with her family and household tasks so she has time to sleep, making opportunities for her to leave the house, and participate in a healthy, non-baby-centric world… and when she feels physically able, to exercise.

Eleanor’s appetite for sweet carbohydrates led her to yet another quick and effective way of improving her postpartum blues.  The foods she consumed were acting like edible tranquilizers, because their consumption increased the level of the good mood chemical, serotonin.  She was eating sugary carbohydrates to increase serotonin activity, but starchy carbohydrates such as  instant oatmeal, a bag of popcorn, or baked potato are just as effective.  The path from eating carbohydrates (except fruit sugar) to more serotonin is a little complex, but the end result is that after the food is digested, more serotonin is made and the edge is taken off all those distressing symptoms.  Eleanor was probably eating larger quantities of carbohydrate than she needed to; about 30 grams (120 calories in a fat free food) would have been enough to raise serotonin levels for about three hours. Two or three small carbohydrate snacks during the day and evening would have made her feel less edgy and depressed.

One caveat: the carbohydrates must be eaten on an empty stomach or at least two hours after eating protein.  When protein foods are digested, their amino acid contents prevent serotonin from being made by preventing one amino acid, tryptophan, from getting into the brain.

Eleanor must of course make an effort to eat the nutrient packed foods her body needs to recover from giving birth and to nurse. A diet of cookies and brownies is incompatible with the nutritional demands of her body. But eating carbohydrates should, by increasing serotonin, decrease stress and induce calmness and tranquility. Which is exactly what the mother and infant need.

Are Baby Boomers Becoming the Walking Disabled?

We were at a museum in the Berkshires whose overflow parking lot was about a 12- minute walk to the entrance. The couple we were with were somewhat dubious about whether they could walk that far. They did, but, after a couple of hours strolling very slowly throughout the museum, asked if they could ride back to the parking lot on the museum’s golf cart.  They were not sick, and neither have any disabilities that would have prevented them from walking further….the weather not too hot to make being outside for long unpleasant. But they were not young and gradually, almost imperceptively, over the years they had decreased the amount of time and distance they could walk. So to them? The additional 8th of a mile to the car was more than their stamina and legs could handle.

Mary (not her real name) mentioned that she had started to record her daily steps and some days was managing to approach 5,000. Her goal was to double that amount, but she admitted that she was so unaccustomed to walking that she tired easily.

Unfortunately, our friends are not unique. As people age beyond their sixties, many are losing the ability to walk for more than a couple of blocks. If they cannot walk a quarter of a mile, seven blocks, without assistance, their lack of mobility is termed walking disabled.

The consequences of being walking disabled have been studied by Dr. Thomas Gill, professor of medicine at Yale School of Medicine. He and his associates followed about 640 people age 70 and older for 12 years and assessed their ability to carry out what is called activities of daily life. Their results, published in the January 2012 Annals of Internal Medicine, found that as people lost the ability to walk, they lost their independence, too. If the inability to walk follows an inability to drive, the effects on quality of life are obvious.

How does someone who can no longer drive and no longer walk more than a block or two manage to go anywhere? The supermarket, library, pharmacy, movies, restaurants, shops,  a local park, museums, and concerts are all out of reach. Even public transportation such as buses that can be boarded by someone with a walker are inaccessible if an individual can’t walk to the bus stop or do errands when reaching a destination. As Dr. Gill points out, the effect is social isolation, dependence on family and friends, and often depression and possibly cognitive decline due to lack of conversation and contact with others.  The walking disabled become shut-ins and, in a sense, shut away from the kinds of casual contact that those of us who are able to walk take for granted.

But physical immobility need not be an inevitable aspect of aging.

The proliferation of devices and apps that measure walking distance or steps should allow everyone to learn just how active or sedentary they are. Day-to-day variations are averaged into weekly totals, and these data are stored so the wannabe walker has a record of steps or miles walked over a long period of time. Variations can occur, of course, because of weather (too hot or cold, rain, ice, or snow) or other factors  such as lack of time.  But daily variations eventually smooth out and offer a good record for the individual, as well as a medical care provider, of average daily activity and how much it changes over time. For example, if Mary continues her walking regimen, she should find herself walking further simply because her increased muscle strength and stamina will allow her to go longer distances without getting tired.

But what caused Mary, an otherwise healthy individual, to be unable to walk to the parking lot from the museum, a distance that presumably was considered close enough for most visitors to cover without needing transportation?

One answer is the national attitude toward walking: why walk if you can drive? Why have sidewalks in suburban communities if everyone drives or is driven? Why enable anyone to walk across a highway to get to a shopping mall if everyone drives to it? Why have children walk to school when they can be bused or driven or eventually drive themselves? Why get out of the car to go to the bank when you can go to a drive-through teller?

A few days ago in the gym I watched a television program featuring prospective house buyers.  A woman, in her early forties, was shown what seemed to be a lovely property and told that a beach was a mile away. She said, “I am not going to walk a mile to the beach. It is much too far.”

“Really, lady…” I wanted to say, “If you can’t walk a mile when you are in your forties, you may not be able to walk around the block 30 years later.”

Fortunately, attitudes are changing.

Urban planners are developing walkable cities and towns. Properties located in walkable areas are considered desirable, not just because the sidewalks and parks provide opportunities for exercise but, just as important, they provide the opportunity to connect with neighbors and with the community. Walking groups are becoming popular now, so someone for whom walking is a boring solitary activity can interact with others in a moving vertical social group. For people like Mary, it is possible to regain the ability to walk long distances by walking in a pool or on a treadmill. Treadmills allow the emerging walker adjust the time and speed and obtain an accurate display of distance. Walking in a park or on sidewalks with available benches upon which to rest, in case of fatigue, removes the fear of not having the energy to get back home.

Changing the walking disabled into the walking enabled may take time, but doing so has benefits far beyond walking to a parking lot.

Might Covering the Skin Cause Vitamin D Deficiency?

It was a beautiful summer day, and the Boston Public Garden was filled with walkers, people feeding the ducks and squirrels and/or listening to the weekend saxophone player near the Swan Boats. But mostly? People were soaking up the sun to remove some of the pallor from six months of relatively sunless days. Most women were wearing typical summer outfits: sleeveless or short sleeve shirts, shorts, or short skirts. These outfits exposed enough skin to allow the ultraviolet rays to catalyze the process of making vitamin D.  Vitamin D is essential because it supports calcium absorption from the intestinal tract into the body. Without calcium, bone tissue cannot be made. In fact, insufficient vitamin D is responsible for rickets, a childhood disease first described in the 17th century. Bones fail to grow and mineralize sufficiently and as a result, they are soft and deformed. Adults need vitamin D as well to prevent osteomalacia, a weakening of the bones and the muscles to which they are attached. Osteoporosis, a disease in which fragile bones break extremely easily, is also linked to insufficient amounts of this vitamin.

But why should vitamin D levels ever be insufficient? It is provided, at no cost, from the effect of sunshine on the skin.

But some, indeed many, cannot rely on the sun to make this important nutrient.

Consider again the scene in the Boston Public Garden. To be sure most of the people have their arms, legs, and faces (and a few torsos) exposed to the sun. But here and there women are walking about or sitting on park benches with only the area between the bridge of their nose and the top of their eyes exposed to the sun. They are wearing a niqab, a small cloth, that covers all of the face except the eyes,  in addition to a scarf that covers their hair and neck. A heavy robe (it cannot be see-through), or long sleeves and pants cover other parts of the body that otherwise might be exposed to the sun.  And it is not only the Moslem women who are so covered up. So are ultra-Orthodox Jewish women and their daughters enjoying an afternoon stroll. Thick tights or stockings, long sleeved, high-necked blouses, long skirts and wigs or scarves cover their hair and limit the amount of skin exposed to the sun only to the hands, small neck area and the face.

Such concealing clothing has a negative impact on vitamin D levels.  Several studies among Moslem communities whose women wear the most extreme style of Islamic dress have found them to be chronically deficient in vitamin D. (Mishal, A.A., Effects of Different Dress Styles on Vitamin D Levels in Healthy Young Jordanian Women. Osteoporosis International, 2001. 12(11): p. 931-935.)

The same deficiency has been observed in Dearborn, Michigan among the Arab-American female population. Veiled women had levels of vitamin D well below the minimum necessary to prevent rickets in their children (their breast milk would have insufficient vitamin D) and osteomalacia.  (Hobbs, R., et al., Severe Vitamin D Deficiency in Arab-American Women Living in Dearborn, Michigan. Endocrine Practice, 2009. 15(1): p. 35-40.)

In one study, 40% of ultra-Orthodox women whose vitamin D levels were tested in a Tel Aviv hospital were found to be deficient in the nutrient. (Siegel-Itzkovich, J, Ultra-Orthodox Jewish women at risk of vitamin D deficiency British Medical Journal 2001 ;323, 10). The effect of skin concealment on vitamin D levels was also found among adolescents in an ultra-Orthodox community in Brooklyn, due to a combination of their clothing, and that boys are indoors studying from early morning to evening.

Vitamin D deficiency can be found among many other groups as well, due to inadequate sun exposure in general. The elderly and others unable to go outside because of sickness or lack of mobility, workers with schedules restricting outside access during the work week, people with skin conditions necessitating avoidance of sunlight, and those who live in geographical areas with weather inhospitable to outdoor exposure…they also suffer. And of course, using sun block is going to prevent most ultraviolet rays from reaching our skin.  Interestingly however, most people (according to dermatologists) do not use enough sunblock, or do not put it so thoroughly over themselves so as to block out some sun exposure. Air pollution also reduces significantly the amount of ultraviolet radiation that reaches the skin.

How long one has to be exposed to the sun varies depending on who gives advice. Dermatologists will probably say avoid sun completely, but other medical folk more concerned with bone breakage and the effect vitamin D deficiency may have on immune function will suggest a spectrum of 5-10 minutes to half an hour daily. Time spent outside walking to the mailbox or walking your child to school does not fit into these calculations. And of course skin exposure to the sun is seasonal and weather dependent. The good news is that Vitamin D is stored in our liver, so try to think about it like banking money in July for Christmas shopping in November in that vitamin D made in the summer should be around in the winter.

Since it is unlikely that people with limited or even non-existent exposure to sunlight are going to be able to alter their situation, or that most of us will risk skin cancer by avoiding sunblock and frying ourselves on the beach? The alternative is to obtain vitamin D from food sources or as a supplement. Having your vitamin D levels measured might be worthwhile if you suspect that you are deficient.

The daily requirement is 600 IU until age 70 when the requirement increases to 800 IU. The best source is the worst tasting and smelling: cod liver oil.  Salmon and swordfish are pretty good sources, while canned tuna in water is marginally good. Vitamin D fortified orange juice, milk, yogurt and even ready-to-eat cereal are reliable sources, but may not be eaten in large enough amounts to meet daily needs. It is important to check labels to see how many servings are needed to get l00% of the daily quota. Supplements that provide the recommended daily allowance should be taken if neither sunlight nor food are going to give the body the vitamin D it requires.

Weakening bones are silent—until they break. Don’t let covering up the skin cover up vitamin D deficiency.