Intuitive Eaters Should Depend on Brain and Stomach

Eating what and when you feeling like eating is one of the attractive aspects of intuitive eating, a program that contradicts traditional instructions about food choices, calorie content, timing of meals and snacks, and portion size. The concept is simple: Pay attention to hunger signals from your stomach, i.e., such as actually feeling hungry, and then eat. Consume what you want and of course, try to make healthy choices, but if you want to eat something that is not particularly nutritious, that is fine, too. Don’t let guilt motivate your decision to eat or not to eat a particular food, and just as important, don’t let emotions affect your eating.

According to Laura Hartung, a registered dietician in the Boston area and one of the proponents of this eating method, you should make sure that your hunger, and not your emotions, is what’s driving you to eat. Indeed, she claims that if you ignore your emotions, you will learn to, ”Choose foods that make you feel energetic and good.” Apparently we shouldn’t be eating out of a need to feel better; i.e. less unhappy, but if we choose the right foods, we will feel better or “good,” in her words.

The intuitive approach makes sense. If we eat only when we are hungry and just as important, stop when we are full, we would or should lose weight and never be vulnerable to overeating. This approach eliminates following instructions in a weight-loss program or eating only pre-packaged calorie-controlled meals or drinks. Indeed we revert, in a sense, to eating as infants do, i.e., responding to signals generated by our bodies to drink to replenish water loss, and to eat to restore calorie loss. And as we become sensitive to these signals, we may even choose foods based on our bodies’ particular needs. For example, when protein or vitamin requirements increase after an infectious illness, we may experience a specific hunger for eggs or oranges. Whether or not the approach will produce significant weight loss is still being investigated. An early report suggests that is does not.

But the intuitive eating approach disregards, or perhaps is not aware of, the relationship between nutrient intake, the brain, performance and mood. The brain, not the stomach, both influences and is influenced by what we eat. Alcohol is a familiar example. Many people feel different after drinking alcohol, either energized, voluble, hypomanic, less stressed, depressed, angry, tired or sleepy. For some, the need to drink is generated by the brain in order to bring about these behavioral states. Should alcohol be eliminated from the diets of intuitive eaters, because drinking is not generated by hunger?

High-fat foods like cheese, sausage, biscuits, ice cream, and cheesecake, so tempting to those freed from the restrictions of calorie counting, are appealing to intuitive eaters. But they may not realize how eating these and other high-fat foods may affect their performance and mood. According to a study by a group of Australian researchers, consuming large amounts of fat at a meal increases daytime sleepiness. The report cited other studies linking sleepiness after the consumption of a high-fat, low-carbohydrate meal.

Shouldn’t intuitive eaters be aware that their food choices might influence their ability to carry out a job requiring alertness and attentiveness?

Intuitive eating’s emphasis on attending only to hunger signals emanating from an empty stomach ignores the possibility that signals from the brain may also be directing the individual’s food choices. Women who experience the mood and appetite changes of premenstrual syndrome (“PMS”) have well-established cravings for carbohydrates, especially sweet carbohydrates. Hunger for these foods does not originate in the stomach, but in the brain due to alterations in serotonin activity. Consuming carbohydrate-rich foods has a well-documented positive effect on the mood and cognitive changes of PMS; women who instinctively (intuitively?) choose carbohydrate foods are responding to brain, rather than stomach, “hunger.”

However, if the premenstrual woman does respond to these brain-based hunger signals, she is not following the objectives of the intuitive eating program, because her food choices are related to her premenstrual mood, not hunger.

Intuitive eating also overlooks the hungers produced by antidepressants, mood stabilizers and anti-psychotic drugs. The urge to eat often occurs even when the stomach is still filled with food, because the drugs seem to weaken satiety signals from the brain. Some patients feel the need to eat another meal an hour or so after completing a previous one.  This side effect of their medication is not related to stomach hunger, and thus eating intuitively is unlikely to help these patients counteract the effect of their drugs on their food intake.

That said, intuitive eating is liberating for so many struggling with excess weight. It tells us to stop paying attention to claims about what foods to eat or avoid, to view foods as not only nourishing, but also a source of enjoyment and to stop mentally calculating calories and their impact on our weight tomorrow.  It brings us all a little closer to the way we should be viewing food.

References

“Assessing the effectiveness of intuitive eating for weight loss – pilot study,” Anglin, JC, Nutr Health. 2012 Apr; 21:107

 Cao Y, Wittert G, Taylor A, et al., “Associations between Macronutrient Intake and Obstructive Sleep Apnoea as Well as Self-Reported Sleep Symptoms: Results from a Cohort of Community Dwelling Australian Men,” Nutrients 2016, 8(4), 207

Wurtman J, Brzezinski, A, Wurtman R, “Effect of nutrient intake on premenstrual depression,” Am J Ob Gn l989 161:1228

If You Use a Personal Trainer, Will You Also Exercise Alone?

As I was changing in the locker room, a woman entered wiping her face with a towel and sighing, “ Thank God that’s over.“ She sat down on a bench looking exhausted.

“Training?” I asked. “Of course,” she answered.  “I hate it, but I know it is good for me. I would never exercise if I didn’t have to meet with my trainer three times a week. In fact, she is going on maternity leave in a couple of weeks, and I am going to have to force myself to come to the gym.” “So you don’t work out on your own?” I asked.  “Never,” came the immediate answer.

I assumed that she had had been going to the gym only recently and depended on her trainer to teach her how to best use the equipment and balance her strength training with cardiovascular workouts. But no, she had been using this trainer for 5 years and earlier, another trainer associated with a gym to which she used to belong.

Obviously using a personal trainer engaged her in sufficient physical activity to keep her fit and confer all the benefits that regular exercise brings. But I wondered how it was that she could not make the transition to exercising on her own. She was not a beginner, she felt comfortable in the gym and, after so many years, knew the routines her trainer put her through.

Was having a personal trainer preventing her from exercising by herself? She reminded me of dieters who are able to restrict calories, adhere to portion size, avoid unhealthy foods and eat the recommended number of vegetable servings each day only when eating the packaged foods of a commercial weight-loss plan, or when checking daily with a nutritionist or other support individual. Indeed, such a dieter finds it difficult to make the transition into eating in such a way so as to maintain the weight loss while being compatible with the dieter’s normal lifestyle (no one eats diet packaged foods forever). Without supervision, often the dieter can’t or won’t avoid excessive portion sizes, highly caloric foods, or eat the required daily servings of high fiber, vegetables and fruits.

The woman in the locker room confessed that she doubted she would return to the gym until her trainer did because she could not make herself exercise with the same intensity and pain.  I suggested that exercising need not be punitive in order to be effective. Perhaps she might enjoy a class (the gym offered many), use some of equipment like the rowing machine, which she never used with the trainer, or join a group that ran together on treadmills.  The summer weather filled the nearby river with kayakers, and the streets with bicyclists and runners, so exercising outside was another alternative.   She looked unconvinced and soon left.

Exercise physiologists and physical therapists, those professionals with knowledge and experience of how best to exercise without injury, can be extremely helpful for the exercise beginner, for those with special needs such as balance problems, recovery from orthopedic surgery, or someone training for a competitive event like a long-distance bike ride or road race. Yoga and Pilates instructors strengthen our bodies, improve our posture, breathing and balance, and are also important in a comprehensive exercise program. A friend recovering from a minor stroke dedicated two years to working with a personal trainer to improve her stamina, a Pilates instructor to improve her balance, and a water aerobics instructor to strengthen her muscles without risking injury.  These professionals restored what she had lost from her stroke and she met her goal of exercising, finally without their supervision.

But the woman in the locker room had no such goal. She made her trainer responsible for seeing that she exercised, and if the trainer didn’t show up or was unable to work, she didn’t.  Her attitude is not unique. I have many weight-loss clients who told me that they used to work out when they had a trainer, but since they don’t have one anymore, they haven’t been exercising at all.  It is as if all the exercise routines they went through, sometimes for months or even years, had no lasting impact on their desire to exercise to engage in any kind of physical activity.

Is it possible that one reason someone seems unable or unwilling to exercise without supervision is that he or she can’t make the transition from being trained to exercising independently?   Does it occur to the individual walking on a treadmill under the watchful eye of a trainer that he or she could also walk outside? Does the trainer suggest ways in which the client might incorporate more walking rather than driving into a daily routine, or use it as alternate form of exercise on the days training doesn’t occur?  Would the woman in the gym be willing to apply her many hours of doing balance exercises to bike ride, rollerblade, ride a scooter, or participate in a yoga or ballet (barre) class?  Might the arm and back exercises she does in the gym make it easy for her to go kayaking, swim or play tennis or golf?  Would she consider entering running races, or going on walks to raise money for charities since her training has increased her stamina?

There is a saying among athletes: use it or lose it. When exercise stops for whatever reason, muscle mass, stamina, and skill decreases. If the woman in the locker room stops her exercise, she loses something else as well, namely a body fit enough, with sufficient stamina and coordination, to enjoy whatever physical activities she might want to do.  And that is a loss that should be prevented.

Opportunistic Eating and Eater’s Remorse

If we had a miniature camera mounted on our wrist or forehead that recorded every time we put food in our mouths, we probably would be shocked at the number of times we eat each day. To be sure, meal eating is usually remembered even if we can’t recall what we had for breakfast or lunch yesterday, or what vegetable, if any, we ate with dinner. But when we nibble food we had no intention of eating, but ate anyway simply because it was there, we rarely remember doing so.

A few weeks ago, I was sitting with a group of women at a luncheon listening to a panel discussion. At the beginning of the discussion, a platter of bakery cookies on the table was untouched by my largely weight-conscious table companions. But as time and boredom increased, one by one, the women reached for and ate the cookies. When the speeches were over, the cookies were gone, and probably the memory of eating them gone as well.

This cookie consumption is an example of opportunistic eating—that is, the unplanned consumption of food just because it is available. Anyone who has a dog or cat knows that if a tasty morsel falls on the floor, the opportunity to eat it is seized by one’s pet. We humans do the same, although the food is usually in a bowl or platter, and not on the floor. My doctor’s office has a large glass bowl filled with wrapped chocolates on the counter in front of the receptionist. It is very difficult to resist the temptation to reach in and take one while checking in or out for an appointment. Supermarkets set up tables to offer tiny morsels of a product the food manufacturer wants the shopper to buy. The food is rarely refused; the area near the table is congested with shopping carts as people stop their shopping in order to sample this free food. A local ice cream shop announces a two-for-one ice cream cone sale on the anniversary of its opening. Pedestrians stop and go inside, even though before they saw the sign they had no intention of having ice cream. But who can pass up the opportunity to get a free ice cream cone? Leftovers from a farewell party are left on the counter of the office kitchen, and the next morning are quickly eaten by people coming in to make their morning coffee. They hadn’t planned on having sheet cake for breakfast, but it was there to be eaten.

All of us who have fallen prey to opportunistic eating are on, albeit temporarily, the See Food Diet (I see it, I eat it). But our degree of vulnerability differs. This has been tested in a study that under the guise of testing a new consumer product, offered chocolates to subjects who recently finished a meal and were not hungry. Not surprisingly, subjects with less self-control ate more than those who exerted some restraint over their food intake.

A similar study was done, again with chocolate, in which subjects were asked to eat chocolate until they were so full they could not eat anymore and then…they were given the chance to start eating again. Those who did had a higher BMI and on psychological tests had a greater degree of impulsivity.

Dieters and non-dieters alike fall prey to opportunistic eating. Often the act of eating is more of a reflex than a conscious act. We walk past a bowl of nuts or chips and, grabbing a handful, munch on the food without perceiving what we are doing. Our mind is on something else. Stopping for fried dough or a sausage and pepper roll while strolling through the street fair becomes part of the total experience, and may be remembered only if some intestinal discomfort occurs afterward. Finding a ten-dollar bill on the sidewalk is memorable. Finding and then eating cookies left on a plate in the office kitchen is not.

Sometimes opportunistic eating takes the guise of being served larger portions than anticipated, especially in restaurants. Although some diners would view a soup tureen filled with pasta, or half a roasted chicken spread over a small hill of mashed potatoes, as cause for horror (“How can I possibly eat this? I’d better take most of it home; maybe someone will share it with me?”), others will justify eating the entire portion because of the opportunity to do so. There will be no guilt or attempt at self-restraint, because the humongous-size portion wasn’t requested, but came as a gift.

Tracking the unneeded calories from opportunistic eating is a challenge. If one is eating mindlessly, noticing and recording what is eaten is rarely done. Often the opportunistic eater is aware of having eaten more than intended only when on a scale.

Even though it is difficult, the only way to prevent weight from being gained or weight loss being slowed is to avoid, totally, opportunistic eating. “Out of sight, out of mouth” works to remove temptation at home and in the workplace.  Removing bowls of nuts or candy or plates of cookies or leftover cake or pie from sight prevents them from being eaten. But it is impossible to remove entirely from our environment the presence of food and the spontaneous chance to eat it. Thus, the only other recourse is to use self-discipline. It is hard, but there are many who exert this type of self-discipline all the time. They may need to avoid foods that might contain allergens, or are not allowed for medical, religious, or dietary reasons.

Avoiding opportunistic eating avoids eater’s remorse. You may not have noticed or remembered what you ate, but you can be sure the scale does.

References

“Unintentional eating. What determines Goal-incongruent chocolate consumption?” Allan J, Johnston M, Campbell N, Appetite 2010, 54:  422-425.

“Psychological predictors of opportunistic snacking in the absence of hunger,” Fay S, White M, Finlayson G, and King N, Eat Behav 2015; 18: 156-159.

Vaping Is Not the Way to Lose Weight

Some individuals struggling to lose weight think they have stumbled, or more accurately, inhaled their way into a perfect weight-loss drug. It doesn’t require a prescription, and although not cheap, its costs are affordable. It doesn’t appear to have dangerous side effects and, in addition, it is fun to use. The drug is nicotine, and when it is delivered into the body by means of an electronic cigarette, it seems to cut cravings for sweets, increase metabolism, decrease snacking, and reduce weight. Indeed, electronic cigarettes have been recommended as an effective way to helping tobacco cigarette smokers wean themselves off  cigarettes without gaining weight.

Electronic cigarettes deliver nicotine into the body through a vapor that is inhaled by the smoker. One of the most popular models is JUUL. It looks like a cigarette, but unlike a cigarette this model, like other electronic cigarettes, emits clouds of white vapor. Using an e-cigarette gives the smoker the appearance of walking around in his or her own fog machine. The device heats up a small quantity of an oil or liquid containing nicotine, and the user “vapes,” or inhales and exhales the vapor.

When a tobacco cigarette is smoked, about 1 mg of nicotine enters the body. A typical electronic cigarette, such as a Juul, provides the nicotine in puffs—and the more puffs, the more nicotine enters the lungs. The nicotine itself is housed in a pod or cartridge. One cartridge contains about the same amount of nicotine as in a pack of cigarettes. Thus, 200 puffs of a Juul would deliver as much nicotine as smoking 20 cigarettes.

Vaping side effects include dry mouth, sore throat, and, for new smokers, the dizziness that comes when nicotine is first introduced into the body. But the most significant hazard associated with e-cigarettes is the same as that associated with tobacco cigarettes—the nicotine. Nicotine is not a harmless substance, no matter how it is delivered into the body, and has an extremely high addiction potential.

Vaping is now is now seen as a gateway to tobacco cigarette smoking, especially for teens. Brian Primack and colleagues reported this a few years ago when they surveyed a random selection of young adults, asking them about their smoking habits. Vaping was a significant predictor of traditional cigarette smoking. The young adults who used electronic cigarettes were four times as likely to begin to smoke tobacco cigarettes as those who did not vape. The authors suggested that vaping makes it easy to tolerate nicotine for those who never smoked, as the vapor may contain sweet fruit flavors rather than the sometimes harsh taste of tobacco. They point out that later on the young adult may become addicted to the nicotine, and require the higher concentrations found in tobacco cigarettes to satisfy the craving.

A new potentially serious health risk from vaping is in the making—using vaping as a weight-loss drug. The internet is filled with anecdotes extolling the appetite-suppressant effects of vaping. It is said to decrease cravings for sweets, and to be effective as a way of ending a meal—vaping rather than eating dessert. Sucking on the e-cigarettes apparently relieves stress, the nicotine increases metabolism, and for some, vaping acts as a substitute for eating altogether.

Research is now being published describing the vaping habits of adults trying to lose weight. Not surprisingly, individuals who wanted to lose weight vape more frequently than those not trying to control food intake.

Individuals with eating disorders are also turning to electronic cigarettes to prevent themselves from eating. According to a recently published study, someone suffering from anorexia or binge eating is much more likely to use vaping as a way of controlling their food intake than someone without such disorders. Moreover, they tend to vape daily and use high levels of nicotine.

There is growing concern among those in the addiction community that not enough attention has been paid to vaping. The casual use of an electronic cigarette to stop snacking or to produce quick weight loss should be cause for alarm. Vaping is not seen as a means of bringing a highly addictive drug into the body by those who are turning to it as a “fun” way of losing weight. Moreover, the vaping dieter is not asking what happens when the weight is lost. The answer: Weight is regained, along with the possibility of an addiction to nicotine.

Withdrawal side effects from inhaling nicotine by vaping are the same as the side effects felt when cigarette smoking is stopped. According to Addiction Resource, those side effects include depression, difficulty concentrating, fatigue, insomnia, and weight gain. Vaping is not the magic pill of weight-loss success. The loss of pounds comes with a price—the need to continue vaping indefinitely to keep the pounds off, and along with that, an addiction to nicotine.

Weight loss can be achieved and maintained only when a permanent switch to better food choices and a commitment to exercise is made. Insight into why overeating occurred is another significant factor. Vaping accomplishes none of this. Rather, it promises weight-loss results only through bringing an addictive, potentially dangerous drug into the body.

References

“Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use among Tobacco-Naïve U.S Young Adult,” Primack, B, Shensa A, Sidani J, et al, The American J of Medicine 2018; 131:44.e1-443.e9

“Vaping to lose weight: Predictors of adult e-cigarette use for weight loss or control,” Morean M, Wedel A,  Addictive behaviors 2017 66:55-59

“ Smoking-related weight and appetite concerns and use of electronic cigarettes among daily cigarette smokers,” Bloom E, Farris S, DiBello A, Abrantes A,  Psychol Health Med. 2019; 24:221-228

The Effect of Legalized Marijuana on Weight

Marijuana munchies seem to have been around as long as s’mores, a gooey, melted marshmallow, chocolate and graham cracker creation favored by marijuana inhalers. Indeed, gobbling fatty-sugary or fatty-salty crunchy foods seems to be the inevitable aftermath of marijuana use. Now that more and more states are making this drug legal, and shops selling it as ubiquitous as Starbucks, will consumption of junk food increase to new heights? And will the weight of the country follow?

The effects of smoking two cigarettes of marijuana or a placebo on food intake and weight was studied more than twenty years ago. Six male volunteers lived in a residential research facility for 13 days and their food and activity monitored after marijuana inhalation or placebo. Smoking marijuana increased daily calorie intake by 40%, and the calories came primarily from junk food like candy bars and potato chips. The subjects’ weight increased as well.

Current market research on the sales of junk food in states where marijuana use is now legal seems to confirm the results of this early study. An article in Medical News Today March 2019 reported a relationship between states where recreational marijuana use is allowed and sales of junk food: Monthly sales of ice cream, cookies, and chips increased from 3 to over 5 percent, respectively, compared to sales before recreational use of marijuana was legalized.

The Internet is filled with suggested snacks for those whose mouths are yearning for sugar and fat, and there are even snacks for the keto folk who prefer their fat with protein.  Research has identified one of the many components of marijuana, tetrahydrocannabionol (“THC”), as responsible for triggering hunger. Indeed, the effect is so potent that clinicians have suggested its use in stimulating appetite in patients who have none, such as cancer patients.

Yet before pot shops start selling clothes in extra large sizes to meet the needs of their customers, it is important to note that marijuana may have an entirely opposite effect on appetite and weight. A review of studies looking at weight change with marijuana use did not find data unequivocally confirming increased food intake and body weight among users. The authors report the results of studies in which marijuana was used to increase weight among patients with HIV or cancer, and found that although appetite seemed to be stimulated, the weight gain was not clinically significant. Conversely, studies looking at large populations of users found them to have lower body mass index than non-users. Explanations for this disconnect between increased appetite and lower weight seem to include everything from how often marijuana is used, whether substance abuse of alcohol and/or other drugs is involved, the presence or absence of mental disorders and THC dose or concentration.

Conversely, there is now a substantial amount of evidence that specific components of marijuana might protect against weight gain. Two large national surveys looked at weight in populations of users and non-users and their results were summarized a few years ago. The two surveys from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC 2001-2002) and the National Comorbidity Survey-Replication (NCS-R, 2001-2003) both found that marijuana users had a significantly smaller prevalence of obesity than non-users.

This ambiguity over the weight-changing effects of marijuana is due in part to the differing effects on appetite of two components of the plant. THC seems to be responsible for munchies, along with the psychoactive effects of cannabis. CBD, or cannabidiol, another of the approximately 100 identified phytocannabinoids, seems to counteract the mood-changing effects of THC and decreases hunger. In June 2018, an FDA approved drug, Epidiolex, that is now used to treat two pediatric seizure disorders, has as one of its side effects decreased appetite. Cannabidiol is the purified component of this drug.

The differing effects the marijuana on hunger has an eerily similarity to what the Caterpillar, in the book Alice in Wonderland, told Alice about a mushroom on which he was sitting. “…the Caterpillar got down off of the mushroom…merely remarking as it went ‘One side will make you grow taller and the other side will make you grow shorter.’ “  Alice nibbles on one side and shrinks; she eats from the other side and grows.

If one smokes or eats, or uses the oils from one component of marijuana, will one get fatter and then switching to the other component, grow thinner?

As expected, the Internet is now filled with pictures and descriptions of various types of marijuana that may help with weight loss. But the recommendations as to how to use these leaves to lose weight could come right out of any weight-loss program: eat healthy, exercise, get plenty of sleep, watch portion sizes. So far, CBD has not been purified and tested in large clinical trials to see its effect on weight and, as important, its effect on acute and chronic side effects.  Nor have there been other studies examining whether CBD might decrease emotional overeating by decreasing anxiety. Should such studies be carried out, they must meet the standards used in testing any weight-loss drug for efficacy and side effects.

For decades people struggling with their weight have been looking for the “magic pill” that allows them to lose weight easily without the need for will power and self-discipline. Is marijuana the magic pill that will allow some who need to gain weight do so and others lose weight? The answer is still in the future.

References

“Effects of smoked marijuana on food intake and body weight of humans living in a residential laboratory,” Foltin R, Fischman M and Byrne M, Appetite, l988; 11: 1-14.

“Marijuana and Body Weight,” Sansone R, and Sansone L, Innov Clin Neurosci. 2014; 11: 50-54.

“Obesity and Cannabis Use: Results from two national surveys,” Le Stat Y, and Le Foll B. Am J Epidemiol 2011; 174:929-33.

Can We Stop Becoming More and More Sedentary?

The past several decades have seen us becoming a country of sitters.  We spend less and less time in physical activity because on the one hand we don’t have to and, on the other, we don’t want to. Getting to work, to shops, supermarkets, social and religious events, movies, concerts, or restaurants is rarely accomplished by walking or bike riding to the destination. This is changing in urban area where bike lanes are gradually replacing traffic or parking lanes. Still, bike riders are still very much in the minority, and even more so when inclement weather makes riding uncomfortable or dangerous. Walking is still a preferred mode of transporting oneself in cities like New York, where the pedestrian often arrives sooner than a car due to traffic congestion. But many cities, and certainly suburban and rural areas, are too spread out or lack sidewalks to make walking to work or the supermarket possible. And then there is a matter of time. A few weeks ago, I decided to walk to a supermarket located about 2 ½ miles from where I live. It was a beautiful spring Sunday and the walk was in lieu of a visit to the gym. The five-mile round trip took a good part of the morning and, combined with carrying a knapsack heavy with groceries back home, I am disinclined to repeat the experience.

We also don’t move enough because work or school necessitates sitting at a desk in a meeting or lecture, in a library, or in an office seeing clients or patients. To be sure, some occupations require physical activity such as running after toddlers in a daycare center or hammering sheet rock in a construction site.  But many occupations now require less physical activity than in the past. Our mail carrier uses a small van to deliver the mail; several years ago he would have walked.  We no longer have to walk to a bank to deposit a check or withdraw money. The cell phone takes care of money-less payments and our groceries, along with everything that we need, can be delivered to our door. Devices, which send signals remotely, like the television remote and the more sophisticated smartphone, have further reduced our need and desire to move. Why get up to turn off a light if your phone will do it? Why sweep the floor if your cute robotic device takes care of the dirt?

Of course, our almost constant use of the cell phone has also reduced our physical activity. In a nearby park people sit on benches hunched over their cell phones rather than walking, or sit on workout benches in my gym checking messages, rather than lifting weights.

Thus it is not surprising that our population is now even more sedentary than it was ten years ago.  A report in last week’s JAMA (April 23) analyzed sedentary behavior or, more simply, hours sitting, in almost 52,000 participants who took part in a National Health and Nutrition Examination Survey (NHANES). Three age groups were involved: children from 5-11, adolescents 12-19, and adults 20 years and older. People were asked how much time they spent each day sitting at work, with friends, commuting, reading, playing cards, watching television or using a computer.

About two-thirds of the participants in each age group spent at least two hours a day watching television. The survey did not include people who might binge watch all the episodes of a particular program for hours.  About half the people surveyed sat in front of their home computer for an hour or more each day. This time spent sitting was in addition to the time spent at their computers at work or at school. Moreover, the amount of sitting time may have been underestimated because the survey did not look at time people spent with their cellphones and tablets at home, in coffee shops, or while traveling. When all the sitting time was added up, the researchers found that as a country we are sitting about 8 hours a day compared with about 7 hours ten years ago.

The report describes such stark consequences of sedentary behavior that the reader feels compelled to stand up and walk around while reading about the increased risk of obesity, cardiovascular disease, cancer, diabetes and overall mortality.  However, the authors offer no specific countermeasures to decrease our sedentary behavior.

Since increasing the time we spend not sitting should have positive effects on our health, it is surprising that so little has been done to accomplish this.  Apps will monitor our activity and may increase our motivation to move more, but in a passive way. There is no app that acts as one’s mother to say, “Turn off the computer and go outside and play.”

It should be possible to program computers, tablets, phones and even television sets to make us move. If cars brake when we are too inattentive to do so ourselves, and keep us from drifting from one lane to another, our devices should be able to make us stand up, walk, stretch and maybe do some exercises. My computer shuts down to install an update even when I don’t want it to.  What if my computer or tablet shut down when it detected my inertia for 50 minutes and won’t go back on until I move?  My cell phone tells me how much screen time I use, but why not tell me to stop bending over the screen, stand up straight and go for a walk?  We all get fidgety watching televised advertisements for drugs that will allow us to float through a field of butterflies with our partner, or scenes of cars driving through deserts or up mountain-sides. What if we could program our television to substitute a virtual reality show that gets us moving through that grassy field, or hiking up a mountain for five minutes?

Technology has made us sit too much. Now is the time for technology to get us to move.

“Trends in Sedentary Behavior Among the US Population 2001-2016,” Yang L, Cao, C, Kantor E, et al, JAMA 2019; 321: 1587-1597

Excess Skin After Major Weight Loss: Might Removing It Prevent Weight Gain?

The financial officer of an organization to which I belong decided to have bariatric surgery. Bob (not his real name) needed to lose about 200 pounds and the operation, called the gastric sleeve, narrowed his stomach and decreased the production of ghrelin, a hormone that increases hunger. He lost about 190 pounds, significantly improved his food choices, and now exercises several times a week. But despite his success, and with it his improved health and energy, he told me that he was unhappy. “I had an image of myself as a thin person, which motivated me to always stick to the diet and work out. But now that I have lost all this weight, I feel encased in suit of loose skin. I have to force myself to go to the gym because I think everyone is staring at the skin hanging from arms and sagging down my thighs.  I have to buy clothing in a size too large. My loose flesh prevents me from getting my arms in the sleeves of my jacket and zipping up my pants unless my clothes are baggy.”

Bob’s problem is not unique.  Many patients who undergo bariatric surgery and are successful in losing very large amounts of weight are confronted with bodies distorted by excess skin. This is not a problem for those who lose much smaller amounts of weight. The skin regains its elasticity after being stretched, and regains its normal shape as it does, for example, after pregnancy. If large amounts of weight are lost very slowly, sometimes the skin regains its original shape, although this is less likely to occur in an older individual.

Surgery to promote rapid and massive weight loss, or extreme dieting and exercise, as seen in the television show program, “The Biggest Loser,” can leave pounds of skin behind.  Although those of us who have not gone through the massive gain and then loss of weight might view the problem as merely cosmetic and a small price to pay for the weight loss, the problem is not simply cosmetic. (“Surgical solutions to the problem of massive weight loss,” Spector J, Levine S, and Karp N, World J Gastroenterol. 2006 12: 6602–6607.) In their article describing surgical solutions to help the newly thin deal with their excess skin, Spector and his co-authors point out that patients who have large amounts of skin draped over their limbs and the torso may be in chronic pain and the skin can be easily infected.  Giodano reiterates their views in an article (“Removal of excess skin after massive weight loss: challenges and solutions,” Open Access Surgery 2015; 8: 51-60) and adds that physical impairment, including difficulty exercising or indeed even walking, and low self-esteem are some of the other problems caused by the excessive skin. Moreover, dieting and exercise are unable to bring the skin back to its original elasticity.

There is a solution. It is called body contouring, a plastic surgery that removes the skin, and by doing so, reveals the body shaped by the weight loss. Bob underwent several plastic surgical procedures over a period of many months but the results, giving him a body that finally revealed its nearly 200 pound weight loss, was attained only after a considerable cost in pain and money. He had to take time off from work, required a brief hospitalization for one procedure and, in his words, ‘”I won’t be taking a vacation for decades to pay for everything.” He justified going through this in part because he believed his professional appearance would be improved if he were able to wear clothes in the appropriate size for his weight and not to house his excess skin.  But he admitted another more personal reason: “I was afraid that I would gain back the weight because I was so disappointed in how I felt and looked. In fact, my body was so distorted that I think I looked worse than when I was obese. ”

The failure of patients undergoing bariatric surgery to maintain their weight loss beyond one year post-operatively has been reported. (“Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy,” Golomb I, Ben David M Glass A, et al JAMA Surg. 2015; 150:1051-1057.) According to the Golomb et al report, a significant amount of weight is gained relatively early, i.e., within the first few years, and many of the patients did not lose enough weight to reach their goals before they started to gain again.

However, for those who did reach their weight-loss goal like Bob, would having body-contouring surgery support their efforts to maintain their weight loss?  There is no answer. Indeed, the way to provide an answer would be to carry out a study comparing weight maintenance of patients whose excess skin is removed with patients who do not get the body contouring surgery. Both groups would receive the same nutritional counseling, personal training and psychological help so the only difference between the groups would be the removal of excess skin. Of course, the problem with such a study is that the results may show a positive effect on weight maintenance of skin removal. And then what?  The cost of such operations is almost prohibitive for most people and rarely covered by health insurance.

But perhaps this will change. Bariatric surgery is paid for by many insurance plans because studies have shown that the medical costs of obesity are much higher in the long run than the cost of the surgery. If body contouring is shown to have a significant effect on preventing weight gain after bariatric surgery, then perhaps this too will be covered by health insurance.

The better solution, of course, is to prevent the excessive weight gain necessitating the surgery.

The Silent Cause of Tiredness

Too often the response to the question “How are you?” is, “Tired.” A list of reasons justifying the fatigue usually follows: working hard and late, a household of children and/or visitors, too many outside commitments with deadlines, school papers and exams, inadequate sleep, recovering from a cold, and, of course, stress. The list could go on. Missing from this list, however, is a silent but potent cause of tiredness: iron deficiency anemia.  Iron is needed by the body to make hemoglobin, the constituent of red blood cells that transports oxygen from the lungs through the blood and delivers it to the cells. If, over a period of time, too little iron is consumed to make hemoglobin in amounts necessary to meet the needs of the body, iron deficiency anemia results.

Extreme fatigue is one of the symptoms of iron deficiency anemia, along with decreased stamina, increased vulnerability to infections, sensitivity to cold, increased heart rate and dizziness. Pale skin is also a symptom, but like so many of these signs, especially fatigue, other reasons for their presence can easily be summoned.  Many of us assume that we are suffering from some yet identified virus if we feel dizzy or out of breath climbing stairs. And, for many people, being pale in the winter is hardly considered unusual. And we often respond to our tiredness by eating. “Maybe if I eat a snack, I will feel more energetic,” we tell ourselves as we reach for a cookie or bag of chips.  We are unlikely to consider that maybe our fatigue is caused by an insufficient amount of iron in our diets. Unnoticed and unchecked, the depletion of iron stores continues to cause persistent fatigue that does not respond to more sleep or getting over a viral infection.

The National Institutes of Health Office of Dietary Supplements recommends that men and women of non-childbearing years obtain 8 mg of iron daily and 18 mg for premenopausal women. The larger requirement for women of childbearing age is based on monthly blood loss from menstruation.  Blood losses from medical conditions may also decrease iron stores. I had a neighbor who had a silent bleeding ulcer for months and was found to be severely anemic.

Iron deficiency anemia is not uncommon.  (“Iron Deficiency Anemia,” Killip S, Bennett J, Chambers M, Am Fam Physician 2007 1: 75: 671-678) According to a recent publication in the American Family Physician, “ The prevalence of iron deficiency anemia is 2 percent in adult men, 9 to 12 percent in non-Hispanic white women, and nearly 20 percent in black and Mexican-American women.” The trend toward intermittent fasting or cleanse diets may increase these numbers as a one or two-day fast cleanse diets, has been shown to rapidly deplete iron. (“Effect of short-term food restriction on iron metabolism relative well-being and depression in healthy women,” Wojciak R, Eat Weight Disord. 2014; 19:21-327)

Obtaining the necessary amount of iron from the diet is not as easy as, for example, getting enough vitamin C.  Although many foods contain iron, not all the iron in the food gets into the body. There are two types of iron: heme iron and non-heme iron. Heme iron comes from animal sources and is considered more “bioavailable” than non-heme iron. This means that the iron in the food is more able to get into the body from the intestinal tract than non-heme iron.

Liver is a good source of heme iron, but this food is not universally enjoyed (except, perhaps, by cats).  Lean meat and seafood, especially octopus, are also good sources, although the latter is also not particularly popular. Indeed, for most non-vegetarians as well as vegetarians and vegans, more of our iron comes from plant sources than animal foods.  According to the Office of Dietary Supplement report, about half of the iron we eat comes from fortified bread, cereal and other grains. In fact, cereal is a good source of iron:  one cup of bran flakes contains 4.5 mg of iron which is about half the amount men and post-menopausal women need each day. An avoidance of grain products means that the vegetarian and vegan eater must depend on obtaining iron from vegetables, lentils, dried beans, soy products like tofu, and nuts and seeds. The amount of iron in plant foods that are not fortified is low so that large quantities must be eaten each day to meet iron intake requirements, especially for women of childbearing age.  Moreover, there often is a misperception of how much iron is in the foods we think of as good sources of this mineral.

“I eat plenty of spinach and nuts,” a friend will say, “so I am not worried about getting enough iron even if I try to avoid eating meat.“  But an entire cup of cooked spinach (which is a large amount raw since it shrinks when cooked) has only 6 mg of iron. A cup of cashew nuts has 4 mg and lots of calories. Two large eggs have less than 2 mg of iron and one would have to eat an entire cup of hummus to get 5 mg of iron.

Iron in plant foods is also less “bioavailable” than the iron in animal foods. There are phytates and other substances in plant foods that grab hold of the iron and prevent much of it from being absorbed into the body from the intestinal tract. In fact, studies on the iron status of vegetarians have shown that they tend to have lower iron stores than non-vegetarians.   (“The effect of vegetarian diets on iron status in adults: A systematic review and meta-analysis,” Haider L, Schwingshackl L2, Hoffmann G3, Ekmekcioglu C ,  Crit Rev Food Sci Nutr. 2018; 58(8):1359-1374)

Fortunately, eating foods that are high in Vitamin C counteracts the effect of phytates on preventing iron from entering the body. Eating a vitamin C-rich food such as citrus fruits or juice, strawberries, broccoli, cauliflower, Brussels sprouts, and peppers including chili peppers, with an iron-containing food like oatmeal or tofu, significantly increases the absorption of iron, especially for people with low iron reserves.

However, if blood tests show that iron deficiency or iron deficiency anemia is present, it may be necessary to take an iron supplement and doing so should be under the care of a physician.  For many, this may be an easier solution than eating chopped liver or grilled octopus.  Once the problem is resolved and iron stores are back to normal, fatigue and the other symptoms of the anemia should disappear.

Eating Late: Will It Make Us Gain Weight?

Is it true that when we eat may influence our weight? For years, some nutritionists and diet consultants have told us “…not to eat dinner later than 6 pm,” or “…If you eat late at night you will gain a pound while you sleep,” or “…it is better to eat most of your calories early in the day.”  Now that daylight saving time has arrived, we may find ourselves eating dinner much later than we did a few months ago when it was dark by 5:30, or even much earlier. Indeed, as the hours of daylight extend into the evening, and the weather becomes benign, dinner may be pushed back even further as we are reluctant to go inside and settle down for the evening. If the timing of our meals does make a difference, might this have an impact on our weight? Should we stick to eating dinner no later than 7 pm because if we ignore this time limit, we will be gaining weight?

Compelling evidence supports the idea that the timing of meals may affect weight. A large study examining meal times among Seventh-Day Adventist church members in the United States and Canada suggests that we should consider rearranging our meal schedule. Researchers looked at food records of 50,660 adult Seventh-Day Adventists and their BMI ( body mass index), a measurement of their weight status. Would there be a relationship between the number of meals consumed, the timing of the major and smaller meals, which meals were usually skipped and their weight? Their results might make one reconsider when to eat.

People who ate breakfast had lower BMIs than those who habitually skipped this meal. Moreover, people who made breakfast their major meal of the day, rather than lunch or especially dinner, had a significantly lower weight than those who ate their largest meal at dinner. Eating a bigger lunch than dinner also produced lower body weight, although the differences were not as striking as between those who made breakfast their main meal of the day and those who ate their largest meal at night.  Snacks were counted as meals and, no surprise, people who ate more than three meals a day were in the heaviest category.

Breakfast consumption has also been linked to weight loss in a study in which dieting subjects ate most of their calories at breakfast or at dinner. Both groups ate the same number of calories but those who ate most of their calories at breakfast lost significantly more weight than the other group.

These results suggest that populations that traditionally eat tiny breakfasts and large evening meals might have a high rate of obesity. In two such countries, Spain and Argentina, breakfast is often only coffee and perhaps a roll or pastry, and dinner usually begins, at least in restaurants, no earlier than 10:30 pm. However, despite their late dining and inadequate breakfasts, the prevalence of obesity doesn’t even come to close to what we have in the States where we finish our dinners before they have picked up their forks to begin theirs. The prevalence of obesity in both Spain and Argentina is around 14%.

In contrast, one out of every four Americans is obese. Moreover, articles lamenting the increase in the numbers of overweight and obese individuals in these countries do not mention the lateness of the dinner hour, but instead focus on the same factors that are responsible in part for our rise in obesity: too many high calorie snacks, too little exercise, too much watching television, too little consumption of fruits and vegetables and too much fast food. Sound familiar?

Nevertheless, can we disregard the studies indicating that consuming the majority of our calories before sunset might help us in the obesity battle? Should we stop having people over for dinner or celebratory occasions involving food in the evening, and switch to brunch or breakfast instead? Should lunch be the default main meal and dinner limited to soup and a salad, or yogurt and fruit?

One problem with transferring information from studies with compelling results such as the one with the Seventh-Day Adventists is that life gets in the way of implementation. Early mornings, filled as they are with getting breakfast for the family, walking the dog, long commutes, getting the kids to daycare or school, and the myriad obligations that arise between waking up and being at work seem incompatible with preparing and consuming a large meal. Moreover, lunch, the other opportunity to eat the major meal of the day, is rarely a complete meal. Do people go home for a hot meal at lunchtime anymore? Most of us content ourselves with a salad or sandwich and consider ourselves lucky if we can eat it at a table rather than at our desk or sitting on a curb near a construction site.

Perhaps the real problem is being too hungry at dinner. If breakfast and lunch are skipped or skimpy, late afternoon-early evening hunger hijacks our control over eating while preparing dinner, at the meal itself, and afterward. We may justify our grabbing and gobbling because we have eaten so little earlier in the day. And we munch on cookies or ice cream after dinner because “they couldn’t have any more calories than the breakfast or lunch we skipped.”

It is unlikely that breakfast will become the new dinner, regardless of research on its impact on weight. But we should not minimize the importance of this meal as well as lunch in controlling our hunger late in the day. It really might work.

Antidepressants: The Hidden Contributor to Obesity

Years after weight gain was recognized as a side effect of antidepressant therapy, researchers have presented evidence of its contribution to the increase in obesity.  For those patients, who for years have described the devastating effect antidepressant have had on their weight, it is a ‘told you so’ moment. Last spring the British Medical Journal published a report by Rafael Gafoor, Helen Booth and Martin Gulliford, documenting the significant weight gain in Britain experienced by  patients on a variety of antidepressants, compared to the general population.  Using electronic medical records, they tracked weight status of the 53,000 British patients who had been prescribed antidepressants over ten years, and compared their weight to a similarly large group of untreated individuals.  Both groups gained weight, but a significantly larger number of those in the antidepressant-treated group increased their weight. Moreover, weight gain did not stop after the first year of treatment, but according to their findings continued, on average, for six more years.  The drug that caused the most weight gain was mirtazapine (Remeron).

Moreover, weight gain as a side effect of antidepressant treatment was not confined to those who were overweight or obese at the start of their therapy, but included patients who were of normal weight prior to treatment. The authors conclude that the impact of antidepressant drugs contributing to the increase in obesity in the UK has been overlooked, and should be considered a major risk factor. Their assessment of the impact of antidepressant therapy on generating obesity can be applied to the USA where, as in the UK, it has been almost entirely ignored as a risk factor.

That antidepressants and related drugs used for bipolar disorder and other mental  disorders cause weight gain is well known to patients and their mental health providers.  Several years ago, my associates and I were asked to develop a weight maintenance center at a Harvard associated psychiatric hospital to help patients lose the weight they gained (or were gaining) on psychotropic drugs.  What was so striking about our clients was that unlike those who have struggled with weight gain all their lives, they rarely had a problem with their weight prior to their treatment: eating a healthy diet and exercising characterized their lifestyle, and few had ever needed to be on a diet.

Because the data for the BMJ report was derived from electronic records, no information about alterations in food choice instigated by drug treatment was reported. However, several papers (as cited in the reviews below) have pointed to an increase in carbohydrate intake, and the absence of satiety associated with antidepressant use.

Those attending our clinic complained of an almost irresistible need to snack frequently on sweet or starchy foods and some (although usually those on mood stabilizers) would report eating a second meal an hour or so after the first, because they did not feel full. A professor of psychiatry at Boston area hospital shared the experience of a patient on Remeron who woke up every night to eat boxes of crackers and cookies.

The BMJ report did not offer information on whether weight was lost after withdrawal from antidepressants; presumably, after the psychotropic drug(s) is no longer in the body, appetite should return to normal. There have been reports of patients unable to lose weight despite dieting and exercising, sometimes for months and indeed years, after they have stopped their medication – but this information is largely anecdotal.

Recognizing the contribution of psychotropic drugs to the rising rate of obesity may lead to interventions to prevent or diminish weight gain. Ideally a patient should be advised on diet and exercise at the initiation of the drug therapy, but one wonders whether adhering to a regimen to prevent weight gain is practicable for a patient while still symptomatic. Moreover, often the dietary advice, although well intentioned, may be counterproductive if it includes restricting carbohydrates. Since the synthesis of serotonin depends on the consumption of carbohydrates, and since not only mood but satiety is dependent on serotonin activity, offering a low carbohydrate diet may only exacerbate the cravings and the absence of satiety.

Acknowledgment by practitioners of the real possibility of weight gain as a side effect of psychotropic drug treatment, and the availability of Individual and/or group weight loss support must be part of the treatment plan.  Obesity is not a benign side effect; it has well known health consequences, and may significantly affect the quality of life of the individual. Social isolation, employment discrimination, embarrassment at a body no longer recognizable are but a few of the consequences. Consideration of a patient’s weight status prior to treatment is also important;  a drug like Remeron known to cause uncontrolled eating may catapult an overweight individual into obesity.

Those who have gained weight as a consequence of their psychotopic medication have been invisible as a sub-group among the obesity community. One hopes that this report is the first step in making us notice and help them.