If We Had More Time to Eat, Would We Eat More?

The national eating day, Thanksgiving, is unusual in several respects. People who rarely cook spend hours in the kitchen transforming a rather ungainly raw bird into something beautifully edible and making artistic creations out of mashed sweet potatoes with marshmallows.  Stale bread that otherwise might be fed to the birds is turned into a complex dish that may or may not cook inside the turkey.  The table is formally set, and many courses with numerous dishes are served.  And the meal will take time.

Unless they have another Thanksgiving meal to go to, or feel compelled to Christmas bargain shop, guests are happy to dine leisurely. The meal may take considerably more than an hour, and rushing through is restricted to getting seconds on desserts before they are gone.  In this respect, Thanksgiving and other major holiday dining differs significantly from the way many of us eat the rest of the year.

That we eat more on Thanksgiving than on other days is not disputable.  Serving excessive amounts of food is appropriate, and we are expected to eat until we feel stuffed, and then eat some more. But would we eat so much if there were less time to do so?  Would we eat less if, like so many other days of the year, late afternoon/early evening activities and obligations shorten supper to a grab-and-chew type meal, rather than a sit-down dinner? Would we change the amount of food we eat if we actually sat and ate breakfast and lunch, rather than standing in line for take-out and then quickly consuming it before going back to work? Is eating quickly a prescription for too much, or too little food intake?

A few weeks ago I was having lunch with a relative who works for a large law firm. She kept looking at her watch as we stood in line for our salads at a food court. “They don’t like us to take more than 30 minutes for lunch,” she told me. “I hope I have time to eat.”

She is not alone. For many of us, eating is something we fit into our busy schedules often while we are doing something else, e.g. sending messages on our cell phone, working at our desks, or driving.

Hypothetically, if we have very little time to eat, we should be eating very little. A muffin or bagel for breakfast and two slices of pizza or a tuna wrap for lunch feels like fewer calories than a traditional breakfast of eggs and toast… or a lunch of baked chicken, potato, vegetables, roll and dessert. However, often when we choose foods that can be eaten quickly, we don’t notice that they can be calorically dense. A muffin or bagel with cream cheese may contain 600 calories, and a tuna salad sub with mayonnaise and cheese delivers as many calories as the hot lunch.

When we do not have time to eat, we may do it so quickly that we dump more food than necessary in our stomachs, like someone competing in an “All the hot dogs you can eat!” contest.  Sometimes when we gulp our food we don’t even notice how much we are eating. This is also true if we are multi-tasking while putting food in our mouths.

Sitting for a long time at a meal has its own perils. We may find it impossible to resist eating more than we intended to because we have the time and the food, especially the desserts, are there to tempt us. We are no longer hungry, yet the cookies or nuts or chocolate or pies are still on the table and it is hard, unless we are sitting on our hands, not to reach for them. A friend who often hosts long, leisurely meals told me that guests who resist eating dessert when she first serves it will often reach for the cake or cookies later on if they are all still sitting and chatting. Of course, meals that are interrupted by speeches between courses are a perfect prescription for overeating. The guest is a hostage to someone’s boring talk and eating seems to be the only way to endure it.

On the other hand, if we have the time to have an “appetizer” of carbohydrate, e.g., a roll, rice cakes, or crackers about 20 minutes before we start our meal, we may find ourselves eating less.  The carbohydrate potentiates the production of the brain chemical serotonin, and that in turn will make us feel somewhat full before the meal begins. This helps control how much we eat subsequently (a critical aid for dieters), and causes us to stop eating before we clean our plates.  But when time is limited, eating quickly and without the benefit of the satiating effects of serotonin, we could be eating more than we should.

Either too much or too little time can disrupt moderate and reasonable food intake. But certainly we should take the time to enjoy Thanksgiving for its own sake regardless of how much, or how long it takes to eat.

Who Cares for the Caregivers?

Her husband’s Parkinson disease had progressed significantly since we’d last seen each other and her stress progressed along with it. The kitchen counter was covered with pill containers and dosing schedules; the wheelchair was sitting by the ramp to the car and her husband waiting patiently for his aide to help him get dressed.

My friend, let’s call her Mandy, barely said hello before launching into a description of the difficulty she had getting her husband ready for bed the previous night. Apparently, he sat in the wrong chair in the living room while watching a football game. The chair did not have the jack that would propel him to his feet. It took two hours to get him upright and ready for bed in a tiny room near the kitchen. He could no longer climb stairs to their bedroom. She was exhausted and near tears.

Her situation is repeated in homes throughout the country where one spouse or child or elderly parent is losing physical, and often cognitive, strength due to neurological diseases that get worse over time. My friend is one of the fortunate ones. She is able to afford the service of professional aides and a physical therapist because of insurance purchased many years earlier when they were both healthy. Someone much stronger than she is can carry out the actual “heavy lifting.” That person is experienced in how to move a body that cannot move itself without great difficulty. But like so many others, she is dependent on the aide showing up, and she has to scramble to find people to fill in on weekends and holidays.

The Family Caregiver Alliance, a non-profit organization that provides support for people like my friend, a so-called informal caregiver, states that the numbers of unpaid caregivers in the U.S. in 2015 is about 43.5 million. Their caregiving, if paid for, would cost more than 470 billion dollars a year. More than 75 percent of the caregivers are women, and more than two-thirds of those receiving care are also women. It is estimated that 20 hours or more each week is devoted to the needs of the spouse, child, or parent so the informal caregiving is akin to an unpaid part-time job, with few entire days off.

Anyone who has filled this position knows that the tasks range far beyond giving out medicine at the right time. Often the number of tasks increase to the point where the patient needs help in just about every activity of daily living, from dressing and undressing to personal hygiene and being fed, and the responsibility of running the household, paying bills, and making medical appointments. The must-do list simply grows longer as the impairment from the disease increases.

The toll this takes on those who give the care is well-characterized and predictable. Just about every aspect of life is affected: sleep, physical and psychological well-being, work, socializing, pursuing personal interests, and hobbies. They all give way to the needs of the patient. Simply getting out of the house to do more than a quick trip to the supermarket or dentist is a rarity for many.

Mandy lives in a residential neighborhood only a few blocks from a library, stores, restaurants, and a supermarket so she sees other people when she takes her husband for an outing in his wheelchair. And she manages to get to a yoga class once a week when her husband is with his aide. But she has rarely has time to work on a collection of essays she has been writing, and her former volunteering activities have been abandoned. But she is fortunate; at least she is able to leave the house a few times a week.

Some diseases are easier to deal with than others, but no one gets to choose. When the caregiver is able to still share an emotional and cognitive life with his or her spouse or partner, the caregiving is bearable. But if the patient is unable to communicate and respond to the caregiver, it makes the caregiving even more difficult. Despite that it is the disease, and not the individual, who is responsible for the changed behavior; it may be extremely hard for the caregiver to hold onto that fact when dealing with unexpected anger, depression, apathy and sometimes non-recognition. In a study of the emotional burden carried by the caregiver, Croog, Burleson, and their team reported that anger and resentment was a common complaint along with lack of personal time and social isolation. There are support groups for the ‘”informal” caregivers, and they are geared toward helping with the specific problems presented by a disease, for example, Alzheimer’s, Parkinson’s, or ALS.

Over a cup of coffee, Mandy told that that the one thing she did not expect, as her husband’s symptoms worsened, was being alone so much of the time. “We have many friends; we both lived in this community for decades. But very few come to visit anymore, and we rarely are invited to other people’s homes because of lack of wheelchair access. And some people just avoid us because somehow they don’t know how to act around someone with a debilitating illness.”

Fortunately, my friend is strong and resilient, an excellent manager and a person who is able to meet the unending obligations she encounters. But she, like so many others in her situation, would like to have someone who understands and can share with her the difficult emotions and conflicting feelings she is experiencing in fulfilling the “in sickness” part of her wedding vows.

She too would like some care.

References

Spouse caregivers of Alzheimer patients: problem responses to caregiver burden. Croog SH, Burleson JA, Sudilovsky A, Baume RM. Aging Ment Health. 2006 Mar;10(2):87-100.

Does Halloween Begin the Trifecta of Weight Gain?

Soon after Labor Day, almost before the bathing suits of summer have been put away, bags of miniature Halloween candy begIn to appear on supermarket and drugstore shelves. Those tiny candy bars will be devoured to celebrate a holiday that has nothing to do with candy, and the hundreds of calories they contain will initiate the fall season of weight gain. Soon the black and orange wrapped candy will be replaced by chocolate turkeys for the national binge day, Thanksgiving, and then towers of green and red wrapped candies, cookies, and cakes will be displayed for the December holidays.

It is understandable how Thanksgiving and Christmas became holidays characterized, in part, by excessive consumption of special foods that are usually replete with cream, butter, sugar, egg yolks and chocolate. In the old days, these holidays represented the few times a year when expensive, scarce food stuffs like sugar, chocolate, costly cuts of meat, and exotic fruits like oranges, and special alcoholic drinks were served in liberal portions.  Religious and national events like Christmas, the 4th of July, or the yearly fair have always been celebrated with copious amounts of food.  Often guests contributed their own special recipes to a gathering, and it was not unusual to have several main dishes, many sides and a large number of desserts. No one worried about how many calories were eaten because food intake was frugal and, for some, even scarce for the rest of the year.  But now, of course, the caloric excesses that begin with devouring miniature candy bars and end with New Year’s Eve buffets may not be compensated with frugal eating the rest of the time.

But how is that Halloween, a holiday which originated as a religious event, has metamorphosed into the opportunity to eat excessive amount of sugars, fat, artificial flavorings and color while wearing a costume? And how is it that the attempt by some food companies to reduce sugar content in many of their products is being offset by large confectionery companies marketing Halloween candy? And how, as our nation becomes fatter every year, are we going to continue to allow this?

Collecting, counting, and collating the candy gathered during an evening of trick or treating is a relatively new phenomenon. To be sure, hordes of face-painted or masked kids have been roaming the streets on Halloween, ringing doorbells and asking for handouts for many decades. Mid-20th century, the handouts were rarely commercially packaged miniaturized candy bars. Treats like cookies, popcorn balls, Rice Krispy squares, brownies and fudge were often homemade. Candy corn, invented in l880, Hersey’s Kisses in l907 and M+M’s in l941, along with a smattering of regular size candy bars, were available as treats, but competed with homemade chocolate chip cookies. Then we became scared of anything that was not made and sealed in a factory. The appearance of razor blades in apples and the possibility of toxic ingredients in homemade baked goods frightened us into allowing our children and ourselves to accept only commercially produced, sealed snacks like miniature candy bars and tiny bags of candy corn. And the confectionery companies responded. Any candy that could be shrunk, wrapped in Halloween colors, put in a large bag and sold in bulk, was.

Of course, the calories per candy item were also shrunk because the candies were one big bite.  Alas (and the candy makers know this), we think, “They are so small, how could they be fattening?” and pop three or four tiny Snickers or Butterfinger bars into our mouths.  The little candies can be stashed in drawers, brief cases, knapsacks, glove compartments, pocketbooks and pockets and constitute an almost endless supply of sugary, high-fat treats—and calories. And so the season of fattening ourselves up begins.

The over-consumption of sugary treats falls at the time of year when we may be feeling stressed because of after-summer vacation workload for adults and for kids, homework.  Are we craving candy because as darkness increases, our good moods decrease? Would chewing through a mound of candy corn be as appealing in the middle of July as it is at the end of October?  We know that the good mood brain chemical, serotonin, is made when any carbohydrate (sugar, starch) other than fruit is eaten. Is candy more appealing than a bowl of oatmeal that brings about the same feelings of calm and comfort?

It is hard to find any good reason for children or adults to consume mounds of candy. In an ideal world, the plastic bags of miniature candy bars would be replaced by bags of vacuum-packed apple slices, or oranges or baby carrots. Treats might also include pretzels, popcorn, miniature protein or high fiber, high-energy bars or breakfast bars. These have the virtue of being low or fat-free, have some nutritional value, and, after the holiday, can be put in a lunch box for a daily snack.

But how are we going to stop the avalanche of fall candy consumption? It means pushing back against the confectionery companies so that like the large soda manufacturers who have reduced sugar in their drinks, they see a profit in offering healthier Halloween treats. It means working within neighborhoods and schools to convince everyone to resist dumping handfuls of candy bars into plastic pumpkins held by seven year-old trick-or-treaters. Perhaps people can be convinced to donate some of the money that would have been spent on candy to a local food bank and contribute the rest to the local school or neighborhood center for a Halloween party.  Halloween is a holiday made for fun, and surely we can figure out how to have fun without the candy calories hanging on our hips the next day.

Excessive Exercising: Is it About Fitness or a Compulsion?

Whenever I am in my gym, I see a skinny but well-muscled woman working out. She is there, already dripping with sweat, when I arrive, and she is there when I leave. My workout schedule is somewhat erratic, but regardless of when I arrive, she is there.

I suspect she is suffering from exercise bulimia, a disorder characterized by compulsive exercising to burn calories. Unlike bulimia, an eating disorder in which large quantities of food are consumed and then quickly removed from the body by vomiting or excessive laxative use, someone with exercise bulimia may be consuming only normal amounts of food. Normal, that is, to most of us. In a desire to attain a very low weight and keep it off, the exercise bulimic tracks every calorie consumed and makes sure that the exercise burns off enough calories so no (gasp!) weight is gained. If in a moment of weakness, a small bag of potato chips or a kiddie size ice cream cone is consumed, exercise to get rid of those calories begins as soon as possible.  And if for some reason it is impossible to exercise—for example, a cyclone has just destroyed the individual’s house—an overwhelming feeling of despair, agitation, and helplessness is experienced. These feelings may be similar to those experienced by someone who has consumed an enormous amount of food, and then is unable to get rid of it by vomiting.

It is difficult to distinguish a compulsive need to exercise, a need that may take priority over other activities, from the desire to excel in a competitive sports event. Someone who trains for a triathlon by swimming, biking and running long distances, can look as if he has exercise bulimia because the pressure to do well in these three activities requires hours and hours of physical activity. But there are two critical differences: the intense workouts required for a competitive event come to an end when the event is over, and the exercise is not coupled with the goal to work off calories. Indeed, the individual in training often increases significantly his or her calorie intake in order to replace the calories used in exercise and also to prevent muscle wasting.

Although weight loss, stamina, muscle strength, and overall fitness may increase because of the incessant exercising, the health risks of compulsively exercising eventually outweigh the benefits. When women lose too much body fat, they stop menstruating and become vulnerable to significant bone loss. Continuous fatigue, and injury to tendons, ligaments, muscles and bones (e.g. tendinitis and stress fractures) may result at any age; these injuries and fatigue rarely stop the exercise until the injury becomes too severe to continue.

Like the purging that occurs after the excessive eating of bulimia, excessive exercise is used to prevent calories from turning into fat and weight gain. To the person with this eating/exercise disorder, it is as if every item of food comes with a label that reads, ”Must exercise strenuously to use up calories in this food!” and then the food label lists the number of minutes or hours of exercise that have to be performed.

”You just ate a doughnut? Run on the treadmill at a high pace for 45 minutes!”

What makes this type of exercise “purging so destructive to health is that every morsel of food is regarded as an enemy of low weight.  It doesn’t matter if the food is healthy and required for nourishment or eaten for pleasure; its calories must not remain stored in the body.

Ironically and sadly, excessive exercise can increase the appetite and cause an inevitable need to eat more. Athletes in training consume much more food than when they are not preparing for a competitive event. So the exercise bulimic who has spent three hours in the gym may go home and eat a big meal because he is really hungry. And then he feels compelled to go back to the gym to work off the calories.

Breaking the cycle of exercising compulsively to get rid of the calories just consumed is difficult. There is the problem of the compulsion itself, a behavioral state of mind that is not easy to change. There is the guilt and anxiety that must be dealt with if exercise is prevented, and also the anxiety and depression that might drive overeating itself. And underlying all this is the uncertainty and bewilderment over what constitutes appropriate food intake. How does one convince an exercise bulimic that the body needs a certain amount of calories to function; that the body demands a variety of nutrients for basic physiological functions; and that the brain needs glucose for energy and other nutrients like amino acids in order to produce the cellular connections that allow it to communicate?

Might the exercise bulimic be helped if he or she stopped eating real food? If every morsel of food announces to the exercise bulimic how much exercise has to be done to remove unwanted calories from the body, why not switch to a food stuff that supposedly has the perfect number of calories for the exerciser’s body?  One possibility is a synthetic food called Soylent that was engineered to meet the needs of people such as programmers who don’t want to waste time eating real food. Rob Rhinehart developed Soylent, a liquid meal replacement, and it provides all the nutrients needed to meet daily caloric and nutritional needs.  Soylent is supposedly palatable, but not so wonderful in its taste and texture, so that anyone would be tempted to binge on it.

If the exercise bulimic is convinced that the food being consumed is in balance with the body’s caloric needs, the compulsion to exercise may diminish. If not, this will be indicating that the exercise is not really based on caloric intake, but instead a compulsive disorder played out in the gym.

Distracting Yourself Into a Better Mood

“My head is full of stuff I am worried about today,” a fellow gym member told me as we were about to start a yoga class. “So if I am standing up when everyone else is sitting down, it is probably because I am not paying attention to the instructor. “

She was right: She was so self-absorbed in her worries that she was always about two yoga positions behind everyone else. About halfway through the class, I noticed her keeping up with the instructor’s moves, and no longer looking so worried.

When the class was over, she said, “I feel so much better! Once I started to focus entirely on whether I was in the correct yoga position, I was distracted from the laundry list of problems that had been bothering me.“

Yoga is one of many distractions that work to relieve, or at least subdue, a variety of emotions from boredom (e.g. “HOW long do I have to wait on the telephone to speak to a representative?!?”) to depression, anxiety, anger, and worry. Think of the scene in a movie or television where people are waiting to hear news about an operation. Someone always says, “Let’s go to the cafeteria and get some coffee.” The coffee is not what is desired; it is the distraction of moving to another place and engaging in another activity (buying and drinking coffee) that may somewhat help relieve the tension.

Sometimes the lack of distraction makes a situation unbearable. Imagine sitting in a waiting area awaiting your own operation. You are awake and alone and there is nothing to distract you from your anxiety and worry. A friend of mine who recently had his cataracts removed told me that, while he was waiting to be operated on, all he could think was “What if something goes wrong and I became blind?” He said. But, “if someone had been there to talk to me, or even if I could have watched television, I might not have worked myself into a panic.”

So-called Retail Therapy has long been recognized as an effective, albeit short-lived, therapy for anxiety and depression. It works, but has its limitations and unfortunate financial consequences if shopping leads to buying items neither needed nor affordable. The distraction of finding something desired and buying it lasts very briefly, and it is a costly way of keeping away unwanted thoughts. But certain shopping venues like gigantic flea markets, or bargain warehouses that require lots of walking and poking through piles of stuff that ultimately are rejected for purchase? They effectively focus the mind and move it away from unpleasant emotions.

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Distracting Yourself Into a Better Mood

Redirecting your focus is a very healthy coping strategy.
Posted Sep 14, 2017
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“My head is full of stuff I am worried about today,” a fellow gym member told me as we were about to start a yoga class. “So if I am standing up when everyone else is sitting down, it is probably because I am not paying attention to the instructor. “

She was right: She was so self-absorbed in her worries that she was always about two yoga positions behind everyone else. About halfway through the class, I noticed her keeping up with the instructor’s moves, and no longer looking so worried.

When the class was over, she said, “I feel so much better! Once I started to focus entirely on whether I was in the correct yoga position, I was distracted from the laundry list of problems that had been bothering me.“

Yoga is one of many distractions that work to relieve, or at least subdue, a variety of emotions from boredom (e.g. “HOW long do I have to wait on the telephone to speak to a representative?!?”) to depression, anxiety, anger, and worry. Think of the scene in a movie or television where people are waiting to hear news about an operation. Someone always says, “Let’s go to the cafeteria and get some coffee.” The coffee is not what is desired; it is the distraction of moving to another place and engaging in another activity (buying and drinking coffee) that may somewhat help relieve the tension.

Sometimes the lack of distraction makes a situation unbearable. Imagine sitting in a waiting area awaiting your own operation. You are awake and alone and there is nothing to distract you from your anxiety and worry. A friend of mine who recently had his cataracts removed told me that, while he was waiting to be operated on, all he could think was “What if something goes wrong and I became blind?” He said. But, “if someone had been there to talk to me, or even if I could have watched television, I might not have worked myself into a panic.”

So-called Retail Therapy has long been recognized as an effective, albeit short-lived, therapy for anxiety and depression. It works, but has its limitations and unfortunate financial consequences if shopping leads to buying items neither needed nor affordable. The distraction of finding something desired and buying it lasts very briefly, and it is a costly way of keeping away unwanted thoughts. But certain shopping venues like gigantic flea markets, or bargain warehouses that require lots of walking and poking through piles of stuff that ultimately are rejected for purchase? They effectively focus the mind and move it away from unpleasant emotions.

Years ago, Boston had a two-story bargain store, Filene’s Basement, where the merchandise was marked down according to how long it had been on the racks. Shoppers hunted for a drastically marked-down piece of clothing or shoes; they rarely found one but considered the hunt itself to be a lot of fun. In order to deal with the death of both parents within a short period of time, one of my mother’s friends told me that she would go to the Basement every weekday during her lunch hour.

“I never bought anything, but searching for the ultimate bargain distracted me temporarily from my grief.”

In order for distraction to work; in other words, doing X to take your mind off of thinking about issue Y, it should absorb all of one’s attention. Moreover, the distraction must be easy to initiate, not necessarily require the participation of someone else, and be convenient. Skill-driven physical activities such as indoor rock climbing or paddle boarding, where loss of concentration means falling off the rock wall or the paddleboard, are effective distractions. Still, simpler and more accessible activities like going to a driving range or playing Ping-Pong also work. Games such as bridge or chess or even group activities such as singing in a choir, or joining a conversation group in a language you are learning? They require total concentration and thus, for a while, are a total distraction. Crossword and other word puzzles work, unless they add a level of frustration to an already difficult situation, like waiting for a long-delayed plane. And sometimes a conversation that forces you to concentrate on what the other person is saying is a distraction from an inner voice that talks too much about your concerns.

Overeating is unfortunately often used as a distraction but, like retail therapy, the distraction is short and the cost, in calories, considerable. Indeed, overeaters are advised to redirect to new distraction activities such as: take a bath, take a walk, make a phone call, see a friend, or read a magazine to decrease the eating. These activities, however, are weak distractions and often are accompanied by the eating they are supposed to halt.

Sometimes thinking outside the box is the only way to identify a distraction that will work. Years ago, a weight-loss client complained that he was eating at night to deal with problems from work he was bringing home with him. “You should find something to distract you,” I told him, listing the obvious contenders.

Nothing seemed to appeal to him. Throwing up my hands in frustration I said, “Well, what about learning to play the bagpipes? That will keep you from eating.”

“What a good idea,” he said. “I have bagpipes in my closet. I haven’t played them in years. I am going to l start playing them tonight.”

I really hope he had soundproof walls.

Moods for Overeating: Good, Bad and Bored

“I am in the mood for  . . .(fill in the blank.)“

How many times have we said this to ourselves or others as we plan lunch or dinner? (Very few people are in the mood for anything except more sleep in the morning.) Sometimes the “mood” for a particular type of ethnic cooking or a prime piece of beef is heightened because the meal is celebratory, or a respite between bouts of unrelenting work or home meal preparation.  But this type of mood-influenced eating rarely lasts beyond a meal or two, and rarely leads to sustained overeating and weight gain. Too many calories may be consumed at a dinner celebrating the completion of a difficult project or an anniversary, but this type of eating rarely results in continued excessive calorie intake.

Not so the type of eating generated by moods we would rather not have. Boredom, and its frequent companion loneliness, may lead to an overly important focus on what to eat as a distraction from a long weekend or evenings alone with little to do. Rainy vacation days with few places to go inside to escape the dreary weather often brings tourists into restaurants for meals for which they may not even be hungry. It is something to do.  Long distance flights generate an appetite for foods that if served on the ground would be rejected immediately. Yet flyers that are not hungry will eat them because, again, it is something to do.

Bad moods are different. Anxiety, depression, premenstrual syndrome, and posttraumatic stress disorder are among negative or dysphoric moods that can provoke overeating, sometimes for days every month (PMS) or years (like PTSD when undiagnosed or untreated). Anxiety seems to trigger the excessive eating of binge eating disorder.  (“Emotional eating, alexithymia and binge-eating disorder in obese women,” Pinaquy, S., Chabrol, H., Louvet, J., Barbe, P., Obes, Re., 2003 11:195-201.)  But anxiety may also cause chronic overeating without the dramatic bouts of excessive food intake seen in binge disorder. In that case, the overeating may be enough to hinder successful weight loss and /or cause small but continuous weight gain. (“The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis,” Gariepy, G., Nitka, D., and Schmitz, N., International J of Obesity 21;2010 34: 407-419).

Sometimes the obesity, which results from “bad mood” overeating, does not appear until years after the mood disorder appears. Researchers who examine the results of longitudinal health surveys have identified participants who have mood disorders at a young age and then become obese many years later. Data from the Nurses’ Health Study that began in l989 was used to see whether women who were diagnosed with posttraumatic stress disorder during the early years of the survey were more likely to be obese in later years than women without this disorder.  They found that having PTSD was a risk factor for obesity; women with this disorder gained more weight than women who experienced trauma but not PTSD and much more than women with neither.  (“The weight of traumatic stress: a prospective study of posttraumatic stress disorder symptoms and weight status in women,” Kubzansky, L., Bordelois, P., Jun, H., Roberrts, A., et al, AMA Psychiatry 2014; 71: 44-51.)

Depression is also a predictor of obesity and, like PTSD, the obesity may not appear for years after the depressive episodes.  Several research groups have used health surveys following male and female participants over many years to look at the weight status of people who were clinically depressed when they entered the study as older adolescents or young adults.  A significant number of them became obese a few or several years after they no longer were depressed. (“Trajectories of Change in Obesity and Symptoms of Depression: The CARDIA study,” Needham, B., Epel, E., Adler, N., Kiefe, C., Am J Public Health 2010; 100: 1040-106. “Overweight, Obesity, and Depression,” Luppino, F., deWit, L., Bouvy, P., et al, Arch Gen Psychiatry 2010; 67: 220-229.) Because the obesity appeared much later than the depression, the weight gain is probably not due to treatment with antidepressants although the studies did not look at this specifically.

 

We know that obesity and emotional overeating are strongly linked; certainly eating in response to anxiety and stress is evidence of this. Sometimes an immediate response to a stress is to grab something to eat. A friend who was renovating an old house told me that the first thing she did after she found that the closets were too narrow to accept a normal-size hanger (after the renovation) was to go to a convenience store and buy candy.  But what explains the development of obesity years after women develop PTSD or among depressed individuals years after the depression is gone?

The problem with looking at survey data as opposed to being able to talk to the people who provided the data is that these questions can’t be answered.  Were levels of physical activity low because of stress-associated fatigue? Did the people who were depressed and then years later became obese suffer in the years in between from chronic “blue mood”? Might they too have been too tired to exercise?  Was food a solution for their moods?  Did they eat to feel better, heedless of the calories they were consuming? Did they eat what they wanted because they had had enough deprivation in their lives and did not want to add the deprivation of a diet to everything else?

More research is needed to know the answers. But what we do know is that when people overeat, the reasons are as likely to be due to their mood as to what is tempting them.

 

Travel Can Leave You Well Fed, But Not Well Nourished

The group of women with whom I was traveling stared at the menu in some dismay. For those who shunned gluten, meat, dairy, and a category of vegetables known to cause intestinal discomfort to some, there was almost nothing to eat.

“Maybe we can find a supermarket somewhere,” one suggested, but then realized that to do so required driving to a shopping mall a few miles away from the gift shop-congested town center. Fortunately, a few protein bars were discovered at the bottom of someone’s tote bag, and hunger was relieved momentarily. We were in a geographical part of the country noted for heat-infused food from chili peppers, the liberal use of melted cheese with pork products, beans refried in lard, gluten-containing flour tortillas, and a notable absence of soy or almond milk for those lactose intolerant.  Although the women were athletically fit and had traveled to spend a few days hiking in remarkable landscapes, their digestive systems did not have the same robustness as their muscles. Eventually, our finding a ride to a large supermarket provided enough food for dinner, as well as snacks for the hikes; an Internet search of restaurants revealed a few that met most of their dietary needs.

But their experience demonstrated how difficult it can be to obtain foods from restaurants in places not accustomed to altering menu options for those whose stomachs need special foods. These days, we assume when we travel, we will be able to get our personalized food needs met.  After all, it is no longer the early part of the 20th century when people traveling on the new highways had to content themselves with eating in small Mom and Pop restaurants their typically questionable cleanliness and food preparation skills.  Standardization of food for highway travelers came only when restaurants like the Howard Johnson franchises opened around the country. Today the ubiquitous fast-food restaurants and the next generation sandwich shops that make salads and sandwiches to order make it relatively easy to find safe and reasonably tasting food.

But even now, eating as a traveler may mean giving up trying to eat a well-balanced diet. The recommended five servings of vegetables and fruit to be consumed each day may not even be consumed in five days. Vegetables rarely appear on the plate with the main entrée, or are reduced in size to microscopic versions of the natural object. Salads and side orders of vegetables are costly, and the vegetables may come coated in cheese, drenched in butter, or breaded and fried.  It is possible, sometimes, to get fruit as a dessert but often the fruit is a few raspberries garnishing chocolate cake or in syrup topping a dish of ice cream. Foods we can obtain at home, such as low or fat-free dairy products (and milk substitutes), may also be hard to find. Many restaurants serving breakfast do not provide low or fat-free yogurt, cottage cheese and milk for cereal and coffee. And finding high fiber foods to maintain healthy and predictable digestion is harder than finding kale in a MacDonald’s.

When traveling is relatively brief—less than a couple of weeks—the scarcity of nutrients or fiber or food items suitable for a limited diet is not going to plunge the traveler into a state of malnutrition. We start our trip well-nourished and certainly are not going to develop scurvy or osteoporosis in a couple of weeks. But many people travel constantly for work and some have the time and financial freedom to travel for long periods for pleasure.  This type of travel can result in more than just piles of dirty laundry to take home; it can affect the nutritional status of the traveler. And curiously, we tend to ignore this problem when packing for a trip.

Packing requires anticipating weather conditions, activities ranging from work to sightseeing and entertainment and even sleeping comfort. But how many of us pack to ensure that we are not surprised by eating environments as unpredictable as the weather? Are we making sure that the eating culture at our destinations will provide food meeting our personal dietary needs? And if not, do we have in our carry-on luggage food items that will prevent us from returning several weeks later in a state of sub-optimal nutrition?

Some simple steps to take before a long trip:

Check out the types of foods typically eaten at the destinations. The Internet will provide this information both from a description of the food highlights of the destination, and also from a brief scan of moderately priced restaurants (these are the ones most likely to be visited, not the very pricey ones).

If breakfast is included in the lodging, try to learn what is served. Sometimes a breakfast buffet will provide foods from all the food groups. (Israeli hotel breakfasts have done this for decades.)

Pack multi vitamin-mineral supplements as insurance against many days of vegetable, fruit and dairy deficient menu options. Lactase pills to digest the milk sugar lactose are tiny, fit into a toiletries bag and allow you to add milk to your coffee or cereal if you have lactose intolerance.

Pack gluten-free baked goods if you must avoid gluten, because eventually a need for some digestible carbohydrate will arise.  Baby carrots, vacuum-packed apple slices, and a sandwich bag filled with high fiber breakfast cereal will provide some fiber. Oat bran cereal can be put in a sandwich bag as wel,l and if the hotel has a coffee maker, the hot water will reconstitute it as hot cereal.

Pack protein bars that contain 15 to 20 grams of protein. These will be useful when the protein on the menu is incompatible with a vegetarian, pescetarian (fish only), kosher, or low-fat diet.

Although these extra items take up space on the outbound trip, their consumption frees up space for the return home to be filled with whatever your heart, not stomach, desires.

Can You Lose Weight If You Don’t Know How to Diet?

Our formerly thin, physically active friend had gained close to 80 pounds following two years of debilitating orthopedic problems that left him with chronic back pain. His previous constant exercise, which included tennis, skiing, long bike rides, hiking, and running had kept his weight normal, but became no longer possible. Now he was able to move only with the help of a back brace and two hiking sticks that he used as canes.

“I am trying to lose weight,” he told us, “but it is slow going.”

When we were guests at his home, it was obvious how physically impaired he was as well as how hard it was going to be for him to attain a weight that would help relieve his back pain. The one day he walked on his long hilly driveway to point out a particularly beautiful landscape, he paid for it in increased pain the next morning. Simply moving from living room to dining room was difficult for him. He talked about how he never needed to diet before he developed a back problem because his level of physical activity kept his appetite down and burned off excess calories. A review of the relationship between physical activity and weight change confirms his experience. (“The Role of Exercise and Physical Activity in Weight Loss and Maintenance,” Swift, D., Johannsen, N., Lavie, C., Earnest, C., Church, T Prog Cardiovasc Dis 2014, Jan-Feb; 56 (4): 441-447.)

Routine physical activity like the type my friend used to do slows, or even prevents weight gain, without any change in calorie intake. And the long duration of many of his physical activities may even have dampened his appetite according to a very recent study published in the Journal of Endocrinology. (“Acute effect of exercise intensity and duration on acylated ghrelin and hunger in men,” Broom, D., Miyashita, M., Wasse, L., Pulsford, R., King, J., Thackray, A., Stensel, D., J Endocrinol. 2017; 232 (3): 411-422.)  Now, however, the beneficial effect of exercise, when added to a reduced calorie diet on hastening weight loss is out of reach for him.

Told by his physician that a substantial weight loss might lessen his back pain has motivated him to decrease his calorie consumption. His strategy, as he told us, is to consume less than he had been eating.  But he has lost very little weight over the past few months of attempting to do just this.  His lack of success may be due to his inexperience in dieting. He doesn’t know how much he is eating, nor does he know whether what he is eating is particularly high or low in calories (he does know the difference, however, between salads and cake.)  Another family member, who has never had a weight problem and likes to cook dishes containing high calorie ingredients, prepares his food. Butter, heavy cream, and cheese are routinely added and her sweet tooth motivates her to bake or buy cakes, cookies, pies and other desserts that are offered to our friend.  Eating in restaurants for dinner (and occasionally both lunch and dinner) occurs frequently, and this adds to the uncertainty of how many calories are being consumed. Overly large restaurant portion sizes, and the habit of chefs to add butter or oil to food to keep them moist, also inadvertently boosts his calorie intake. And, unlike experienced dieters, he has not developed an eye for judging portion sizes and not eating the entire amount if it is too big.

None of this would matter if losing weight were for cosmetic rather than medical reasons. However, when weight loss is crucial to improving health, and, in his case, restoring lost freedom of movement and removing his pain? Dieting must be done with the same care and knowledge as any other intervention to improve health. The approach cannot be casual or haphazard, and would probably benefit from the professional services of a dietician or nutritionist. The type of diet must also be sustainable and balanced nutritionally for the many weeks it takes to lose the necessary weight. Many alleged quick weight-loss diets, so tempting because results after only a few weeks are supposedly so dramatic, often lead to weight gain as soon as the diet is over. (Remember the Oprah Winfrey’s famous fast weight-loss from a low calorie liquid diet, and the subsequent rapid regain several years ago?) Regaining weight is not an option when it may bring about a return of the medical problem like intolerable back pain. Thus the diet plan has to be malleable enough to change into a long-time maintenance program to keep the now lower weight stable.

Being honest with family and friends about how hard it is to lose weight and consequently asking for help will improve the chance of success. Imagine how much more weight our friend would have lost if his meals had been significantly lower in calories and size. Preparing meals at home that that could be made without the addition of fat-dense ingredients such as cheese would help reduce the calories he was eating. If others wanted to add more cheese to their dishes, for example, they could do so after the food was prepared.  His problem in reducing calorie intake in restaurants could be solved by either eating in establishments that served normal-size portions, or ordering appetizers for a main dish or splitting an entrée. The temptation to eat dessert would disappear if it were not on the table in front him.

Dieting is like any new activity. As it is with playing the piano, speaking a foreign language, or planting a successful garden, it has to be learned. Instruction is needed, along with patience, the willingness to practice and make mistakes, and encouragement from others. And like taking on any new activity, even small successes are worthy and worth striving for.

Would Walkable Sidewalks Keep Us Thinner?

A few weeks ago on a trip to a picture perfect Vermont town, we asked the proprietor of our B&B if we could walk to the concert that night.

“You can, sure… it is less than a mile, but it will be dangerous walking home in the dark. There are no sidewalks and no street lights,” she told us.  So we drove, despite feeling silly at using the car for such a short distance, but happy we had done so when we left the concert. Ground fog was adding to the darkness in concealing the road, and we were sure we would not have felt safe walking back up the hilly, winding route.

The next day, we chatted about the lack of sidewalks and street lights with our hostess. She told us that daytime walking on the roads was manageable in the non-snow months, but not in the winter; the snow banks reduced the width of the roads and eliminated any possibility of stepping off the pavement.  “See, there’s is no side of the road to stand on when a pick-up truck comes speeding down the mountain….no one walks; it’s just too easy to be hit.”

There is no lack of activities in Vermont to provide opportunities to exercise, even if taking long walks in the winter is not one of them (Unless it is on a packed snow trail.) But unlike the quick convenience of going out the door to take a walk when sidewalks (plowed, of course) do exist, the lack of sidewalks in suburban or rural areas makes this simple activity difficult to carry out.

For the exercise committed, there are, of course, numerous opportunities to engage in physical exercise regardless of weather or environment. Not so for those who prefer being sedentary and are unlikely to seek out opportunities to move. In an episode of a television program focused on finding a house to buy, the client announced that she was too old (she was in her fifties) to buy a house with stairs. “Too much walking, “she told her realtor. Not surprisingly, the community in which she was house hunting had no sidewalks. If this woman had been advised to walk for her health and weight, she would have had a ready excuse. “Where? There is no place to walk where I live!”

No one has to be told about the rising incidence of obesity. Simply looking around confirms its prevalence, although the effects such as diabetes, back & leg pain, as well as the increased risk of certain types of cancer are silent.  One obvious culprit is that we eat too much, in part because portion sizes of just about everything have increased. Another fault lay in that we no longer live a lifestyle readily allowing us to burn off those excess calories. When physical activity was unavoidable in order to earn a living and maintain a household, a large caloric intake provided the fuel for the constant physical activity.  Now caloric intake has remained the same, or most likely increased, while physical activity has become optional for the most of us most of the time.

Because they eliminate a source of calorie use, might the absence of walkable sidewalks be a contributing factor to the continuous rise in obesity? The Journal of the American Medical Association (“JAMA”) published a study in 2016 showing that residents living in walkable urban neighborhoods had a slower increase in obesity and diabetes than those living in less walkable ones.  For this specific research, almost 9,000 urban neighborhoods in southern Ontario were studied over more than 11 years.  This study’s “Walkability Index” was based on safety of the sidewalks, the residential and commercial density, cross walks at intersections, schools, coffee shops, banks, and other retail establishments which might be walkable destinations.  People living in the walkable neighborhoods, and New York City is another example; they use sidewalks not only to get to their routine destinations like work, stores and restaurants but as places for urban hikes. These city dwellers may spend an entire day outside, hiking and exploring different parts of their city. The seemingly limitless places to walk allow them to do so.

However, it’s important to note the benefits of walking by city dwellers are not available to residents of towns such as the one we visited in rural Vermont. The population density is too low to justify the expense of sidewalks, and indeed many of roads are not even paved. Of course there are numerous places to hike, but this activity is not only seasonally limited, but also limited to people whose stamina and age enable them to climb mountain trails.

Perhaps the answer is to emulate many European cities which have set aside parkland filled with paved paths for walking. From my limited experience of these parks which I have seen in Holland, France and Germany, they are usually filled with walkers early in the day and then especially in the summer, after dinner. Benches are numerous for those who need to rest or just admire a view.  Strolling through one of these walking parks has the additional advantage of allowing members of a community to see and talk with each other. People often walk in small groups, or stop and greet others coming in the opposite direction. When so many members of a neighborhood are out walking?  It is easy to see this activity as a routine and healthful aspect of the day.

Eating less to prevent weight gain and/or lose weight is difficult because potential temptation lurks in the next meal. Walking may not compensate entirely for excess calories, but it can have a positive effect on preventing weight gain… unless of course, one walks to the doughnut shop.

Cite: Association of Neighborhood Walkability With Change in Overweight, Obesity, and Diabetes. Creatore M, Glazier R, Moineddin R.  JAMA  2016, 315; 2211-2220