Surgery Can Remove Hunger, But Can It Also Remove the Emotional Need to Eat?

Dieting may be the traditional method for losing weight. Yet more and more obese individuals are giving up counting calories and measuring their food and instead are turning to surgery. Advances in bariatric surgery over the past 10 or so years has made possible a relatively short, simple operation to turn the pouch-like stomach into a skinny sleeve that holds no more than 2 to 7 ounces of food. The operation, called the gastric sleeve, is done laparoscopically, which means recovery is quicker than conventional surgery.  According to the American Society for Metabolic and Bariatric Surgery, almost 42 percent of all bariatric surgeriesperformed in the United States in 2013 were sleeve gastrectomies,i.e., it’s currently the most popular weight loss surgery.

The operation is non-reversible; the major part of the stomach, which looks like a mildly curved banana pouched at one end (as if the banana swallowed a golf ball), is cut away. The original stomach cannot be reconstructed any more than a pair of jeans can be reconstructed after the legs have been cut off to make short shorts.  The stomach still functions, but eating has to be miniaturized. Eventually, the stomach may stretch somewhat so food does not have to be measured with an eyedropper. Still, people who have had this operation will be unlikely to be able to eat a large pizza or a 12-ounce steak unless they spread the eating over several days.

Fortunately, one of the biggest advantages to this type of weight loss surgery is that when the fundus, that bulge at the bottom of the stomach, is removed, so too is ghrelin (rhythms with melon). Ghrelin is an appetite-stimulating hormone produced in the fundus. Normally, when the stomach is empty or (and this is bad news for a traditional dieter) when low calorie diets and/or chronic exercise regimens are followed, more ghrelin is produced. Hunger does not make dieting easy. Ghrelin goes up before meals and, not surprisingly, decreases after food is eaten. But the gastric sleeve surgery significantly decreases this hunger hormone.

The resulting lack of hunger is so striking that for months after the surgery, patients must remind themselves to eat. Consequently, during the post-operative year, weight is lost easily and many of the medical complications of obesity-like diabetes are lost as well. But as with other types of bariatric surgery, getting to a goal weight is not always attainable. It is possible to gradually restretch the stomach enough to hold more food and more calorically dense food.

But for most, the hunger may be gone, but the need to eat remains.  As a woman wrote on an Internet site devoted to bariatric surgery, the operation does not ‘mend the mind.’ She was describing her need to eat sweets when she was tired or stressed. Others chimed in with their stories of being unable to control their eating when they experienced the mood and appetite changes of PMS. A man wrote in about drinking alcohol again as a substitute for eating candy to which, he said, he was addicted.

Will power, the surgically imposed inability of a now skinny stomach to hold much food at a time, and motivation to reach a healthy weight, keeps many from giving in to these cravings. But for some, not capitulating is like not taking a pain reliever during a bad headache or backache. These individuals use food as a sort of self-medication; they eat when they are depressed or anxious, or in an irritable mood and by doing so, feel better. The improvement in mood is not wishful thinking or a placebo effect.   

Nature gave us a way of eating our way out of stress. We can do so by consuming carbohydrates that, in turn, results in the production of the brain neurotransmitter, serotonin.  Serotonin is made when the amino acid tryptophan enters the brain. It does so only after starchy or sweet carbohydrates are eaten. (Eating fruit does not have this effect.) Eating small amounts of carbohydrate increases serotonin levels within about a half an hour.

Serotonin levels may fluctuate during the day, leading some people to feel a serotonin low in the afternoon. Serotonin is also lower during PMS and the dark days of winter.

However, nature never intended for the carbohydrates to be consumed in the form of cookies, chocolate, ice cream, pie, doughnuts, muffins, cinnamon rolls or strudel. The effect on producing serotonin is just the same if steamed rice, plain pasta, unadorned bread, unsweetened cereal, and boiled potatoes are eaten, rather than the fat and sugar-filled pastries or salt and fat-filled crunchy snacks. Again, it is unnecessary to eat large amounts of carbohydrate; about 25-30 grams, the amount in a small bag of fat-free pretzels, is sufficient. Presumably someone could consume this amount with a sleeve-like stomach once enough months passed since the operation, and real food is once again being eaten.

Of course it would be better not to eat out of emotional need. It would be wonderful if those of us who think ‘I have to eat something’ when confronted with a distressing situation or experiencing PMS, stopped feeling this way and managed to get through the stress or PMS without giving in to ourselves.  But our brains are not all alike in this regard, and there will always be some of us who really need to eat some carbohydrate when we are upset. Only a brain transplant will stop us from doing so!

Post-operative gastric sleeve patients are given detailed instructions on how to eat to recover, regain their strength and not alter the size of their tiny stomachs. Would it not be helpful for these instructions to include how to eat to minimize stress without risking weight gain? Shouldn’t women be helped to get through their premenstrual days without imploding by showing them that tiny amounts of carbohydrate can have a enormously positive impact on their mood? The same remedy applies to people suffering from the winter blues, as well. Information about post-op refeeding should include the fact that the absence of carbohydrate will decrease serotonin, and perhaps lead to depressed or anxious moods.

Patients who eat out of emotional need can be taught to consume controlled, small portions of non-fat, non-sugary carbohydrates. By doing so, they will find that their emotional well-being will match their improved physical well-being.

How Do You Milk An Almond?

“My trainer told me that I should drink a shake each morning made with almond milk, protein powder, and fruit.” The young woman was discussing her new fitness routine with a group of us drying our hair in the health club’s locker room.

“Why almond milk?” I asked, wondering how to get milk from an almond.

The answer, agreed to by everyone listening to the conversation, was that almond milk was much healthier than milk from that definitely milk-able animal, a cow.

“But almond milk doesn’t have any protein, well, at least not much,” I responded, trying to remember when I had last read a food label on the side of an almond milk container.

“That’s all right,” she replied. “I just add some protein powder to the shake.”

At this point, my wet hair demanded more attention than her nutritional needs, so the conversation stopped. But later on that day, while in the supermarket, I stopped by the milk case to read food labels. I was right. Almond milk contained only 1 gram of protein per serving. Cow’s milk contained 8 grams. But to my surprise, almond milk contained a lot of calcium, actually about 45 percent of the daily requirement for this mineral. But where was the calcium coming from? Almonds don’t naturally have much, if any, calcium. There it was on the label: calcium carbonate, an additive. So why not instead, eat some almonds and swallow a calcium supplement?

Almonds are natural, but almond milk? Well, it’s not quite as natural as cow’s milk. It contains sea salt, carob or vanilla bean extract, cane or brown rice sweetener, emulsifiers and preservatives, added Vitamin D and, of course, the added calcium carbonate.

At least my locker room acquaintance was getting protein from the protein powder she added to her blender. But is protein powder as good a source of protein as that derived from real food, e.g., milk or eggs? Trying to ignore my mild obsession with her breakfast, I looked up the nutritional adequacy of protein supplements. It was not a topic for the faint-hearted. Claims for bodybuilding power were as thick as mosquitoes on a humid summer evening. And reading on, I came across blogs with horror stories of protein powders containing rat droppings, heavy metals, and genetically modified plant extracts. Who writes these stories? Were they true?

It is necessary to get beneath all the hype promoting the potency of one protein powder over another to find out about the amino acid contents of these various powders. In order to make new protein, for muscle, skin, or any other organ that needs new or replacement protein, our bodies must have amino acids. Protein is made from amino acids and although we, as humans, can make some amino acids, there are eight, the essential amino acids, which we cannot. We get them from the proteins we eat. Not all proteins contain adequate amounts of these essential amino acids, and are ranked according to their amino acid contents.

Two of the most widely used proteins in muscle building supplements come from milk: casein, which gives milk its milky look, and whey, the watery residue formed when cheese is made as in “Little Miss Muffet, sat on a tuffet, eating her curds and whey.” (Curds are goes into the making of cheese.) Miss Muffet’s muscles must have been outstanding, since whey protein is especially good for building muscle. Perhaps this is why she was able to run so fast when the spider frightened her away! The other widely used protein in protein powder supplements is soy isolate, which is produced in a concentrated form, from soybeans.

The Chinese have known about the importance of eating soybeans since approximately 2838 B.C., but they probably did not consume it as a muscle-building protein powder until late last century. And because the amount of essential amino acids is smaller in soybeans than in animal protein, it was assumed that soy was not a particularly good source of protein for athletes, or anyone attempting to develop a large muscle mass. However, in a review of which proteins athletes should consume, Drs. Hoffman & Falvo, in the Journal of Sports Science and Medicine, pointed out that the concentrated form of soy protein has an amino acid content equal to that of whey and casein.

So for people who would rather drink their meals rather than eat them (no, not a regimen of beer for breakfast and liquor for lunch), soy protein powders are an option, along with powders containing either of the two milk proteins.

But other than eliminating the pesky need to chew, is it better to drink a shake for breakfast containing purified and/or synthetic ingredients than to eat foods in their natural state? On one hand, the answer is yes. Blending rather inedible foods with other foods that taste good (for instance, raw kale and blueberries), makes their consumption less of a challenge and permits the consumption of foods that otherwise might be overlooked. Moreover, shakes can be consumed more easily than a bowl of cereal and milk in the car, or on commuter train, or while hanging onto a trolley car strap.

But we seem to be straying away from eating foods in their natural state and perhaps, ironically, eating more foods that are highly processed. Dumping synthetic foods like almond milk and highly refined foods like protein powder in a blender is not eating naturally. Maybe the time has come to go back to eating real food: milk from cows, eggs from chickens, bread made from wheat flour, and turkey made from turkeys (instead of tofu). If we do so, we can stop trying so hard to get milk from almonds.

Are We Working Ourselves To Death?

If you are an executive, manager, emergency medicine physician (EMP), Silicon Valley employee or struggling law associate, you and many like you are probably working more than 60 hours a week. According to a survey published in the Harvard Business Review a few years ago, you may be working an average of 72 hours a week.

Contrast this with the government’s desire to limit excessive working hours about 80 years ago when, on June 25, 1938, Franklin D. Roosevelt signed into law the Fair Labor Standards Act (FLS). This law banned oppressive child labor, set the minimum hourly wage at 25 cents, and the maximum workweek at 44 hours.

Moreover, more than a hundred years ago, workers were given an entire weekend off from work. (How many EMPs can expect this?) The five-day workweek was started in 1908 by a New England cotton mill owner to allow Jewish workers to observe their sabbath on Saturday. They were expected to make up the work on Sunday but complaints about having the mill operate on a Sunday resulted in closing the factory for the entire weekend. Later, in l926, Henry Ford shut down his automotive factories for the entire weekend. He wanted his employees to have leisure time to buy automobiles. The Amalgamated Clothing Workers of America Union demanded a five-day workweek in 1929, and received it; but it wasn’t until 1940 that the two-day weekend was adopted countrywide.

But now, many people work at least 10 hours daily or longer; some companies even provide dinner to make sure their employees stay late. Salaried employees often are tethered to their smartphones during the weekend and expected to be available. Their jobs often require working throughout the weekend. If their company, sensitive to criticism that their employees have no time off at all, tells them not to work one day during the weekend, the employees find themselves working twice as hard on the other day to catch up with the work handed to them on Friday afternoon. To be sure, their work load is not as relentless as that of a galley slave who was chained to his bench for the length of his servitude, rowed for up to 20 hours a day, was whipped incessantly and fed vanishingly small rations. They, by and large, did not live long. But now we are learning that the modern day equivalent of the galley slave may not live out his or her natural life expectancy either.

The medical journal, The Lancet Online First, published an article recently comparing health risks of people who worked 55 or more hours weekly compared with those who worked 35-40 hours. Working many more hours was associated with a 13% increase in the risk of cardiovascular disease and a 33% increase in the risk of a stroke compared to working 35-40 hours (the so-called normal work week). The report is sobering. The many researchers who contributed to the study pooled information from 25 different studies that tracked the health of adults for 7-8 years. When the study began, the more than 600,000 participants had no evidence of coronary heart disease and nearly 530,000 of them had no evidence of stroke. Seven or eight years later, the formerly healthy workers who had the greater work burden were now facing medical risks that might shorten their longevity. The scientists searched for reasons. Was it economic status, smoking, age, gender and/or weight? What might be contributing to these dire findings? The answer was none of the above. Only working 55 or more hours per week was associated with these risk factors. 4
Interestingly, the authors did not conclude their article by suggesting a decrease in working hours. Rather, they said that employers should pay attention to identifying and managing heart attacks, stroke, high blood pressure and other symptoms of cardiovascular risk among their employees. Maybe they meant that employers should be trained in CPR in case a worker keels over in his cubicle.

The reasons for a deterioration in health associated with galley slave-like hours are not hard to find: stress, depression, lack of sleep, lack of exercise, lack of fresh air and sunlight, too much sitting: the list goes on and on. The overworked worker is told to make better food choices, get more sleep, exercise and relax. These are all good suggestions, but if deadlines and excessive work assignments reduce free time to hours spent traveling back and forth to work, it is almost impossible to make use of this advice.
Yet one suggestion might be some help to those struggling under an impossible work burden: eat to perform better and to relax.

Lean protein helps maintain two brain chemicals that are involved in mental alertness and rapid mental processing. Caffeine also increases mental alacrity and focus. Water prevents silent dehydration associated by many hours in a dry environment. People don’t realize that their bodies are losing water because they are not sweating. However, consuming too little liquid often causes fatigue and headaches. And fat should be avoided: it makes the brain sluggish and the body slothful.

Starchy carbohydrates, in contrast, help the brain and body relax when, finally, work is over. Serotonin, the mood chemical produced when all carbohydrates, except fruit, are eaten, decreases stress and anxiety and soothes the mood and the brain into a calmer, less agitated state.

It doesn’t take much, perhaps a small baked potato, or a bowl of oatmeal, pasta or rice, to do this. But protein and relaxation do not mix. Protein prevents serotonin from being made. Eat it when you want to be alert, not tranquil.

Exercise, sleep, and recreational activities all help combat the health risks of extended working hours. Sleep is the most important; even the galley slaves were allowed to sleep, (maybe they did not row in the dark) but exercise and taking some personal time are also important.

Let us hope that we do not have to wait for a new version of the Fair Labor Standards Act to be enacted before the 21st century worker is given some relief from an impossible work schedule so that death does not precede retirement.

Will The Crusade Against Sugar Be The Next Prohibition?

There seems to be an eerie similarity between the current rages against the consumption of sugar, in any form, and of any amount, that parallels the rampages against alcohol in the early part of the 20th century. To be sure we don’t yet have axe wielding anti-sugar fanatics crashing down the supermarket aisles throwing boxes of brown sugar on the floor and setting cookies ablaze.  And so far, sugar is not contraband property, available only after whispering a password and exchanging money with some scary figure guarding the door to the pastry shop. But given the books, documentaries and internet sites devoted to demonizing this sweet carbohydrate, such events may not long in coming. Mary Poppins, who sang that a ‘spoonful of sugar makes the medicine go down,’ might be burned as a witch were she to sing that ditty today. Or to put a contemporary spin on the response of the anti-sugar crusade to her advice, she might be fined several thousand dollars and forced to drink a glass of unsweetened lemonade.

No one disputes the unhealthy consequences of consuming too much sugar.  We must stop teenagers from  drinking  20oz of a sugar containing soda or fruit drink as their  breakfast, or elderly people eating only cookies for dinner. They will suffer not only the consequences of eating too much of this simple carbohydrate, but also the consequences of disastrously poor nutrient intake. And we should be aware that large amounts of sugar lurk not only in soda, but in the very popular energy drinks. One might think that the entire country is overcome with fatigue when considering that not only adults, but also teenagers and children drink these beverages. The energy in energy drinks comes not only from the caffeine but also from sugar; per ounce the drinks may have the same or even more sugar than Coca-Cola.  

No one needs that much sugar for energy unless running 100 miles, biking across the continent, or shoveling out from a three day blizzard. In England, there is presently a campaign to ban the sale of such drinks to children. Given that caffeine and sugar are hardly optimal food groups for kids in any country, these drinks ought to be limited to adults as well in the U.S.

Very few of us consume sugar by itself.  Perhaps Pooh Bear could polish off a jar of honey, but few humans, fictional or otherwise, sit down and consume the sugar in the sugar bowl, or eat maple sugar candy. Anyone who has attempted to eat the latter knows how difficult it is to consume more than a few bites because of its granular consistency and intense sweetness. We consume sugar as an ingredient in prepared foods, and oftentimes foods that contain large amounts of sugar (other than beverages) contain large amounts of fat as well: doughnuts, cake, cookies, candy bars, pies, frosting, fried dough, etc.  Thus, when we decrease our sugar intake we concurrently decrease our consumption of saturated fat. This is a win-win all around, unless one believes that eating large amounts of fat is healthy.

But why insist that those of us who eat moderate amounts of sugar in an occasional cookie, cupcake, piece of wedding cake or chocolate bar, stop eating sugar entirely?  If I want to add a few teaspoons of sugar to tomato sauce, sweet and sour red cabbage, or a marinade to offset the white vinegar or lemon juice or to help caramelize the meat, is this sugar going to shorten my life?  Will eating a piece of birthday cake cause my brain cells to implode and hasten the coming of dementia?

The ‘Sugar is Death’ people seem to overlook the fact that honey, a sugar containing food, has been consumed for thousands of years and in every major religious group; this sweet, sugary food symbolizes health, a sweet future, longevity, and spiritual strength.

I believe it is important to compare the anti-sugar campaign with the concerted efforts of well-meaning people to ban alcohol. To be sure, those folk were not worried about people drinking sacramental wine during religious ceremonies, or the small glass of sherry drank by a 90 year old woman to honor her birthday. Nevertheless, the ban on alcohol was all encompassing, unless of course one had connections. The anti-sugar crusaders seem to be taking the same Prohibitionist approach, and even though they are not banning sugar (yet), they certainly are making many of us feel guilty and embarrassed if we eat a chocolate truffle, or ice cream. And many people who proclaim themselves non-sugar eaters look askance at their friends and family members who are still putting that supposedly toxic ingredient in their bodies.

Could we call for a bit of moderation here? No one condones binge drinking or alcoholism, and no one condones excessive consumption of sugar from energy drinks, sodas and a diet of pastries and ice cream.  We attempt to make people recognize the dangers of drinking too much, to one’s own health and that of others (drunk drivers). In this vein, the intake of sugar ought to be limited and people made aware of its negative effects on health if consumed in large quantities and/or too often.

Truly, a world without any sweetness? Without any sugar, honey, or maple syrup? It would be a grim world indeed.

The Vanishing Bread Basket

My breadbasket disappeared.  It was a small container, big enough to hold a couple of rolls or freshly toasted garlic bread, but its size and shape announced that it was meant to hold something small and solid, not gravy, roasted Brussels sprouts or pickles.  My problem is that I cannot find a replacement. Stores selling housewares, from the lowly discount store to high-end retailers, don’t seem to carry this item.  However, I have not tried the summer antique fairs because I don’t want to find something tarnished and in need of buckets of silver polish.

But not only has the breadbasket disappeared from my kitchen; it seems to be disappearing from restaurants as well. Over the past several weeks I noticed that during the time between giving an order and receiving the first course, a time when a basket of freshly baked bread, rolls, or even bread sticks used to appear, nothing is put on the table.  In the past, the starchy delights would soothe the (presumably) hungry diners into not growling at the server, “Why aren’t you here with my appetizer?”  Now there is nothing to prevent the growl.

Recently, looking at the empty spot on the tablecloth where the breadbasket should have sat, my spouse asked for some bread. The server looked taken aback as if the request had been for a roasted pig’s head or bucket of live eels.

“Bread?” he asked. “You want bread?”  

And then several minutes later, a very small roll was served—one roll served to one person. “Uh, could I have a roll also? “ I asked. The server’s glance seemed to say, “You shouldn’t be eating this.”

What has happened to us as a formerly bread eating country?  Haven’t most of us grown up eating sandwiches all through elementary school, making sandwiches for picnics and car trips, discovering ethnic bakery shops that made us want to eat a freshly baked baguette, a raisin, nut and cranberry whole grain roll, a puffy hot pita or a savory corn bread on the spot? Haven’t we mopped up a delectable wine sauce or rich gravy with sourdough bread and thought we were in heaven?  Most cultures reserve special breads for special holidays, and its true that the scent of freshly baked bread, wafting over a sidewalk, has the power to make most of us salivate.

But something strange has happened.  It’s as if an evil queen from a non-bread eating fairytale kingdom has cursed us. Self-appointed gurus have convinced us that eating bread will produce the direst consequences for our brains, our bellies, maybe even our investments in the stock market.  To be sure, there are a very small number of people who suffer from celiac disease associated with the consumption of gluten, and others who may have some type of allergic response to the gluten protein, or perhaps some other protein in wheat flour. But copious information is available pointing to the rarity of these conditions, not that most self-diagnosed gluten-avoiding folk want to know this.

And bread—plain, ordinary, unadorned bread, made from yeast, flour and water—has been reviled as a major contributor to obesity. That the calorie count for a gram of bread is the same as a gram of an egg white is ignored.

What is also surprisingly ignored is the role bread plays in controlling our appetite. Bread, like any other starchy carbohydrate that contains very little protein, has a prominent role in increasing our brain’s supply of serotonin. The amount of carbohydrate in a medium size roll (not the golf ball size roll my spouse was served) when digested increases the amount of serotonin in the brain.  And this serotonin, in addition to soothing our moods, decreases our appetite. Around forty years ago, serotonin was identified as the brain chemical that turned off our desire to continue eating. It functions to increase satiety, that is, the feeling that we just don’t want to put more food in our mouths, even if we haven’t eaten that much.

Indeed, we developed a successful weight-loss strategy by advising dieters to eat a small amount of carbohydrate, such as a roll, about an hour before mealtime. Doing so ‘spoils the appetite,‘ as your mother undoubtedly told you when you asked for a cookie an hour before dinner. The carbohydrate initiates serotonin production, which serves to calm and subdue a ravenous appetite.

Is it possible that restaurants don’t want we diners to eat bread before the main course because we will be too full for dessert? Could be. Because as our dieters found out, the increased serotonin in the brain really did diminish their desire to keep eating after they finished their main (calorie controlled) course. We never did a study to see whether eating bread at a meal improved relationships between the diners because their mood was improved, but it is possible.

So I say bring back the breadbasket before it is such a rare item, it is displayed on “Antiques Road Show.”

Is There an App to Tell Me How to Cook Strange-Looking Vegetables?

“What am I eating?” my spouse asked, poking at the roasted wedges of an orange vegetable on the dinner plate. “They look and taste like beets, but I thought beets were, well, red.”

“They are beets. I got them at the Farmer’s Market,” I explained. “They were next to the red beets so I knew what they were. But I wish all the vegetables came with nametags. I have no idea of what at least of third of them are.”

That is the problem. Every Tuesday and Friday, I walk over to the outdoor market with my cloth shopping bags planning to buy vegetables for supper. And every Tuesday and Friday, I leave with pretty much the same assortment although fresher and younger than what is available in the supermarket down the street: spring onions with dirt still clinging to their long green leaves, delicate lettuces, pale pink radishes, misshapen tomatoes (the more misshapen, the more expensive), just picked corn and, of course, beets.

But the stands are also filled with mysterious greens whose long tough stalks look inedible. What are the funny looking lumpy peapods that look like pregnant green worms and those purply round root-like vegetables that vaguely resemble turnips? Maybe they are turnips. Next to the conventional zucchini and yellow summer squash, there’s a pile of squash-like looking vegetables with either stripes or scalloped edges. They look like models in a still-life painting and, if I could paint, I would take them home and make art of them. I want to ask the nice people selling the produce what these squash-like vegetables are called, if I should I peel them before cooking and how should they be cooked. But the stands are always crowded, and this being a city where people rush about, not too many would be happy if I were given a cooking lesson while they are behind me in line.

So even though I should be more adventuresome and attempt to wrestle those aggressive greens into submission in a shopping bag and then figure out how to prepare them, or throw the squash-like vegetables in the oven and hope for the best, I walk away with the my predictable purchases.

But as I trudge home, filled with frustration about my ignorance of those nutritious-looking but nameless vegetables, I wonder why there isn’t some way of giving shoppers like myself information about what is being sold. Obviously I don’t expect the squash-like vegetables to come with food labels or the greens packaged with a machete so they can be cut into mouth-size pieces. But think how useful it would be to see pictures of these vegetables on a large poster with their names and a brief description of how to prepare them. Many shoppers might buy new to them vegetables to try at home, at least once, if they know their names when family members ask what they are eating. It would be really helpful to see instructions on whether the vegetable is to be eaten raw, or cooked and if the latter, how? Doing so would keep us from serving something hot that was meant to be eaten cold, or baked if it should have been boiled.

Why stop with the Farmer’s market? How useful it would be to go into an ethnic supermarket and know how to prepare the many vegetables and fruits that are unfamiliar? I live near several Asian supermarkets but, as with the Farmer’s Market, rarely do I deviate from purchasing only the vegetables that are familiar. Should I buy bitter melon? What if it is bitter? What do I do with lemongrass? Does it taste like grass or lemon? Are those red berry-like fruits covered with little spines meant to be peeled? Plantains look like bananas but I know they have to be cooked not eaten raw. But how? What do I do with yucca, or other tubers that look sort of like potatoes? Is a Japanese sweet potato sweet?

Some adult education classes take their students on field trips to ethnic supermarkets so the students can learn from an expert the names of produce sold in such stores, and how to prepare them. But what about the rest of us? Why do we have to sign up and pay for a course to learn how to shop for exotic vegetables, and then be taught how to cook them correctly?

Almost all packaged processed foods that cannot be eaten straight out of the box or pouch come with detailed instructions on how to steam, microwave, bake, or roast the food inside the package. The irony is that the foods we should be eating, i.e. the unprocessed, fresh vegetables and fruits, are information orphans.

Maybe the answer will be an app. The shopper will take a picture of a weedy-looking vegetable that might or might not resemble a stalk of broccoli, or a green-skinned pear-shaped vegetable that can’t be a pear (it is in the vegetable section) and send it to a virtual nutritionist. Then instantly, the shopper will receive its name, nutrient content, instructions on preparation, and maybe even a hint of what it tastes like (chicken?). Could we have this app by August, please?

Can You Be Too Fat to Lose Weight?

Several years ago, Mary, a young professional woman, came to see me for help in losing weight. She was about 40 pounds overweight, gained in large part because of the sedentary nature of her job; she endured a long commute that gave her little time to go to a gym or even jogging before or after work. A decreased calorie intake more compatible with her decreased level of physical activity and a health club opening in the office complex where she worked made weight loss relatively effortless.

A few weeks ago, she came to see me. I did not recognize her; she now weighed considerably more than 300 pounds. A perfect storm of family tragedies, job loss because of her firm’s bankruptcy, and two years of treatment for anxiety and depression with a medication known to cause weight gain had left her morbidly obese. Each time she went on a program such as Weight Watchers or dieting with calorie-controlled shakes, she lost 50 or so pounds, but gained them back as soon as she stopped the diet. She told me, “I am heavier than I have ever been, and I am still gaining weight.”

Bariatric surgery had been recommended but the stumbling block was the requirement to lose 30 pounds before she would be considered eligible. This is pretty standard procedure: The group caring for her prior to and following the surgery wanted to make sure that she would be able to stick to the rigorous diet plan she would have to follow for months after the surgery. She wanted me to help her lose the weight as I had many years earlier.

But now it was going to be so much harder. Mary was no longer a healthy young woman. Her obesity had spawned a cluster of health problems: type 2 diabetes, high cholesterol, high blood pressure, sleep apnea, chronic back and knee pain, and difficulty walking. And, she told me, she was horrified at the way she looked. “The doctors said not to worry about my weight gain. It was more important to get rid of my depression. But how can anyone not be depressed if they look in the mirror and see a fat body staring back at them? And now I can’t get a job! Sometimes I find part-time employment, but my weight makes it too hard for me to take any job that requires standing. And when I apply for a job that I know I can do, I don’t get hired, probably because employers don’t want to hire someone who is so fat.”

Isolation from not working, along with an extremely limited social life, contributed to her difficulty in losing weight. “I am alone all the time. Since I rarely work, I stay at home during the day, and I never go out at night or on weekends. No guy is going to date someone looking like me, and most of my girlfriends are married. I don’t know what to do. There aren’t any support groups to help people like me, who become obese on antidepressants and, as a result, have our lives fall apart.”

She was right.

Helping her lose weight now was not merely a matter of having her eat more salads, fewer pizza slices, and getting to the gym more often. Now losing weight meant dislodging her from the lifestyle self-imposed by her morbid obesity.

She already had a diet given to her by a clinical dietician and if she followed it, she would lose weight and her diabetes would be in control. But as she told me, she cheated after less than a week on the diet, and did not think she was capable of staying on it long enough to be eligible for bariatric surgery.

We discussed ways to make small changes in her life that might positively affect her weight loss. Her physical inertness from chronic back pain and fatigue from her medication had to be overcome. I urged her to move, even if it meant going from one chair to another, at least once an hour and to walk for five or ten minutes, twice a day.  She knew from exercising years ago that physical activity would make her feel more, not less, energetic and perhaps even less depressed. And as she lost weight, walking, climbing stairs, and even getting up from a chair would become easier.

Volunteering seemed a good way of getting her out of the house and might generate a paid position, or at least recommendations that she could use in applying for a permanent job. Her acute loneliness on weekends might be diminished by volunteer activities that took place on Saturday and Sunday afternoons and early evenings.  Educational workshops scheduled for weekends could also decrease her isolation, and she lived close to an adult education center that offered such courses.

We both knew that her progress in losing weight would not be without setbacks. Unraveling the complicated reasons for her weight gain cannot be undone by a few workshops or 10-minute walks. Progress would depend on resolving them with a therapist whom she was already seeing, a post-bariatric surgery body that was no longer a visual and physical liability, a job and, hopefully, a better social situation.

Mary may not be too fat to lose weight, but her situation demonstrates how hard it is for the morbidly obese to become thinner. It is a heroic undertaking.





The Inedible Food Diet

Having recently returned from a weeklong conference, I noted, happily, that I had lost a couple of pounds. This was surprising, since so much of the day was spent sitting in seminar rooms or large lecture halls, with a large buffet lunch and dinner served each day. Moreover, the meeting took place in Jerusalem, where hotels traditionally served breakfasts whose variety and abundance of food rival that of any cruise ship.

But when I considered why I had lost weight, I realized that the cause was frustration with the foods served at lunch and dinner. At breakfast I ate the foods I usually eat at home, probably because in my jet-lagged state, making decisions about what to eat so early in the morning was beyond my cognitive ability. But by lunch, I was hungry and dinnertime corresponded to lunchtime back in my home time zone, so I was even more hungry. However, I found I could not eat the food served beyond what it took to minimally satisfy my hunger.

The food was abundant and looked attractive, but it was more or less inedible. The salads were limp and watery, the bread stale, the pasta overcooked and underseasoned, and the fish, chicken and beef tasted as if they had been cooked several days earlier and reheated. Fortunately, fresh fruit was always served for dessert, but the small cubes of cake served along with it tasted like leftovers from a long ago party. No one complained about the food; we were not at the conference to eat and conversation at meals offered enough “food for the mind” so that we didn’t pay much attention to the food for the body. But I did notice that no one went back to the buffet table for second helpings. The one meal we had away from the conference, in the home of a friend, made me anticipate eating a well-cooked meal. Alas, I had forgotten that she hates to cook and her food actually competed with that of the conference for its inedibility index. Thankfully, the company made up for the absence of culinary pleasure.

My unanticipated weight loss made me wonder if an inedible diet plan might work in a weight loss program. Some diet plans answer this question by eliminating the consumption of normal foods altogether, offering instead complete nutrition shakes or food bars. But many others advertise themselves as offering reduced-calorie foods that have been engineered to make them as tasty as foods with traditional ingredients. Other weight loss plans teach their clients how to substitute ingredients in baked foods to make them taste like food with more fat, sugar or salt so they won’t miss their favorite dishes while they are losing weight.

Could it be that this is the wrong approach? Could it be that manipulating ingredients so that a lasagna or sausage and egg patty with engineered ingredients to make it less caloric than its original version is the wrong way to get people to lose weight? Could it be that putting people into a residential facility like Canyon Ranch and presenting guests with flavorful and attractively prepared foods is sending the wrong message?

The diet industry is telling people that they can continue to enjoy eating and lose weight at the same time. Maybe this is one reason why diets are so unsuccessful. The dieter and indeed the non-dieter are rarely taught that the reason we eat is to provide nutrients and calories to keep us alive and healthy. We accept this premise when feeding our pets and quarrel with ourselves when we give in to the demands of our pets to feed them tasty but not particularly nutritious foods. “Don’t feed your dog table food!” we are admonished. The dog must eat only foods that are designed for its own nutritional and caloric needs. If you don’t give him cheese, chicken, hamburgers, etc., then he will learn to eat only dog food.

But we don’t apply this advice to ourselves. Like some pets, we want to eat only foods that taste good and when we get those foods, we often overeat them. Perhaps just as we try to get our pudgy Labrador or Dachshund to lose weight by restricting tasty foods, we can help ourselves lose weight by eating only foods with a low taste quotient.

It is well known that dieters and non-dieters use food as a substitute for whatever is missing in their lives. For many, eating is rarely done to nourish or take away hunger. Indeed, we eat when we are not hungry or continue to eat after hunger is satisfied for the pleasure of putting food in our mouths. Food is consumed as a source of gratification, a substitute for loneliness, a recreational and social activity, a stress reliever, as a symbol of celebration and ritual and because it tastes good. There is nothing wrong with using food for these objectives, unless and until, consuming them for these reasons causes weight gain or prevents weight loss.

It might be interesting to do a study in which dieters are given palatable but not particularly tasty foods and their meals are accompanied by pleasurable social interactions. Might they find it easier to eat less? If we can be weaned from thinking that life’s pleasures are found in an ice cream bar coated with chocolate, or a sandwich dripping with melted cheese and bacon, might we begin to look for non-edible pleasures and find them? This is not to say that eating delicious food is not one of life’s pleasures. But clearly it should not be the only one we seek.

Should You Be Eating High Fat Before a Endurance Events?

As with every aspect of the high/low carbohydrate diet argument, there is now some controversy about whether eating fat, as opposed to carbohydrate, is better for endurance sports.  Although lard has not become the preferred pre-Marathon Dinner menu item, there are some whom are promulgating for credit, even, that avoiding carbohydrates and eating fat will make you run or bike longer and faster. 1 Obviously if the only running you may do is after your spouse who is making off with the last pint of ice cream in the freezer, your response may be, “Who cares?” And if you are following a high protein, low carbohydrate diet, you may feel that exercising is irrelevant since you are losing weight without it. (The benefits of exercise on longevity, reduction of muscle loss, and delay in cognitive decline are something you will think about when you are much older).

But maybe you have a personal trainer who tells you to avoid carbohydrates; she read that you will lose more weight exercising if you eat only fat and protein.  Or you play golf with a friend who eats six strips of bacon before a game, convinced it improves his drive.  You begin to question something you learned decades ago: that muscles use carbohydrate for fuel. Do marathoners now chow down on lard rather than pasta before a race? You begin to wonder whether eating fat before exercising will allow you to losemore weight, because it will be burned for energy. Or maybe you can exercise even better if you just eat protein. After all aren’t muscle made of protein?

The answer is that despite what books and blogs are telling you, your body still depends on carbohydrates as its basic source of energy.

A tiny bit of biochemistry to show you why:

Adenosine triphosphate or ATP is the energy compound inside the cells.  It is metabolized to release the energy to allow you to pick up the remote if it fall off the sofa or to run a 100 mile ultra marathon. 2 Carbohydrates, fat and even protein can be converted to ATP with varying degrees of rapidity and efficiency. Protein is rarely used to fuel muscle movement because it has to be converted to glucose first; but it is needed to repair used muscle fibers after exercise and build new muscle. 3

What happens when we begin to exercise? Let’s say you are walking the dog, slowly until suddenly he  jerks the leash out of your hand and races off to catch a squirrel (a futile endeavor). For the first 2 or 3 seconds, your muscles move rapidly, using  tiny amounts of stored ATP. Then, at second 4 and beyond there is no more ATP. Your muscles begin to convert  stored glucose, called glycogen, to ATP and you and your dog can happily  run for several more minutes without the need for additional oxygen. At this point, unless you supply more oxygen to your muscles, you will hurt. Lactic acid builds up causing a burning sensation and your muscles  feel tired. You need to breathe.

In this scenario, if the squirrel runs to the next town, you have enough stored carbohydrate to run after the dog and the squirrel for about two more hours. But then you run out of stored carbohydrates and,  “hit the wall, “ or “bonk,” in athletic parlance, i.e. you run out of steam.

So now assuming you and your dog have several miles to run to get back home, your body must switch to fat as its backup energy source.  It might be a good idea to sit down on a park bench and talk to your dog about the futility of chasing squirrels, because it takes a little time for your body to mobilize fat from your fat stores.  Unlike carbohydrate, which is readily converted to ATP, fat has to be dragged out of your fat cells (the bacon you ate for breakfast is not going to be used up on the jog home) and broken down so that  one component, the  free fatty acids, are transported to muscle cells .There they are   converted to ATP with the help of lots of oxygen. You and your dog are going to be doing a lot of  panting on the way home. 4

Athletes who do endurance sports such as 100 mile ultra-marathons , day long mountain hikes, or long distance bike rides  can transition from carbs to fats as an energy source very quickly.  According to the sports nutritionist, Sunny Blende who writes for UltraRunning magazine, during a six hour or longer run, about 90% of energy will come from fat. 5 (My pudgy dachshund should read this Blende article).

So does this mean that if we plan on going on for a six hour run with our dog and squirrel, we should eat lots of melted butter the night before, or at least a pint of ice cream? Well according to Ms. Blende, and I quote, “…Even the leanest ultrarunner has about 800 miles worth of fat stored within their skinny-little self.”6  Presumably the rest of us have more than  enough fat for any energy requiring endeavor,  and do not have to eat more in order to move.

So if we can use fat for exercise, why do we need carbohydrates?  According to Matt Fitzgerald, author of Diet Cults, research done long before Dr Atkins promoted chicken fat for dieters, showed that carbohydrate is needed both for high intensity performance and endurance. He cites the diet of the Kenyan marathoners whose diet is about 78 percent carbohydrate. (They are clearly not obese). He says, “If you want to go fast, your body needs carbs for fuel.” This is true if you are running after your dog, or after a tennis ball.

Avoiding carbohydrates in the pursuit of leanness makes sense only if you want to avoid exercising. And if that is the case, you may need a dog that can pull you in a wagon.



Are Supermarkets the New Take Out Restaurants?

A new supermarket opened a month or so ago in a building that once housed the one and only original Filene’s Basement. In the place of racks of designer clothing reduced to the cost of a cup of Starbuck’s coffee, there were gleaming cases of prepared foods from spareribs to salads, freshly baked breads, rolls and muffins, assorted cookies and pastries, plus an enormous area devoted to cheese. Samples of freshly made mozzarella were being given out by a woman pounding the cheese into submission and having taken one, I wandered around to see if someone was also handing out samples of crackers.

There were, of course, long aisles of packaged goods from dry pasta to an exorbitant display of mustards. And like any conventional supermarket, the produce, dairy, meat and fish sections offered up food items that had to be processed, i.e. cooked, in order to be edible. But what was so entrancing about this supermarket, right in the center of a busy shopping area and near the Financial District, was the accessibility of foods ready to eat. The choices ranged from the banal (fried chicken and mashed potatoes) to the gourmet (freshly cooked seafood, salads with fashionable ingredients such as farro and arugula, and freshly squeezed juices and smoothies). It is hard to think of a restaurant that could offer such a wide variety of foods with prices that would match those in the supermarket.

Markets are already feeding zones for those who prefer getting their meals from a cardboard container rather than going to their refrigerator and preparing their meals themselves.  This one happens to be a newer generation of markets, located in an area where a food court and food pushcarts had been the most accessible options. Unlike older, more conventional supermarkets, the most prominent feature is the prepared food area. When the shopper walks in, he or she is assaulted and beguiled by counter after counter of ready-to-eat foods. It takes some walking and a bit of scouting around to find the produce section, way in the back of the store, the fresh fish case scrunched up against a back corner and dairy products somewhere behind a maze of aisles.  The message sent to the shopper is, “Don’t even think of buying something that needs preparation. We have already made it for you.”

Given that many Americans eat at least one or more meals away from home every day (this includes school children as well as adults), buying meals at a supermarket may be a more practical and less expensive option than going to a restaurant, fast-food chain or coffee shop. And the prepared foods at a supermarket may offer a healthier option than those at a chain hamburger or burrito shop. This is because supermarkets offer a variety of cooked vegetables, a variety rarely duplicated in upscale restaurants, and missing entirely in less expensive restaurants.  How many fast-food chains offer curried carrots, roasted Brussels sprouts or cherry tomato, red pepper and spinach salad? .

And consider this: The shopper who may be vegetable adverse can buy a tiny portion of a vegetable dish for a taste. Unfortunately, the supermarkets don’t allow the shopper to try a vegetable dish for free the way ice cream stores allow the shopper to taste an unknown flavor.  But spending 75 cents on two tablespoons of curried carrot salad or broiled cauliflower might convince the reluctant and vegetable phobic eater that vegetables can taste good. 

Supermarkets offering a large selection of take-out foods are next best thing to having your mother cook your dinner (if she is a good cook), but they could go a little further in helping shoppers put together their meals, for instance suggesting that they choose foods that are moderate in calories and high in nutrients. Suggestions for side dishes to go with a main course of grilled chicken or sliced brisket or salmon stuffed with crabmeat would be useful so the shopper would be eating a nutritionally balanced meal.  For example, a display could suggest adding a high-calcium dairy product to the meal by featuring a dessert of fresh raspberries topped with low-fat yogurt. The shopper would be encouraged to buy the yogurt and the berries and combine them at home.  Nutrient information near vegetables that may be unfamiliar, like beets or lentils, might induce the shopper to consider trying them.  

The down side of this is that the foods are much more expensive than if prepared at home. There is a substantial cost differential between buying roasted Brussels sprouts in the take-out section or buying them fresh, sprinkling them with a little olive oil and salt and roasting them at home. The same is true for throwing a potato in the microwave or buying it already cooked. And the shopper should be aware of the high oil content in many prepared foods; this ingredient keeps the foods moist and looking attractive.  However, lack of time, lack of even rudimentary knowledge of how to prepare foods, and lack of motivation to come home and prepare foods from scratch makes the enormous array of the supermarket prepared foods so enticing.

 This trend to using the supermarket as a restaurant is growing, and in the near future it is possible that the prepared food section will overtake most of the space formerly occupied by the traditional food displays. Should this begin to happen, let’s hope the decision of what prepared foods to sell is based on health considerations, as much as profits.