Why Most of Cannot Become, Nor Maintain, Thin

A few days ago, my husband and I were walking back from the farmer’s market lugging plastic bags full of corn and tomatoes. It was hot, dinner was still a few hours away, and we had all those ears of corn to shuck. Then I saw her. She was thin, almost wiry, carrying her own bags of farmer produce but one hand held a large soft serve chocolate ice-cream cone that she must have bought from the ice-cream truck parked near the food stalls. My mouth watering and stomach grumbling, I watched her take a large bite of the ice cream and smile. I would have smiled also had I just taken a bite. But then what she did astonished me. She walked over to a nearby trashcan and, with a napkin, dislodged most of the remaining ice cream into the can so that only a tiny bit remained barely visible above the rim of the cone. “Did you see that?” I asked my husband. “She threw away most of the ice cream!”

“No wonder she is thin,” he replied. “I couldn’t have done that. “ “Me neither,” I said, thinking that as hot and hungry as I was, the ice cream would have been inhaled by the time I walked home.

Indeed, how many of us practice what weight-loss professionals are forever suggesting: eat only half of what is served to you in a restaurant. If you want a fattening treat, take a few bites and throw the rest away. Don’t allow a micro drop of fat or sugar or salt to cross your lips even by accident. Never, ever, eat anything dipped in batter and fried. If you are at birthday party, eat a rice cake (bring it with you) rather than birthday cake. Don’t skip meals. Make sure breakfast consists of more than a cup of coffee and piece of toast. Don’t eat after 9PM. Avoid drinking more than one glass of wine and don’t do that too often. If you want to snack, eat fruit, fat-free yogurt or oven-roasted kale. Oh, and exercise as much as possible.

Many people are able to summon the compulsive discipline, and motivated aspects of themselves when they are determined to lose weight. “Set a goal and stick to it!” people are always advising the obese. Then you WILL lose weight. To be sure, we can do this whether it is going on a five-day cleanse, eating nothing but grapefruit and broiled salmon for a month, or living on a 500-calorie beverage that contains all the nutrients we need to stay alive until we lose 75 pounds. Years ago Oprah Winfrey did this and lost an enormous amount of weight, appearing on one of her shows dragging, in a wagon, bags full of the same amount of fat she had lost.

But then the diet is over. And as the professionals tell us, we now must practice discipline and rigor to KEEP OFF the weight. And sometimes, some people actually do. I have a friend who lost more than 70 pounds before she got married many years ago and has never deviated more than 2 or 3 pounds from her goal weight. If she finds herself weighing more than that, she races to her nearest Weight Watcher meeting. A life member, she goes back on a diet and loses those two or three pounds before they turn into 10 or 15. The woman who dumped most of her ice cream into the trash can may be another example of someone who took to heart the advice of eating a tiny amount of a treat and disposing of the rest. But as a neighbor who is always going on and off diets told me, “Who can live like that?”

Maybe we were not intended to live like that. Is it not unrealistic to expect that we humans should eat like machines, consuming the precise number of calories in relation to the precise amount of calories we use up? After all, we are not fitted out with a car-like fuel gauge, with the need for fuel, i.e. calories computed before and after we eat.

Obviously eating too many calories, meal after meal, day after day, will rather quickly elevate our weight to unhealthy levels with all the attendant health risks associated with obesity. But on the other hand, once we attain the weight we want, we should be able to feast occasionally on entire ice-cream cones, or a plate of fried clams during a once-in-the-summer trip to a clam shack, or a Sunday morning chocolate croissant from a French bakery. The key word is occasionally.

Exercise, the other factor keeping us at the weight we want to be should be a regular part of our daily activities. But this doesn’t mean going to the gym every day or walking around the block ten times or doing 200 push ups daily. It means being cognizant of how and when our bodies are moving so that we do not mimic a 200-year-old tortoise in the amount of energy we expend in physical activity. However, having an occasional lazy day is something that ought to be built into the post-diet exercise regimen as well. Once your body is accustomed to regular physical activity, it will want to get moving again after an afternoon lying in the sun watching dandelions turn to fluff or catching up with all your recorded television shows over a weekend.

Even our pre-civilization ancestors rested after chasing a wooly mammoth for three days and feasting on it until nothing was left but the wool. So if you find yourself hot and hungry on a sunny late summer afternoon, and a soft serve ice-cream cone crosses your path, indulge yourself. Just don’t do it too often.

Why Didn’t Subjects Stay on the Low Carb Diet?

The recent widely publicized study by Tian Hu and colleagues at Tulane University School of Public Health put a small number of subjects on a supposed low carb or low fat diet for a year and monitored cardiovascular health and weight loss. To the delight of carbohydrate bashers, subjects on the low carb diet lost 8 pounds more (over 12 months) and improved levels of their good cholesterol and triglycerides.  So the conclusion is that Dr Atkins diet is really better: fats are good and carbs are bad.

If one believes headlines, that is truly the case.

But…..look at what was not hyped by the media:

This ground breaking study had 148 subjects at the start, but by the end of the study 20% of the subjects in both groups dropped out.  If this study were testing blood pressure medication or the best way to treat poison ivy, results with the tiny number of subjects would have been considered interesting, not ground breaking.

More to the point: by the end of the year, many of the low carb subjects did not follow the strict low carb regimen.  Contrary to the study imposed limits of 40 grams of carbohydrate each day (slightly less than the carbohydrate in two servings of oatmeal), they increased, if you can call more than tripling a mere increase, their intake to 130 grams a day. Interestingly, the high carbohydrate group was allowed only 200 grams of carbohydrate a day, hardly a gigantic amount of starchy grains, legumes, beans, and rice.

A disturbing feature of the study purporting to be a definitive answer as to how to lose weight is that sedentary subjects were told NOT to exercise. That’s right. Just stay on your couch.

But this was probably a good idea since those not allowed to eat carbohydrates, wouldn’t have had the fuel, i.e. carbohydrate for their muscles.

And no one is talking about the lack of fiber in the low carbohydrate diet this research study espoused. Not even a serving of Fiber One cereal was allowed.

The next time such a study is done, call it by its correct name: low fat versus high fat. And make sure the subjects stick to the protocol.

But the good news is that when the baked potato is served, a pat of butter or sourcream might actually prolong your life, or at least be good for your good cholesterol.

Finally: An Explanation of Night Eating?

Even though many of us wake up in the middle of the night thirsty and/or needing a bathroom, few of us decide to stay awake to eat another dinner. To be sure, we may munch on a graham cracker, nibble on some leftover pie, or drink a glass of milk with some cookies. But with the exception of a category of people called night eaters, we rarely are hungry enough to eat a full meal, even though it has been hours since we last ate. The almost physical inability to put much food in our stomachs is evident with the lackluster appetite we may approach breakfast served on a transatlantic flight at two or three in the morning. We are awake, more or less, but our stomachs are not. Conversely, some of us can tell time by the mid-day and early evening rumbles in our stomach signaling, “Time to eat!” Why are we hungry for lunch or dinner five or fewer hours since the previous meal, and yet not hungry in the middle of the night, eight or nine hours after we had dinner? By the time we leave infancy, most of us are unlikely to wake up for a 2 A.M. feeding.

A hormone, secreted by the stomach, but acting on the brain, may be the answer. Ghrelin (rhythms with Mary Ellen) seems to initiate eating at certain times over a 24 hour cycle, but not at other times. Although it seems as if we eat by the clock as in, “It is noon so I must be hungry,” this is apparently not the case (At least not in a research situation). About seven years ago, in a study published in the American Journal of Physiology by D.E. Cummings and colleagues, ghrelin levels were measured in volunteers whenever they started eating a meal. The researchers found that when the volunteers were most hungry, right before they started a meal, their ghrelin levels were high. After eating, ghrelin levels in the blood decreased and, as time passed, slowly began to rise again. Five or six hours after the previous meal, hunger and ghrelin levels again were high, and the subjects started on their next meal.

So why are we all not in the kitchen at 1 or 2 A.M. looking for something to eat, 6 or 7 hours after dinner? Most of us are asleep and if awakened would probably turn down a sandwich or some scrambled eggs. We are not hungry. The reason? According to research reported in the European Journal of Endocrinology by Natalucci, et al, the level of the hunger hormone is lowest between midnight and 7 A.M.

But some people do wake up every night hungry enough to eat more than a few crackers and drink some milk. These so-called night eaters may actually consume as many calories as the rest of us eat at dinnertime. They are not eating in order to fall back asleep but because they are hungry. It is unclear if they wake up because they are hungry or notice how hungry they are when they wake up for other reasons such as noise or a need to go to the bathroom. Hungry they are, however, and apparently because night eaters have an abnormally high level of ghrelin in the blood between midnight and morning. It is as if this hormone is out of sync with the other hormones, primarily melatonin, that should be keeping them asleep, not microwaving pizza or defrosting a steak in the middle of the night.

No one quite knows what to do about the high levels of the hunger hormone in the wee hours of the morning. Researchers acknowledge that the rise of gherlin is delayed, so that instead of increasing late in the afternoon/early in the evening, when we normally would be eating our evening meal, it seems to peak five or six hours later. One thought is to expose night eaters to early morning light therapy similar to the light boxes used by people with SAD (Seasonal Affective Disorder). According to a paper by Goel N. Stunkard and others in the Journal of Biological Rhythms, night eaters who have been exposed to early morning light respond by eating at normal meal times and will decrease their nightly food consumption. Maybe the light changes the rhythm of ghrelin release so that it approximates the normal sleep/wake cycle. Or perhaps waking people up early to sit in front of a light box gets them to eat breakfast early in the morning (although it is hard to believe they will be hungry) and this sets up a normal ghrelin prior to lunch and then dinner time.

Or perhaps the answer is to move to Spain where everyone seems to eat supper after the late show.

Might Candy Now Be the Answer to Alcohol Dependence?

Australians now reserve two months of the year when they stop drinking and donate the money they might have spent on alcohol to charities. February and July are designated abstinence months and, according to reports in the Australian papers, the effect is by and large positive. Charities get sizable contributions and the temporary non-drinkers, according to self-reports, find themselves able to go to a gym on Sunday mornings or for a run rather than nursing a hangover. The one negative effect of giving up alcohol, according to a friend who is a health writer in Melbourne, seems to be a craving for sugary non-alcoholic drinks and sweet snacks.

The link between a decrease in alcohol intake and increase in carbohydrate intake is familiar to those who have gone through alcohol withdrawal. Sweet carbohydrates such as doughnuts are served at AA meetings, and stories of intense sugar cravings among the newly abstinent are common. It is assumed that the reason for this carbohydrate craving is the need to replace the carbs in alcohol with those in sweet and starchy foods like pastries, chips or crackers. But most alcohol contains very little or no carbohydrate unless it has been added to make an intensely sweet drink like Sacramental wine or as syrup or sweetened fruit juice in a mixed drink. (Distilled alcohol contains no carbohydrates; beer and wine have between 2 and 4 grams per drink.) You would have to drink gallons of beer to equal the amount of sugar in a doughnut or cookie. So why do people crave carbohydrates as they go through withdrawal?

The answer may reside in how alcohol and carbohydrates affect mood.

Both alcohol and carbohydrates have the ability to change mood. Both are sought to quell anxiety and other emotionally painful moods such as depression. They may work by different mechanisms in the brain, and each presents its own set of side effects (although no one yet has been charged with a DUIC (driving under the influence of carbohydrates). And the calming effects of both are time limited. When they wear off, more cookies or cocktails may be consumed to renew the sought-after mood elevation.

High protein, low-carbohydrate diets prevent the synthesis of serotonin, the mood calming brain chemical that alleviates depression and anxiety. Interestingly, such diets have been associated with greater alcohol intake than those offering more carbohydrate and less protein. According to a review in the Journal of Studies on Alcohol by O. A. Forsander published several years ago, high-carbohydrate diets were associated with a significantly lower alcohol intake than diets with a high-protein, low-carbohydrate content. Might people seek alcohol to relieve emotional distress if their diets prevent serotonin synthesis?

The answer to this question requires further research. But it may explain why some people who can no longer rely on alcohol to ameliorate their moods seek carbohydrates.

It makes sense.

If some drinkers are self-medicating with alcohol to feel better, when it is no longer available they are left with nothing to help their emotional distress. Sugar and other carbohydrates eaten in very small amounts (25 grams) are sufficient to increase serotonin, and take the edge off painful moods. Unfortunately, the effect lasts only about three hours and when it wears off the cravings and the bad moods may return. Thus, the consumption of more sweet carbohydrates repeats.

The solution may be for people in the early stages of withdrawal to imitate the eating patterns of people who successfully cope with weeks of depression, anger, lethargy and social withdrawal during the late fall and winter. These people who suffer from Seasonal Affective Disorder have a chronic need to consume sugary foods but if they eat whole grain, complex carbohydrates instead, they will experience the same relief that they get eating gumdrops and chocolate bars. Moreover, since the starchy carbohydrates are digested more slowly than sugary carbohydrates, their good moods may last even longer.

So no to candy but yes to rice, whole-grain bread, oatmeal, potatoes, pasta, polenta and low-fat granola. Obviously eating carbohydrates is only one of the many strategies necessary to support people in their quest for sobriety. But the calm, focused mood brought about by nature’s own tranquilizer, carbohydrates, may help in the recovery process.

Obsessed with Counting Calories? There’s an App for That!

It had to happen. Once digital electronic calorie tracking became available on the smartphone, uncounted numbers of diet-obsessed women began fixating over how many calories they were putting into their bodies every day. Of course, the Apps did not generate the calorie-counting obsession; rather it allowed the already compulsive mind to note and record the caloric value of every morsel of food swallowed. These Apps remove the guesswork from figuring out how many calories three Cheerios or a sprig of parsley contain. And none of this information has to be written down since it is all on the App.

The very many Apps available to inform the eater about his minute-to-minute calorie intake and to record it for eternity, if necessary, are useful for the diet newbie, the dieter in denial, and the dieter who is not losing weight. Presumably keeping a daily record of calories consumed, and perhaps calories expended, through physical activity will make losing weight less haphazard and more scientific and controllable. One can’t pretend or hope that a recently consumed snack has fewer calories than it actually contains, or excuse lack of weight loss to the phases of the moon or bad karma. No longer is it necessary to pore over a thick book of calorie counts to work out a meal plan that meets the diet plan’s calorie allowance, or add up at the end of the day how many calories you have consumed. The App will do all that for you and perhaps motivate you to use up 400 or 500 calories through exercise so you can indulge in a treat and still lose weight.

Unfortunately not everyone uses these calorie-counting Apps for healthy dieting. The down side of these Apps is that they reinforce compulsive dieting, and its unfortunate outcome of anorexia. Just a brief scan of personal anecdotes from self-described compulsive calorie counters sadly confirms how hard it is for some people, often women, to eat when they see how many calories they are consuming. Like a miser who cannot bring himself to spend money even when he needs to, the compulsive calorie counter has a hard time consuming calories, even when such behavior may jeopardize his/her health. If the goal is to become as thin as possible, then doing so requires eating as little as possible. So it is easy to see how individuals with this mindset can have their App tell them what foods contain the least amount of calories, i.e. a leaf of iceberg lettuce versus one leaf of spinach, or one radish versus one half of a cucumber.

One wonders whether compulsive calorie counters recognize that calorie intake keeps us alive? The non-intake of calories is called starvation, and its outcome is always the same, which is not good. Without calories coming in, the body has no way of obtaining the energy to carry out the functions that keep us alive. We are not plants that are able to convert the energy of light from the sun into chemical energy necessary for growth. Moreover, unlike plants that make their own food (remember photosynthesis?), we also must eat because our bodies require nutrients that we are unable to synthesize ourselves.

Thankfully in this country we are not vulnerable to the many diseases brought on by an inadequate intake of these essential nutrients, since we have available so many foods that provide them. But it wasn’t so long ago that people were dying from scurvy caused by lack of vitamin C, developed the malformed bones of rickets due to lack of vitamin D, or experienced nerve or cardiac disorders due to the absence of vitamin B1.

So, to be truly useful in keeping us healthy (as well as thinner), Apps should be designed to advise the user to make food choices according to nutrient content. Why not have an App suggest eating spinach or kale rather than cucumbers or iceberg lettuce as the former are much denser in nutrients? Why not build an App that suggests to the user that she is not getting enough calcium and should start eating some low-fat dairy products? Or what about an App that alerts the user that, according to her weekly food record, insufficient protein and fiber has been consumed? Designed to capture and motivate the user to alter food choices, such Apps can improve nutrient intake – or at least tell the user to call her mother and ask her what to eat.

The Frequent Flier Weight Loss Plan

Although it has been said that travel broadens the mind, travel may also shrink the body.  Jet lag, sleep deprivation, minor intestinal upsets due to foreign water and unfamiliar foods, necessity to walk  miles inside airport terminals, as well as the unavoidable need to use one’s feet rather than a car to sightsee at a museum or church, may allow you to return home thinner than when you left.

Weight loss can begin even before the trip begins.

Outrageous prices for junk food at airport newsstands and kiosks  may decrease the temptation to snack  while waiting to depart and once on the plane, eagerness to eat a meal (served if the flight is 3 or more hours) is tempered by its resemblance to high school cafeteria lunches. The timing of the meals on the plane also helps you resist consuming them. Typically flights that go cross country or across the ocean depart late in the evening. ‘Supper’ may be offered at 11 pm or midnight when the traveler’s tummy is ready for bed. Skipping that meal as well as the frozen bagel and plastic fruit served for breakfast the next morning at 3 am (well, it is morning isn’t it?) will further diminish your calorie intake.

Once at your destination, you should continue to lose weight if the following conditions exist:

1. Alien food…If restaurant specialties feature grilled octopus, marinated baby eels (they do indeed look like eels) or still living shrimp, dinner might consist of bread and water, or a protein bar back in your room.

2. Not understanding the language on the menu.  Ordering from a menu written in an incomprehensible language, may present you with dishes that contain ingredients you hate or don’t recognize.   (Years ago on a trip to Budapest for a meeting, my husband and I found that we had ordered , without knowing it, dishes made mainly of cabbage, including dessert of a cabbage strudel).

Caveat: If the  destination city is known for steak smothered in cheese sauce,  chowder made with heavy cream, fried clams with greasy  French fries and mayonnaise loaded coleslaw or half a pig’s worth of  barbecued ribs, weight can be accumulated as fast as used napkins at the barbecue.  The frequent flyer diet works best when the foods at the destination are more or less bizarre, or inedible.

3. Smaller portion sizes. The size of meals served outside the US are almost always smaller than those offered in the states.   Pasta in a restaurant in Florence may come on a salad size dish rather than on a platter large enough to hold a turkey, and almost nowhere will you be given 16 oz. steaks or half a chicken. Desserts tend to be tiny compared with our outsized offerings, and more likely to be a fruit and pastry combination, rather than a densely rich production of egg yolks, heavy cream and chocolate.  Sandwich fillings are sparse and do not require a veritable unhinging of the jaw in order to bite into them.

4. Contaminated food and/or water.  Sometime simply drinking the water may produce digestive discomfort ,and although most travelers avoid eating food that obviously does not meet US standards for hygienic preparation, even cautious eating may not prevent picking up a food born organism. Travelers may lose considerable amounts of weight if the problems persist, although often the weight lost is, alas , from muscle as well as from fat.

5. Increased exercise. Tour buses don’t pull up to the front door of a museum or church or monument; you often have to hike quite a distance from where the bus parks.  Moreover, you have to walk to see. How else can you look at art, botanical gardens and zoos, explore historical buildings ( think of the Tower of London) or marvel at the natural wonders of a  national park ? Some destination cities are so hilly ( think San Francisco, Seattle, Vancouver, Sydney) that your legs will feel as if they are on an elliptical trainer at the gym.  And  shopping requires walking ; open air markets, for example,  may cover blocks and walking is the only way to find something to buy.

6. Jet Lag. Even a three hour time difference, for example between coasts in the US, can disrupt normal eating schedules. Your hunger will be at odds with the meal schedules of your destination: if you are in Europe, your body may want  dinner when everyone is going to sleep and the restaurants are closed. Conversely, no matter how flaky the croissants served at a Parisian breakfast, if you are overcome with sleepiness at 8 am because it is 2 am back home, you may prefer to sleep through the first meal of the day.  Substantial time differences of 6 or more hours, can make eating seem physically impossible. When you desperately want to sleep, you simply cannot bring yourself to put any food in your mouth.

If  your destination is a  cruise or beach resort where you  can lie on a chaise and be brought drinks with umbrellas stuck in a piece of pineapple, the frequent flyer diet will not work. Otherwise you may find upon your return, that there is less of you than when you started.

Sunlight: The Natural Appetite Suppressant

About 30 years ago, a depression associated with the dark seasons of the year was identified. It was called Seasonal Affective Disorder (“SAD”)1. For reasons still not well understood, late sunrises and early sunsets caused people to sleep excessively, experience fatigue and disinterest in work and social life and, alas, eat too much. Long hours of daylight starting in the late spring and lasting through most of the summer were seen to have the opposite effect. Formerly depressed, lethargic, often-chubby SAD sufferers turned into energetic, upbeat, salad eaters and many managed to shed their winter pounds along with their sweaters.

For most of us, this transition from a darkness-induced depression and overeating to a gym- seeking, snack-rejecting mild mania is very subtle, like the tiny increments in minutes of sunlight all through the spring. But this past month, my travel schedule made me a research subject for what happens to mood and weight when going from darkness to light.

Almost two weeks spent in Australia, as the country entered the short daylight hours of winter, caused me to be suddenly aware of a creeping fatigue (not related to substantial jet lag). Grumpy mornings waking up in darkness had me seeking out caffeine and carbohydrates in the late afternoon when the sun set hours earlier than the States. Weight gain was checked only because, like any tourist, I spent many hours walking, and the jet lag took away my appetite during the early days of my visit. Who can eat dinner when one’s body says it is 3 A.M.? Moreover, where was I going to find dinner when I became hungry 3 A.M. Australian time?

A few weeks at home, and then a trip to Israel with its endless summer blue skies and brilliant sun flipped my mood, energy and appetite. My traveling companions and I were like Energizer bunnies: charged up and moving constantly. The early sunrises and long sunsets elongated the hours during which we could sightsee. The mounds of locally grown fruits and vegetables available in the gigantic souk (market) made salads a constant feature in the menus we prepared in our rented apartment. My caffeine and carbohydrate consumption all but disappeared in the afternoon. And, to my astonishment, I found when returning home that I had, without trying, lost a few pounds.

Unfortunately, the culture of weight-loss programs do not acknowledge the dramatic effect spring and summer daylight has on losing weight2. Magazines, newspaper articles, and advertisements for diets cluster in the early weeks of January. How many New Year’s resolutions include dropping 20 pounds before springtime? Insisting that weight-loss efforts begin in the depths of winter darkness is usually as effective as forcing one’s jet-lagged body into going to the gym, or eating dinner when it desperately wants to sleep. A friend of mine who had visited China told me that her head narrowly missed hitting the salad plate when she fell asleep at a restaurant a few days after returning home.

June, July and August are the best times to lose weight in the Northern Hemisphere, and as June is already gone, there are only about two months left. The long hours of sunlight (alas, diminishing as we move toward autumn), are a natural appetite suppressant. Long hours of sunlight elevate our moods so that we feel optimistic about taking care of our bodies. Long hours of sunlight also elevate us off the couch, into long walks or finally trying a class at the gym. Extended hours of sun make local produce available at farmer’s markets or your backyard garden so it is possible to feast on newly picked tomatoes, summer squash, or the impossibly sweet tiny kernels of newly harvested corn.

What better combination can be found for removing those pounds added in the winter?

So unless you are planning a trip to the southern hemisphere next winter (when it will be their summer) the time to start that diet is now. And love yourself for doing this.

1) Rosenthal, N.E., Sack, D.A., Gillin, J.C., Lewy, A.J.,Goodwin, F.K., Davenport, Y., Mueller, P.S., Newsome,

D.A. and Wehr, T.A “Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy.” Archives of General Psychiatry.41 (1984): 72-80

2) http://www.livestrong.com/article/35715-effects-sunlight-weight-l…

If Antidepressants Don’t Cause Weight Gain, What Does?

To Sally (not her real name), who wrote to me recently about her 100-pound weight gain after being given antidepressant medications for fibromyalgia, the recent study carried out by a group from the Massachusetts General Hospital will come as a surprise. Before starting treatment, her weight was normal, but after a year on a combination of Effexor and Celexa, she went from petite to extra large. Yet according to a study published a few days ago in the online issue of JAMA Psychiatry, this should not have happened. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. Most of the 11 antidepressants taken by the patients produced similar, small amounts of weight. Elavil and Wellbutrin were associated with the least weight gain and Celexa, the most. But even though Celexa caused significantly more weight to be gained, the actual amount was only a few pounds. Conclusion: The researchers said that patients should not be scared of taking antidepressants because they think they will gain weight. [1]

Although the electronic medical records refuted the connection between antidepressant use and substantive weight gain statistically, it left unanswered the question of how to explain more than a decade of reports of weight gain on these medications. A psychiatrist colleague told me that when he prescribes antidepressants, it is a race to get the patient feeling better before the weight gain is so great the patient decides to stop the medication. How does one reconcile the face-to-face experience of practitioners with the results of this medical record survey? What does one say to Sally and others like her? Your weight gain of 100 pounds on a combination of antidepressants is not related to your therapy? Even though your weight was normal before you started your therapy, you might have gained the weight anyway?

Maybe the explanation is to be found in the type of depression being treated. A Swiss researcher, Dr. Aurelie Lasserre, measured changes in weight over five years among more than 3,00 Swiss who live in the city of Lausanne, Switzerland. As reported in another issue of JAMA Psychiatry, about 7 percent of this population suffered from major depression. Weight was gained among those who had depression, but according to the author, only among those who had what she described as atypical depression, a depression characterized by increased appetite. [2] An example of atypical depression familiar to many of us is seasonal affective disorder (SAD). This winter-based mood disorder is associated with an increased appetite and people often gain 10 or more pounds during the weeks of limited sunlight.

Dr. Lasserre’s findings do not look at whether antidepressants are causing weight gain. However, they suggest that people who gain weight on antidepressants may be doing so not because of the medication, but because their depression has not gone away, and thus they continue to overeat.

This is a handy explanation but leaves several issues to be resolved:

1. Most people are of normal weight before starting on their medication despite weeks of the mood disorder. In my experience running a weight-management center at a psychiatric hospital, most of our patients never had trouble controlling their food intake until they started antidepressant therapy;

2. If the weight gain during antidepressant treatment is a function of an underlying tendency to gain weight while depressed, then how does one explain the tendency of a particular drug, Celexa, to cause more weight gain than other drugs? [3] Theoretically, no drug should be affecting weight;

3. If antidepressant drugs are not associated with weight gain, what is the explanation for the results of a year-long weight-loss trial with Prozac, many years ago, in which non-depressed, obese patients, gained weight? [4]

4. And what about Sally? She was being treated for fibromyalgia, not atypical depression.

Alas, statistics are not going to help Sally and the many others who have indisputably gained weight on their antidepressant treatment, regardless of why they were being treated. One hopes that patients who are gaining weight are not ignored their weight gain because a study says that they should not be doing so.

References:

1) http://www.nlm.nih.gov/medlineplus/news/fullstory_146648.html

2) http://archpsyc.jamanetwork.com/article.aspx?articleid=1878921#Abstract

3) http://consumer.healthday.com/mental-health-information-25/psychology-and-mental-health-news-566/weight-gain-from-antidepressants-is-minimal-study-suggests-688510.html pp 13

4) Michelson D., Amsterdam J., Quitkin F. et al . Changes in Weight During l Year Trial of Fluoxetine, Am J of Psychiatry l99, 156-1170-1176

Are Australians Becoming the New Fat Americans?

On our first recent trip to Australia, I could hardly wait sighting our first kangaroo, hopefully with a joey (baby) in its pouch. They did not disappoint, nor did the adorable but totally inert Koala bears, cockatoos with designer plumage (who talked back to me), wombats which looked like horizontal furry fireplugs and the platypus, first seen in a 2nd grade book on mammals that lay eggs.

But what I did not expect to see were obese Australians. My uninformed image of the sheep rancher in the outback, the crocodile wrestler, or surfer barely escaping shark attacks made me assume that all Australians were lean, muscular, vigorous, tall and wind-burned. And in the first city we visited, Sydney, this was largely true. No sheep ranchers were in sight but the crowds of men and women going off to work in their suits, briefcases, and sleek hairdos were by and large thin or of normal weight. They walked fast and looked like they spent some of their leisure time in gyms, or running or biking.

However, in conversations with some health writers, including physicians, at meetings my husband and I attended, I quickly learned that the low BMIs (body mass indexes) of Sydney residents were atypical. “Just wait until you get into the suburbs, small towns and other cities,” they told me. “Then you will see how fat we Australians are becoming.” And indeed, not only were their observations accurate, they were also reinforced by daily newspaper accounts about the obesity race Australians were about to win. Even though we Americans still rank number one in our prevalence of obes

One of the reasons given for the rapid rise in weight gain was to enable Australians to disguise themselves as Americans when they traveled abroad, but my nutritionist /health writer acquaintances described other causes as well:

• Too large portion sizes (although not as large as ours)

• Little awareness that excessive calorie intake will caused weight gain.” People seem not to understand that eating a fast-food lunch of 2500 calories will affect their weight,” one health journalist told me. “People just think they are getting more for their money.”

• Too much sugar in their beverages, both hot and cold. Australians love their coffee, which is understandable as it is superb, and are more likely to add sugar to their drink rather than a non-calorie sweetener. And they drink many fizzy, sugar and fruit-flavored drinks along with sugar- filled sodas.

• Butter is consumed like water. “Watch how we eat our bread and rolls,” another told me. “We slather it on, carefully covering the entire surface of a piece of toast or roll and would be horrified if bread were not served with butter. “ She was right. At the various dinner-lecture evenings we attended, I noticed that everyone split opened their roll and carefully used up the two pats of butter placed next to their plate. And at the ubiquitous breakfast buffets, the toast had a thick layer of butter before being layered with several slices of fatty bacon and/or sausage.

• Snack foods are very high in fat as well as sugar. Our low or fat-free starchy snacks like pretzels, rice crackers, and popcorn are not that common and people will, for example, eat scones, pastry tarts, doughnuts, and turnovers with an afternoon cup of coffee.

• As in the U.S., too little exercise is also linked to obesity among adults and children. Long commuting times and work hours, lack of physicaleducation in schools, and disinterest in playtime for children adds up to a sedentary life style.

Advice on stopping and reverse obesity was similar to those in the States: cut out sugar, increase physical activity, and eat less meat (they are great meat consumers). Also, consume more fruits and vegetables, whole-grain products and low- fat dairy foods. But none of these recommendations addressed what I was told was the major contributing factor to obesity: alcohol intake.

Everyone I asked told me that many Australians might drink a bottle of wine every night at dinner and then really drink over weekends. A physician friend said that binge drinking was common and not just among the young.

A young female wellness advocate said that she is pressured to drink excessively when out with friends. She went on to tell me that no one talks about the calories people consume from alcohol. It is rarely mentioned as a cause of obesity. And no attempt is made to decrease alcohol intake to promote weight loss. “The reason,” she went on before I could ask, “is that drinking is a cultural thing. It is who we are, what we do, and people are not willing to change. They focus on cutting out sugar even though that has 4 calories per gram and alcohol has 7. ”

She was right. Scanning articles suggesting ways of losing weight, I found all the familiar 21st century recommendations such as eating gluten-free foods, drinking smoothies made of lemon juice, kale, and kangaroo tail (no, not really), avoiding all sugar, fasting and feasting diets, and lap banding, an increasingly popular form of bariatric surgery to shrink the stomach.

After spending only two weeks in Australia, I hardly qualify as an expert on any aspect of their obesity problems. It took me almost this long to learn how to order coffee (black, white, long, flat white). But I suspect that just as with the U.S., the medical and financial costs of obesity will bring about changes, even in the current untouchable aspects of their butter, meat and alcohol intake. If not, most of the population will end up looking like wombats.

e adults and children, the reports stated that obesity was increasing at a much higher rate in Australia than in the States. And children, according to one long weekend newspaper article, were becoming so heavy, that it was hard for some of them to walk.

Unfit & Proud of It!

There is little dispute about the health benefits of physical activity. A comprehensive review of 152 articles studying the health benefits of exercise was published in the Canadian Medical Association Journal in 2006, providing evidence that physical fitness decreases vulnerability to a variety of medical problems and improves overall quality of life.

So why isn’t everyone exercising? Why aren’t we all fit? According to the Centers for Disease Control and Prevention, only 20.6 percent of us meet fitness guidelines for aerobic and muscle-strengthening physical activities. The number is rather shocking, and indeed probably would be even lower were it not for some occupations, such as construction or farm work, that involves sustained physical labor.

There are many in the 80 percent of the population who do not meet physical fitness standards, but would if they could. The reasons for this deficit include that time to exercise is incompatible with their over-loaded life; terrible weather conditions (too hot, too cold); too little money to join gyms; too much travel; too many home obligations; pain and disabilities; shift work; long commutes; caretaking for parents; and probably dozens of other reasons. Until exercise becomes compatible with the constraints of their lifestyle, they are simply unable to do it on a regular basis.

And yet, for many in the 80-percent unfit group, the response to such statistics is: So what? Who needs exercise? An older couple I recently met, let’s call them the Smiths, told me, quite proudly, that they never exercised in their lives. They obviously do walk since, unlike some ancient potentate, they are not carried from place to place on a litter. Presumably, they also climb stairs occasionally or bend down to pick up something they drop. But they valet park their car; use elevators rather than stairs; avoid recreational activities like hiking that require physical effort; and overall seek to avoid breaking into a sweat when moving. Assiduous dieting keeps them trim, for their age, and the wife said they try to eat relatively unprocessed, high-fiber foods. “We are healthy,” they said to me, “so why do we need to exercise? We have better ways of spending our leisure time.”

How does one reach out to and convince the Smiths, and others like them who have the time and economic means to exercise, to do so? Or to turn it around, how does one convince them that by not doing so, they may risk a silent deterioration of their overall health? The loss of bone and muscle, gradual worsening of memory, and the deterioration of balance are just some of the natural changes that come with aging. These changes come slowly, quietly, and often do not reveal themselves until they become symptomatic. Physical activity is known to slow down these processes and maybe even reverse them. Should it be necessary to wait until there is already evidence of bone or muscle loss, for example, or decreased balance, to convince the Smiths and people like them to start on an exercise regimen?

Clearly prevention makes more sense.

The reason the Smiths can believe their well-being is not dependent on exercise is that they have no evidence to the contrary. Changes in weight or blood pressure or blood glucose levels are routinely measured as part of a medical examination, and when the numbers veer into an abnormal range, therapeutic interventions begin. But early stages in muscle, bone and balance loss are not routinely measured. Women are not sent for bone density measurements until a certain number of years past menopause, and few physicians measure muscle strength or balance until their patients become elderly or show signs of weakness and/or dizziness. Even though exercise may improve memory and mood, how many physicians tell their patients to exercise when they complain about normal age-related memory loss, or feeling slightly depressed?

People need to be shown, not told, how their lifestyle is helping or hurting their health. Baseline measurements of physical fitness, including muscle strength and aerobic stamina, should be part of medical examinations every five or 10 years. Everyone accepts the necessity of medical testing to detect the early stages of disease. Shouldn’t the early stages of physical decline also be included so that positive interventions can be started before it becomes necessary to order the cane, walker or wheelchair?