Are Sugary Foods Less Unhealthy During the Holidays ?

The disconnect between 11 months of dire warnings about the evil of consuming sugar, and one month in which the ambitious baker produces prodigious numbers of sugar-sweetened cookies is glaring. The internet, print media, and holistic gurus on television tell us that sugar will, at the very least, cause diabetes, inflammation, cancer, cognitive deficits and, of course, obesity. If you want to live into the next calendar year, these experts tell us, stop eating sugar in this calendar year.

And yet, come the late days of November, baking supplies are prominently displayed on shelves in the front of the supermarket, many with sugar as a significant ingredient. Chocolate chips, sweetened coconut flakes, candied fruit, sugared pecans, and refined, brown, turbinado, and powdered sugar compete for shelf space. The shopper is motivated to buy and use these ingredients by the countless articles in newspapers featuring recipes for cookies and other holiday sweets. Television shows about food also are similarly focused, and show the viewer taught how to make mouth-watering cakes, pies, and, of course, cookies. Who wouldn’t run out to the supermarket and stock up on sugar, eggs, cream, butter, chocolate, and nuts?

But it is curious how those food components we are told to shun (because eating them will lead to a variety of health disasters…) are the dominant ones in these recipes. Sugar is present by the cupful, but generous amounts of butter, egg yolks, heavy cream, and even salt are also major players in the holiday bake-off. The recipes in the newspapers, magazines, and television programs promise taste-bud delight. Where are the nutrition experts now warning us that if we eat these potentially harmful ingredients, we may be giving the gift of future illness to our loved ones?

But wait. They will be around in January.

In the meanwhile, we are told that giving something homemade is to be prized above other gifts. It makes sense. There is much labor that goes into making and then packaging cookies, fudge, peanut brittle and homemade jams. Because they are not available with the click of a mouse, we are told that they represent some of the best gifts we can give. Obviously knitted, woven, or crocheted homemade items are also prized, except that they may not be in a color, size or shape the recipient likes.

For those without the time, talent, or motivation to make edible gifts, but who see such gifts as sufficiently impersonal to be given to people they don’t know very well, the alternative is to buy gift food baskets or boxes. Most will include a least one item that is made from sugar and fat, although some of the options include protein and high-fat foods like processed meats, or just mostly fat such as gourmet cheeses. To be fair, some gift package options are fatfree and feature fruit and nuts, gourmet honey and jams. But some of these items contain plenty of sugar.

Receiving such gifts may be awkward if the donor expects the food item to be open, tasted and shared. A friend who does not like chocolate says that she never knows what to do when presented with a box of gourmet chocolate. “I feel I am expected to open the box, take a piece and then share the rest. I don’t mind the sharing, in fact I would happily give away the entire box, but I don’t like having to eat something I don’t care for.

Returning homemade edible gifts is out of question, and regifting socially dangerous if the new recipient knows the person who made the food or perhaps received some herself. But what do we do if the food gift is incompatible with our dietary needs? What if we are pre-diabetic and told to reduce our sugar intake? What if our bad cholesterol and triglyceride levels are above normal, and we are told to reduce our consumption of saturated fat like butter and egg yolks? Or what if we know we will binge on that jar of buttery sugar cookies or tin of peanut brittle if these foods are in the house? Giving them away, rather than throwing them away, is one solution, but a recipient can’t always be found. And finally, how do we convey to the gift giver that we appreciate the labor and the thought that went into the homemade holiday food gift, but that we are unable to eat it so the person does not give us a similar gift next year?

Perhaps it is time to pay attention to the dire nutritional warnings coming at us the rest of the year about our rising rate of obesity and obesity-related disorders, and find acceptable gifts that do not war with our health needs. Indeed, gratitude at receiving a basket of buttery sugary cookies may turn to dismay when the scale reveals the aftermath of consuming the gift. It is very hard to resist tempting foods displayed on the coffee table. Better not to have them in the house at all.

But that leaves the challenge of finding gifts that are either impersonal (money is impersonal but that is another matter) and /or reflects who we are rather than a commercial enterprise. Making donations to causes that appeal to many people, like organizations which foster and adopt abandoned dogs and cats, or which support environmental protection, or help those less fortunate (such as victims of California’s fires), are alternatives that could be considered. Donating to these organizations in the name of the person to whom you want to give a gift makes everyone feel good. Donating money to organizations that feed those who do not get enough to eat, rather than spending it on baskets and boxes containing foods that no one really needs to eat, is an alternative that benefits everyone.

Do College Students Get Enough (Nutrients) to Eat?

Thanksgiving week is often the first time parents get to see their college-age children after they leave for the fall semester. They often come home not just with a knapsack filled with dirty laundry and a serious sleep deficit, but with the possible beginnings of nutrient deficiencies. It is unlikely that the student will have symptoms of scurvy (Vitamin C deficiency) or iron-deficiency anemia. But, at the very least, many will have been following a nutritionally questionable diet.

Worried about the eating habits of a young relative who is completing his first semester as a freshman, I queried him about the nutritional adequacy of the foods provided in his college’s dining room. The food was acceptable, I was told, although since he was a vegetarian, he couldn’t comment on the meat dishes. His problem, common to so many, was a schedule that included long afternoons in a physics or computer laboratory causing him to emerge for supper  after the dining room had closed. Then his only options were sandwiches and fries at the college-owned café that was open much later, or pizza from a place down the street.

But he mentioned that his friends teased him about his food choices because when he did eat in the dining room, he always had a salad and fruit (his mother would be proud). Asked what his friends usually ate, he quickly tossed out,  “Mac and cheese, pizza, hamburgers, onion rings, and soda. They eat terribly. They never eat vegetables or fruit.”  Knowing that he rarely drank milk and ate yogurt infrequently, I was happy to know that his calcium needs were being supplied by the chocolate milk he drank after long runs.

His perception about the  poor food choices of his friends has been confirmed by many studies of the food habits of college students. The reasons are pretty obvious. Breakfast is often skipped in favor of sleep, and often lunch and dinner may be obtained from food trucks, nearby pizza shops, fast-food restaurants, and snack shops rather than the college dining room. This is particularly true if meal tickets can be used at food trucks, coffee shops and other nearby restaurants.  One consequence, however, is a minimal consumption of fruits, vegetables, and often dairy products. Dieting, especially following  diets  that arbitrary eliminate various food groups (i.e. paleo, keto, cleanses), may also cause inadequate nutrient intake, although this is hardly confined to college campuses.

As the article by Abraham, Noriega and Shin point out (“College students eating habits and knowledge of nutritional requirements,” Survey of attitudes and eating habits  Abraham S, Noriega B, Shin J, J of Nutrition and Human Health 2018 ; 2:13-17), college students often know very little about their nutrient requirements, believe that food additives rather than high calorie content is the reason fast foods should be avoided, and either disregard or know very little about the relationship of nutrient intake to health.

Alerting this population to the consequences of inadequate nutrient intake is a mission that must wait its turn behind education on the perils of nicotine, excessive alcohol and unprotected sex. Not surprisingly, it is a subject rarely discussed, except perhaps by coaches who realize the importance of adequate nutrient intake for their players.  (“Web-based nutrition education for college students: Is it feasible?” Cousineau T, Franko D, Ciccazzo M, et al Eval Program Plann. 2006; 29: 23-33) Male college students, according to the article by Cousineau, Frano, Ciccazzo et al, are particularly uninformed about what they should or should not be eating. But all college students seem to know little about food labels, appropriate number of servings from various food groups, the relationship between calorie intake and energy metabolism, the need for fiber, vitamins and mineral rich foods, and indeed, what happens to food after it is ingested.

One wonders if the ready acceptance of misinformation about diets, effects of certain foods on cognition, inflammation, the intestinal tract, mood, and energy is not a consequence of college age and older adults knowing so little about basic physiology. Often the nutritional information is about as accurate as the belief that the world is flat. Yet where and when does the college student, and indeed anyone in the population, obtain some basic facts about how the body uses what is being consumed?

Weight gain is common in college, especially during the first year, due to a combination of lack of exercise, stress, too little sleep, and perhaps too much pizza and beer. Students are especially vulnerable to this when midterms and final exams approach. Somehow the message that good nutrition and adequate sleep might help cognition and mental performance, has not been able to offset the constant snacking and staying up all night that characterize these periods of intense study.

A simple solution to possible inadequate nutrient intake is a daily vitamin supplement or a vitamin supplement that also contains calcium and iron for those who avoid dairy products and foods rich in iron (such as red meat.) The vitamin supplement is, of course, no substitute for those fruits and vegetables, and dairy products the college attender should be eating. But until that happens, a chewable vitamin or a pill may be the best solution.

The Guest with the Surgically Shrunk Stomach & Thanksgiving Dinner

Surgical interventions to reduce the size of the stomach are increasing in popularity, predominantly because they have been successful in reversing years of dieting failures. Patients who have had these procedures, however, may find themselves struggling to deal with the excessive amounts of food commonly served on Thanksgiving.  Although Thanksgiving is still a day when we pause in our daily lives to be grateful for what we have, including food, health, family and friends, the holiday sometimes seems to be almost exclusively concerned with only the food. Judging by the number of media articles and television shows advising us on recipes and methods of cooking, sometimes it seems that the purpose of the holiday is to see how successful we are in preparing the meal.

The amount of food served on Thanksgiving Day must resemble a feast. If the host decides that the turkey, two vegetables and just one dessert are sufficient, he or she will be regarded as a food miser. “What are you making for Thanksgiving?” is the greeting of the week before turkey day, and guests often arrive with dishes to supplement the many made by the host. One young woman who is hosting Thanksgiving dinner for the family for the first time was gently reminded that her dinner plates were not sufficiently large to contain all the side dishes she thought she had to prepare.

The typical guest, confronted with all that food, manages to eat much more than the amount he or she would normally consume at a dinner meal.  Despite protestations of feeling too stuffed to eat another bite after the main course has been consumed, most will manage somehow to sample at least a couple of pies when dessert is served.

But what if the guest does not have considerable room in his or her stomach to eat the many dishes being offered? What if the guest has had bariatric surgery to reduce the size of the stomach, and now it can hold no more than a couple of ounces of food at one time? The point of the surgery is to make the stomach so small that the patient, eating only tiny amounts of food, will lose weight.

What makes an occasion like Thanksgiving so difficult for those who have had this surgery is that for years, they were able to eat whatever they wanted, and as much as they wanted. Even though they know it is physically impossible now for them to do so, emotionally this may be hard to accept.  I wonder if any one us who has not had such an operation can imagine how difficult it must be to watch others around the Thanksgiving table help themselves to large portions, take additional servings and eat as many desserts as are available. The guest with the surgically reduced stomach not only is unable to eat normal-size portions but must also restrict what is eaten to the foods that will nourish his body rather the foods that he may crave. Filling up on stuffing or marshmallow-topped sweet potato pie or onions in cream sauce is not an option when his body needs lean protein.  A normal size stomach can handle the turkey and all the side dishes; a surgically reduced stomach may accept only the turkey.

Moreover, those who have had this type of surgery may be reluctant to share this information with others at the table.  But then, how to explain the sudden significant decrease in food intake? Several years ago, I noted that a relative who was known for consuming large quantities of food was eating tiny portions, and refusing most of the dishes offered to him. When I asked him if he was not feeling well, he told me about this surgery to reduce the size of his stomach. Suddenly others, overhearing our conversation, threw questions at him so quickly he couldn’t answer them: What was the surgical procedure? Did it hurt? How much weight have you lost so far? What can you eat? Are you hungry? Even though it is no one’s business and the guest should not feel obliged to answer the questions, often, especially when relatives are present, people want their curiosity satisfied.

Fortunately for our guest with the surgically smaller stomach, there are probably others who are also limiting their food intake.  Many Thanksgiving dinners will have guests who are avoiding gluten, dairy, meat, all animal products, all carbohydrates, foods without probiotics, cooked foods, certain fruits and vegetables, fat, and salt. Thus several of the diners may be putting only one or two items on their plate, and in some cases guests may even bring their own food because they don’t want to risk eating foods which may make them ill.

But even if the limited food intake due to bariatric surgery is camouflaged by the presence of others who pick, choose, and reject the food being served, the psychological difficulty of not being able to eat freely remains. Portion control is essential as is eating slowly, limiting fluid intake including alcohol so the stomach has room for food, and knowing when to stop eating. This is not easy, and often is accompanied by a sense of loss as acute as that experienced by others…such as a diabetic or someone with certain types of gastrointestinal disorders who must accept that they can no longer eat everything they want.

Perhaps the presence of some guests who cannot indulge in unlimited eating might be a catalyst to decrease the excesses of the Thanksgiving meal. Certainly, one point of the meal is to be thankful that we can feed our families, friends, indeed, those in our community.  But feeding one’s guests and feeding them to excess are not the same thing.  If we simplify the menu, provide a realistic amount of food, and alter the emphasis from what is on the table to who is around the table, then even those who cannot eat much will not feel deprived.

Might Physical Activity Be as Effective as Antidepressants?

The well-known recommendation to exercise in order to relieve and/or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and obesity, as well as decrease vulnerability to diabetes, heart disease, and cancer. That is an awful lot to ask of a daily bout of physical activity.

However, many studies over the past several decades have confirmed the positive relationship between exercise and an array of health effects. Exercise is not going to prevent anyone from eventually exiting this world, but engaging in physical activity may make us more healthy while we are still in it.

Studies over the past decade on exercise and mental disorders have added another benefit to consistent physical activity: Depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Craft and Perna published an extensive review of studies on whether or not exercise might have a therapeutic role in clinical depression. The ability of depressed patients to carry out physical work has been shown to be significantly impaired, and they are less fit than the general population, according to some studies cited in the article. It is not hard to find reasons for the diminished physical well-being. Depression is often accompanied by fatigue, social withdrawal, sleep disturbances, and the side effects of antidepressants include dizziness, nausea, and even weight gain. These factors may make engaging in routine physical activity difficult, unless there is outside support to do so.

In a typical study to see whether exercise might be beneficial not just in improving physical status but also in relieving the symptom of depression, the patients are enrolled in an exercise program, walking three or four times a week, for example, or doing resistance training. The severity of their depression is compared with a control group of patients who do not exercise but engage in some other type of intervention so they receive the same amount of care and attention from the research staff. The results have been consistent study after study: Exercise has a positive effect on depression.

In one particularly compelling study, the effect of exercise over 16 weeks was compared with the effect of an antidepressant (sertraline) alone and with sertraline and exercise. About two-thirds of the patients in each group went into remission after the four-month testing period. The results indicate that exercise alone was as effective as the medication alone or medication plus exercise in relieving the depression.

If exercise is treated like any other therapeutic intervention, it is important to determine the most effective dose, timing, and type, as one would with medication. Walking slowly on a treadmill versus jogging or resistance training once a week, or four times a week, are some of the variables that have to be examined. Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight, or does this make any difference? Might yoga or other group exercise be more beneficial than solitary workouts, or a walk, because they diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressant therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect; should the patient wait the same amount of time to see whether exercise relieves symptoms?

These questions can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat the patients? Therapists are rarely, if ever, also trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain, but how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help/motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Visits to a psychotherapist and medication may be paid for now in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness, and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness, in addition to relieving the symptoms of depression without the side effects of drugs, cannot be overestimated. Now is the time to figure out how to apply this knowledge.

References

“The Benefits of Exercise for the Clinically Depressed,” Craft L and Perna F, Prim Care Companion J Clin Psychiatry. 2004; 6(3): 104–111.

“Effects of exercise training on older patients with major depression,” Blumenthal JA, Babyak MA, and Moore KA. et al. Arch Intern Med. 1999 159:2349–2356

The Social Isolation of a Painful Disease

We visited B for the first time in three years because of our infrequent trips to the country in which she lives, thousands of miles and several time zones away from us. Emails and phone calls had informed us of her worsening fibromyalgia, but we were not prepared for the almost total isolation imposed by her chronic pain. She has trouble walking because of pain in her legs, and simple movements, such as getting up from a chair or climbing a flight of stairs, are difficult or on some days impossible. Plans to socialize with friends or attend a lecture at the university where she used to be a professor are often canceled, she told us, due to overwhelming fatigue.

Fibromyalgia is a disease that seemed to defy diagnosis or categorization for decades, because no objective measurements, such as blood tests or scans, revealed the source of the symptoms. An advertisement for a drug to relieve the pain of fibromyalgia demonstrates the hidden nature of the disease: A woman tells us that we might assume she is perfectly healthy, because there are no outward signs of her symptoms, yet she is in constant pain.

Fortunately, the medical community has now accepted fibromyalgia as a real disease with multiple symptoms. The most common is pain that seems to migrate almost randomly around the body, affecting soft tissue, tendons, ligaments, and muscle. However, patients may experience severe migraines, sleep disturbances, mood and cognitive disorders, gastrointestinal disturbances, and fatigue.

It is not clear what causes the disease or why pain is felt when there is no visible injury, inflammation, infection, or sign of any other cause, such as cancer. Now researchers are investigating whether the pain is not due to some injury or other disorder within the body, but rather to inappropriate messages from centers in the brain that signal the presence of pain.

One therapeutic approach has been the use of drugs which activate neurotransmitters such as serotonin and norepinephrine to see if they can counteract the pain signals from the brain. But the drugs are not always effective and have their own side effects. Presently, a multifaceted therapeutic approach is advised, incorporating psychological counseling, cognitive-behavioral therapy, meditation, exercise, and reducing sleep disturbances.

However, these interventions are not always successful. Our friend swam and did exercises in the water for two years with no improvement. Now an exercise physiologist trained to work with fibromyalgia patients is available to help her exercise twice a week, but the sessions are often canceled because the intensity of her pain makes any type of exercise too difficult.

Physicians and other health professionals have not been able to find any effective intervention to allow this once-vibrant woman to return to her former active life. She taught university-level courses, turned her research into highly regarded books, and was active in an organization that worked with disadvantaged children. Now, most of her days are spent alone in her apartment with a part-time caretaker. Her friends have dropped away, not because they don’t want to be with her, but because her pain makes it difficult for her to be social. Her hands hurt too much to text or email or engage in social media, and she finds it hard to carry on phone conversations. We don’t know how much our visit cost her in pain. Because we had traveled so far to see her, she never revealed to us, honestly, how she was feeling.

And yet it was apparent that having visitors who made a point of not focusing the entire conversation on her disease had a positive effect. We amused her with some interesting gossip, engaged her in a political discussion that we knew would animate her, shared memories of a time when we lived in the same city, and talked about her research.

Did her pain recede as a result? We never asked, but the energy she summoned several minutes into our visit seemed to indicate that perhaps her pain was not taking over her life at that time.

Sadly, we had to leave her and return home, promising not to wait so long before we made the trip again. But our visit pointed out how a chronically painful disease reduces the quality of life and in particular the loss of human contact. And it is not obvious what can be done. It is hard to spend time with someone who is in constant pain; we don’t know what to say, how to help, or how to understand what they are feeling unless we have had similar experiences. We fear that we may be causing the patient more stress by forcing her to put on a cheerful face and chitchat with us as if nothing is wrong when we all know that she is deeply distressed. Sometimes it’s easier to stay away.

But we shouldn’t stay away. We should not allow the pain and other symptoms, such as sleep disturbances, limit our visits with the patient. If we allow this to happen, then we are allowing the disease to replace our relationships.

When we saw our friend, it was apparent that once we stopped talking about her disease and switched to topics that have consumed our mutual interests for decades, she seemed to focus less on her pain and more on engaging with us in discussing the interests we had shared for many years. Indeed, at some point, we all forgot about the fibromyalgia and simply remembered how good it was to be with each other.

Perhaps social contact should be added to the top of the long list of interventions for this disease. Pain may be present, whether the patient is alone or with others. But when others are around, good conversations, laughter, stories, arguments, etc., may prove an invaluable distraction from the pain. It may not always work; pain may cause social interactions to be delayed or canceled. But it is important to try, because the rewards of seeing a friend or family member relieved of chronic pain, even temporarily, are immense.

References

Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. JAMA 1987; 257:2782.

Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health 2009; 9:402.

Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014; 311:1547.

When Bone Soup Promises More Than It Delivers

One of my neighbors was recently diagnosed with liver and pancreatic cancer. She is rapidly losing weight because eating and digesting food causes her pain, but her weight loss may make recovery from chemotherapy more difficult. She told me she is drinking bone broth in order to obtain the nutrients she needs, and to halt her weight loss.

Why? I asked her when we talked today.Everyone says it is good for me,” she answered, everyone upon further questioning being some relatives and a few friends. “But you need nourishment, I protested. You need to eat protein, you need carbohydrates for energy, and you need vitamins and minerals. You aren’t going to stop losing weight by drinking bone-flavored water.“

Fortunately, her oncologist referred her to a hospital dietician experienced in the nutritional needs of cancer patients such as my friend, and the bone broth is now watering some house plants. But this incident is an example of how popular food fads, health food supplements and neighborly advice may exacerbate, rather than solve nutritional problems.

Bone broth, a soup containing mostly water and the flavor and some nutrients from the bones cooked in it, is a broth that people have been eating for eons. It is, in some respects, like drinking liquid, salty Jell-O. When beef bones are cooked for long periods of time, they turn into a gelatinous mass, as I discovered when I forgot about a pot of water and bones I was simmering in order to make stock for soup. (Washing the pot became a major endeavor.) This gelatin in the hands of competent cooks can be turned into aspic, a translucent covering for pates and cold chicken, or a sweet “Jell-O” type dessert. Proponents of bone broth point to the gelatin as evidence of its vast nutritional value: all the good protein and the collagen from the bones is going to decrease inflammation, fortify your bones, and lubricate your joints. What is not mentioned is that gelatin is an incomplete protein because it lacks the essential amino acid tryptophan, and contains very small amounts of another amino acid, tyrosine.

Both tryptophan and tyrosine are needed for the synthesis of new protein in our bodies. Thus, if my friend depends on the gelatin in bone broth in order to make new protein for her muscles that are wasting away, she will be unable to do so. Moreover, the collagen in bone broth is digested in the intestinal tract, and is no more able to lubricate our joints than the butter or oil we may be eating.

Ironically, if a chicken were simmered along with the bones it would turn into (drum roll please) chicken soup. The chicken is a good source of protein, and although the power of chicken soup to heal the body may be exaggerated, its ability to soothe the distress of a bad cold or flu, or maybe restore the body after a bout of chemotherapy does not seem to be in dispute.

It is disconcerting to find bone broth sold in supermarkets and online for not inconsiderable amounts of money. In the old days, before this fad, people threw a few bones in a pot of water and whatever vegetables they had to make a very cheap soup. Bones also used to be given to dog owners or sold in enormous quantities to be turned into gelatin, or the fertilizer bone meal. Paying $10.00 or more for a box of bone broth containing mostly water seems absurd.

What is so worrisome about this food fad, and the many others that pop up like mushrooms after a wet spell, is that they suggest we don’t have to rely on food for our daily nourishment or to compensate for some nutritional deficit such as lack of vitamin C or iron. The health food store, not healthy foods at the grocery store, is promoted as the path to nutritional wellness. I receive updates from several online newsletters describing the latest supplement entering the health food market. It is often astonishing to read about the promises made, without any evidence, for these products. One of many entering the market this past month includes bitter melon, cinnamon bark, fenugreek seed, olive leaf and artichoke leaf, holy basil herb and lycium fruit. These are presented in a liquid and supposedly will maintain normal blood sugar levels in people with normal blood sugar levels (italics are my own). Apparently the makers of this supplement never heard of insulin that our pancreas secrete (for free) when we eat carbohydrates. Another product also just now for sale is made from Siberian rhubarb roots and promises to help menopausal symptoms like hot flushes. The research supporting these claims and many others is often not real or reproducible, but how would a consumer know this? 

My friend with cancer believed that the bone broth she was drinking, even though her weight was melting off, was nourishing her. Unfortunately, she was getting none of the nutrients she needed. People may hesitate to seek medical advice or ignore it completely because they are convinced that the promises made by the supplements will be the answer to their medical problems. Supplements can interfere with drugs one is already taking. Given the number of supplements on the market, and the sometimes bizarre source of ingredients (who knew that rhubarb could be grown in Siberia?), physicians may not know whether the ingredients are dangerous. Plus the dose of a supplement may be entirely too high. For example, many doses of melatonin range from 3 mg to 10 mg; the dose established by clinical research puts the dose at 0.3-0.5 mg and the higher dose may dampen the body’s own melatonin production.

The FDA has information about the ingredients, function and side effects of many supplements, and it is worth spending time learning about a supplement that has been recommended or advertised before taking it. Some are critically important, such as those providing the vitamins and minerals an individual may not be able to obtain through food. My friend does take a vitamin-mineral supplement because she finds it too painful to eat many fruits and vegetables.

Our health is too important to be left to the sellers of health products. Checking out the scientific validity of a product may not be possible without the help of dieticians or others knowledgeable about the contents and claims of these products. But it is worth making the time to do so.

When Mindless Eating Has a Function

Mindless eating is always trotted out as a significant factor in the increasing incidence of obesity. If we only paid attention to what we are eating, perhaps we would eat more 1) healthily and 2) frugally. We would never eat potato chips, butter-drenched popcorn, French fries, peanuts, M & M’s and nachos or, if we did, we would notice every peanut or M & M going into our mouths and would stop after eating only one or two (in our dreams, perhaps). We never would eat everything on our plates, unless the portion size was so small we noticed its reduced size.  When served the typical overly large serving, we would carefully portion out the amount we should be eating and leave the rest, or eat it at another meal.

But who eats this way?  Probably people during the early stages of a diet, or after bariatric surgery when they are left with a tiny stomach. Restaurant reviewers pay attention to what they are eating, as do judges on televised competitive cooking shows or at state fairs tasting pies.  Of course, pathological food restrictors are extremely mindful of what they put in their mouths (three slices of apple, two leaves of lettuce), as are toddlers who chase cereal bits around the trays on their strollers.  Picky eaters notice what they are eating in order not to risk putting anything in their mouths that is distasteful or has unacceptable mouth feel. But once they remove the offending food from their plates, they eat as mindlessly as the rest of us.

Stress is a significant trigger for mindless eating and is often cited as an obstacle to weight loss or its maintenance. Often the eating is so unnoticed that only the empty ice cream container or bag of chips signals that eating has actually occurred.

Some studies suggest that chewing and not the swallowing of food is what decreases stress. Supposedly the repetitive motion of chewing produces a decrease in physiological markers of stress such as blood cortisol levels. (“Mastication as a Stress-Coping Behavior,” Kubo K, Iinuma M, and Chen H Biomed Res Int. 2015; 2015:876)  Laboratory rats given wooden sticks to bite or chew will show lower levels of cortisol when stressed, than rats not allowed to chew. Humans may chew gum or gnaw on other objects (pencils, pipe stems, coffee stirrers, fingernails) when they are stressed and as with the rats, this chewing decreases levels of cortisol and other physiological indicators of stress. If chewing does easing worry and anxiety, then the chewed object should have few or no calories (for instance, gum or crushed ice).

Unfortunately, we usually swallow what we are consuming when stress-associated mindlessly eating. This, of course, may significantly affect our weight if the stress and the mindless eating are prolonged. But is mindless eating at a time of emotional distress all bad?

Recently, while dining with friends we had not seen for several weeks, we learned that the husband was scheduled for a medical test that would reveal whether his medical problem could be helped by a simple, safe procedure, or major surgery with considerable risks. We had ordered a variety of small dishes meant to be shared among us, including two types of pasta which were served in large bowls. One bowl of pasta happened to be set in front of the wife of the individual whose medical condition we were discussing. “I can’t believe I ate the entire bowl of pasta,” she exclaimed several minutes later when someone asked her to pass the now empty bowl.  I didn’t mean to eat so much,” she said. “I didn’t even realize I was eating it!”

Mindless eating? Yes. Might it have been related to her worry and anxiety that her spouse might not survive the more drastic medical procedure? Probably. Did it help ease her emotional distress? Perhaps.   Certainly the carbohydrate, the pasta, would have increased serotonin synthesis in her brain, and that, in turn, may have lessened her anxiety, helplessness at not being able to do anything but wait and worry, and maybe even increased her ability to cope with the unknown.

It wasn’t necessary for her to eat the entire bowl of pasta to ease her anxiety. Indeed, had she eaten a few skinny bread sticks, or a slice of crusty bread from the basket placed on the table as we sat down, she might have started to feel better before the pasta arrived. Once digested, the carbohydrate in the bread sticks would have initiated the physiological process leading to an elevation of her brain serotonin levels. The subsequent increase in serotonin activity and possible reduction in her anxiety and worry might have prevented her from consuming all the pasta without noticing what she was doing.

However, the mindless eating our friend experienced is not without some benefit in addition to an easing of her distress. It can be regarded as an early warning of her vulnerability to eating uncontrollably in order to feel better. Our friend should be asking herself: “ Why did I eat all that food without noticing?  Am I using food  to block out my emotional pain? Is it working?”

Positive answers do not mean that mindless eating should be continued. Rather, it should be replaced by mindful eating.  It is not necessary to eat large quantities of carbohydrates  to experience relief from stress. The stressed eater need consume only about 30 grams of a fat-free carbohydrate (i.e. rice crackers or oatmeal) that contains no more than 4-5 grams of protein to bring about an increase in serotonin and a decrease in stress.  (“Brain serotonin content: Physiological regulation by plasma neutral amino acids,” Fernstrom, J. and Wurtman, R. Science, 1972; 178:414-416). Eaten as a snack, or indeed in a meal, once the carbohydrate is digested, the increase in serotonin should bring about some emotional relief.

Stress happens to all of us, and usually when we are not prepared. A bowl of pasta or a few breadsticks is not going to take away the cause or offer a solution. But at least these carbohydrates may take the edge off of our emotional pain, and make the problem a little more bearable.

 

 

 

What’s the Best Way to Help People Lose Weight?

If weight-loss programs advertised on television were to be believed, then it is obvious that the best way to get people to lose weight and keep it off is to eat commercially available, calorie-controlled packaged meals and snacks. In just [insert number of days] you, the consumer, will drop at least 10 to 20 pounds, lose your hunger completely, and never have another food craving, according to the promises in the ads. Two runners-up would include an FDA-approved weight-loss drug that takes away appetite and replaces the pleasure you get from eating with something not defined, and/or an exercise device that melts off pounds and replaces them with a “ripped” body that looks good in a minuscule bikini or swim trunks.

Despite the allure of such advertisements, and the wish to look like the models proclaiming the efficacy of such weight-loss interventions, extensive research indicates that they are not the best way to lose weight and keep it off. No surprise.

A few days ago, the Journal of the American Medical Association (JAMA) published a paper that summarized several years of analyzing current interventions on weight loss and maintaining weight loss. The report did not include results from surgical interventions that reduce the size of the stomach, such as putting a balloon in the stomach or removing food from the stomach through a tube that empties into a receptacle. The criterion for review of the weight-loss interventions was whether or not they could be “provided in or referred from a primary care setting.”

The report stressed the importance of identifying the most effective means of bringing about weight loss because of the alarming prevalence of obesity in the states. The commonly accepted definition of obesity is a body mass index (BMI) of 30 or higher. (This is weight in kilograms divided by height in meters squared; there are websites that help with this calculation for the arithmetic-challenged reader.) More than 40 percent of women and 35 percent of men in the United States today meet the criterion for obesity.

Intensive, multifaceted weight-loss interventions were found to be the most successful based on the authors’ review of published studies. Such interventions lasted one to two years, with monthly or more frequent meetings. Although food plans that would support weight loss were part of the intervention, the report did not single out any particular type of diet, other than inferring it would have to be a food plan that could be followed for many months. People were encouraged to monitor their weight and exercise levels, to use food scales to weigh their food, and behavioral support was consistently offered. The settings ranged from face-to-face meetings with individuals or a group to remote interactions via Skype or other computer-assisted interactions.

Even though the review looked at programs that could be carried out in a primary care setting, as opposed to surgical interventions, primary care physicians were rarely involved in the programs. A “village” of behavioral therapists, dieticians, exercise physiologists, and life coaches offered a variety of services designed to enhance not only the weight loss but also its subsequent maintenance.

The study rejected the use of weight-loss drugs because the authors wanted to find interventions that caused the least harm. Such drugs come with a long list of side effects: anxiety, gastrointestinal symptoms, headache, elevated heart rate, and mood disorders, to name a few. The side effects from behavioral interventions might be aching muscles from a new exercise or a longing for highly caloric foods. The authors did note that when pharmacological interventions were combined with behavioral ones, the results were better than with either intervention alone. But there was a high rate of attrition, i.e. withdrawal from the studies among those taking weight-loss drugs, perhaps due to the side effects.

The takeaway message from this comprehensive report is that the thousands of people in need of weight loss should locate a primary care physician who will then direct them to an intensive and comprehensive behavioral weight-loss program meeting at least once a month for 18 months or longer. The program should help them buy and prepare the foods they should be eating, make sure that they have the time and money to participate in frequent exercise, identify or solve problems causing emotional overeating, and make sure that weight-loss successes are supported by family and friends and not sabotaged. The report did not mention cost; the studies the authors reviewed were free to the participants.

“When pigs fly!” might be the somewhat cynical response to this paper. Yes, of course, all these interventions will presumably work, except perhaps for those patients whose weight gain was a side effect of their medications. It is very hard to lose weight when drugs such as antidepressants and mood stabilizers cause hunger that does not go away.

But how many primary care practices have the money and time to formulate and carry out the intensive programs recommended? How many hospital-based weight-loss clinics have exercise physiologists, life coaches, therapists, and dieticians to pay personal attention to the participants? Where does one go to find such programs?

And yet, what are the alternatives? The list of medical problems associated with obesity, ranging from orthopedic disabilities to cancer, is not getting smaller. Might technology be the answer? Smartphones allow us to monitor many aspects of our daily lives, from how we sleep to whether we feel stressed. Might robots or some other form of artificial intelligence prevent us from eating portions that are too large or moving too little (some do already), or ask us what is really wrong when we open the freezer to look for the ice cream? Can a robot remind us to do our exercise routine, or meditate, or stop working and give ourselves some private time…or turn off the computer or television and go to sleep? And would we be less likely to deny that we have just eaten a bag of cookies to a robot?

Human interventions have not worked all that well; perhaps it is time to turn to the other.

References

“Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults,” US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force JAMA, 2018; 320(11): 1163-117.

Does Your Mood Fall Before the Leaves Do?

When fall officially arrives on September 22, the number of hours of daylight and darkness are equal. As we proceed further into fall and early winter, hours of darkness overtake those of light, and a well-rehearsed (because we sing this every year) chorus of “It is so dark in the afternoon!” will be heard.  By the end of November, the refrain of, “It’s so depressing!” is added to our song of complaint.

And every year, even before the leaves change color, we noticed changes in energy, appetite, sleep and mood. At first, these changes are hardly noticeable: sleeping a little longer, disinterest in new activities or commitments, feeling tired, craving for starchy comfort foods rather than large salad, and a bit of irritability, annoyance, impatience, and gloominess. That’s seasonal affective disorder, SAD or the winter blues,  arriving.

This seasonal disorder with its symptoms of overeating, fatigue, sleepiness, and grumpy mood is provoked by a decline in hours of daylight. Inhabitants of our northern states are more vulnerable than those in the south because the southern states have more daylight in the late fall and winter. For example, on  December 21, the first day of winter, Chicago has a little over 9 hours of daylight; Key West, Florida, 10 and a half hours.  The symptoms of SAD are not weather related (although there is a variant called summer SAD that seems to be linked to heat and humidity). Indeed, the early symptoms may begin during the early days of fall with its sunny crisp days, and naturally cool nights.

SAD was first described in the mid-l980s, but not much more is known today about how an environmental input like sunlight is able to bring about so many changes in our well-being.  The hormone that puts us to sleep, melatonin, has been implicated because daylight naturally reduces its levels in the blood. It was thought that the late sunrises of the fall and winter seasons delays melatonin destruction and leaves us sleepy, but how this would affect the other symptoms such as mood and overeating was (and is) not understood.

One of the first therapies offered to patients was exposure to artificial light that mimics the spectrum of sunlight. Sitting in front of a lightbox or “sunbox” for thirty minutes or so in the early morning upon awakening was shown to relieve the symptoms of SAD. Lightboxes are still used, and some who work in windowless offices often keep them on throughout the morning to brighten their mood. Treatment with antidepressants that increase serotonin activity is now an alternative treatment based on studies showing that serotonin activity seems to be reduced in patients with seasonal affective disorder.

However, many people fortunately never experience the clinical depression of SAD; rather they have milder symptoms which now have taken on the name “winter blues”. Although their weight, sleep, work productivity, and mood are all changed (not for the better), their symptoms may be relieved in part simply by using light therapy.

One of the problems with winter depression is that it creeps up silently, triggering an almost imperceptible change in behaviors that seem to have their own justification, rather than associated with diminishing daylight. Fresh fruit desserts are less appealing than the fruit baked in a cake or pie; fall activities make a good excuse for skipping the gym; new projects or commitments are better off delayed until spring because the holidays will be coming; the irritability, depressed mood, anger symptoms are justified because of work/kids back to school/ family or financial stress; and sleeping longer is necessary because of a persistent tiredness.

Recognizing the early symptoms of winter blues, such as cravings for sweet carbohydrates or increased fatigue, allows strategies to be put in place (like rakes before the leaves drop) to decrease their impact on quality of life.  For example, weight is often gained due to the dual effects of craving high-fat sugary foods (like chocolate and cookies) and drastically decreasing exercise because of fatigue. Recognizing this should lead to removing highly caloric carbohydrate snacks like chocolate and ice cream from the kitchen. Once the full blown carb cravings of winter blues hit, it will be difficult to resist eating cookies or ice cream or chocolate, especially when the sun sets by late afternoon.  Replacing these highly caloric foods with very low fat breakfast cereal—such as oat or wheat squares or cornflakes—will increase serotonin, turn off carbohydrate cravings, and increase satiety without doing damage to your weight.

Fatigue and disinterest in taking on new activities may shut down any commitment to frequent (if any) exercise. Plenty of excuses will be available as weather, early afternoon darkness, work, holiday, and family commitments erode time for a workout at home, at the gym, or outdoors. It is all too easy to stop going to a yoga or Pilates class or cancel a walk with a friend. One solution is to use an APP, or wearable exercise tracking device that will nag you into taking 10,000 steps a day, or indicate how many calories you are eating and how many you are using for energy. The APP doesn’t care what your excuses are for not moving, but if programmed correctly, will ping and alarm and buzz until you do move.

Better yet, be competitive with someone at work or in the family so that you have to display daily (or at least weekly) whether you met your exercise goals. If you start doing this before the fatigue of the winter blues sets in, it is possible that you will continue with the exercise even if one part of you is begging to lie down on the couch and watch Netflix. There is no cure for SAD or the winter blues other than moving to states where the days are longer. Fortunately, the days start to get longer on the second day of winter, and the symptoms will go into remission by mid-spring.

We can’t keep the leaves from falling, or snow, for that matter. But it should be possible with the right interventions to keep weight from rising, mood from falling, and energy levels intact until that happens.

References

Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy Rosenthal N, Sack D, Lewy A et al Archives of General Psychiatry  1984 ;41: 72-80

(β-CIT SPECT imaging shows reduced brain serotonin transporter availability in drug-free depressed patients with seasonal affective disorder  Willeit M, Praschak N, Rieder A et al Biological Psychiatry  2000 ; 47: 482-489

Can Being Put on Hold Cause You to Gain Weight?

It is entirely possible to spend an entire week talking to computers, or whatever records the messages that act as an impenetrable wall between you and communication with a human. My problem was trying to reach a human employee in a county courthouse to trace a seemingly lost file for a minor, but important, transaction. Various phones were answered, but by robotic voices and the one time, after at least a dozen calls, a human answered, I was put on hold for about 20 minutes.   Unlike the old days when my wall-mounted kitchen phone had a cord that barely reached to the sink, now I could wander over to the refrigerator or kitchen cabinet while waiting for the human voice on the phone. It was only worrying that when or if someone would respond I would be too busy chewing to talk that prevented me from eating my way through these hold times. But I wonder: Is frustration at being put into cyberspace, instead of personal space when a problem needed to be solved, an overlooked cause of obesity?

A friend who works at a large US government agency complains incessantly at computer problems that no one is able or willing to fix. Another friend, a doctor, was visibly shaken when he could not understand the information given at a mandatory orientation on how to use the hospital’s new computerized record keeping system, and muttered about early retirement. An office mate goes into a high-stress mode about every 3 ½ days when a document he spent hours revising is nowhere to be found in the Cloud or Dropbox or wherever those files are stored. And an aunt moans constantly about having to navigate her way through online forms every time she wants to refill a prescription for her dog’s heartworm medication. The animal hospital’s pharmacy no longer takes refill orders by phone.

A recent talk by the New York Times columnist Thomas Friedman, at an endowed lectureship at MIT, provided the not too shocking information that we spend on average over 60% of our time in cyberspace. Presumably only a small amount of this time is spent stressing over glitches in our cyber interactions.  And given the intensity and severity of stress previous generations experienced in their jobs, family, and communities, stressing out over confrontations with recorded messages or errant computer programs seems frivolous.

And yet: not being able to talk to a human when a problem really needs to be solved, now. Not being able to get through to a physician’s office because the recorded message does not allow the patient to say, “It is not a crisis, but I have to talk to the doctor.” Not understanding the accent of the technician who is attempting, valiantly, to figure out why the cell phone is not responding and is simply not communicating.  These, and other situations too numerous to count, impose a stress on our lives.

And what do many of us do when we are stressed? Eat, of course. To be fair, we often don’t eat when we are attempting to follow directions as to what to click to fix a computer problem, because our hands are busy (one on the phone and one on the mouse). And when our adrenaline is extremely high because we are not sure we will ever get a human on the phone or a technician to resolve a phone issue, we are not eating, because the our stress and agitation has taken away our appetite. But afterward, to calm ourselves when the problem is fixed, or to calm ourselves when the problem cannot be fixed, we eat. And we are not racing to the refrigerator to steam broccoli or rip open a container of fat-free cottage cheese. We eat the foods we always eat when we are stressed: sugary or salty high-fat carbohydrates like cookie or chips, ice cream or French fries.

If technology is causing our stress and overeating, might technology take it away?  There are apps that monitor our stress levels by picking up changes in heart rate, and some other physiological measures of distress. However, then what? Wouldn’t we know we are stressed without the app telling us? There are apps that will keep track of our caloric intake, so if we are munching on peanuts while listening to the on-hold recorded music, we will know how much we are eating. But of course we have to do mindful munching; otherwise, how can we tell the app how many handfuls of peanuts we have thrown in our mouth?

But perhaps someone will/can develop apps that help us meditate when we are on hold to calm our breathing, to speak to us in reassuring tones when we cannot get through the. “Listen carefully because our menu choices may have changed…” message without grinding our teeth, to detect when we are opening a bag of cookies or the freezer to get at the ice cream and gently remind us that eating isn’t going to fix the computer.  Another exercise-oriented app can suggest useful pacing techniques, and record the number of steps we are taking while waiting for a technician to come on the line. A third should tell us to stop hunching over the computer or tablet and to relax our neck and shoulders and remind us that even though we think having our computer crash, or never being able to though to a human on the telephone, is not the end of the world.

It only feels like it is.