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How Can You Get Enough Nutrients If You Don’t Eat Very Much?

Some of the more popular reality shows on television display various mental health pathologies such as super rich housewives always fighting with each other (when they are not having their hair done and drinking wine), or a show about hoarding to the point of suffocation, or even a view into living inside a 600-pound body that is so heavy, any movement is difficult and painful. The latter program is particularly sad, in that it shows how obsessive eating is almost always the result of early trauma, and how difficult it is for the overeater to deal with the pain of such trauma when the emotionally deadening effect of food is removed.

 

What has not been depicted so far is a reality program on the struggles of people at the other end of the eating spectrum. These are the people who believe that, like the Duchess of Windsor, one can never be too rich or too thin. These are the people whose body weight is so low that they run the risk of death. These are the people whose obsession with being extremely thin is as unshakable as the 600-pound individual who seems to be addicted to food.  

 

Perhaps the stories of the too thin are not told because the viewer may not be interested in watching an anorectic chase an almost invisible morsel of food around the plate, before grudgingly eating it and then exercising for three hours to work off the 3 calories the food may have contained. Or perhaps it is because the fashion industry has convinced us that thinness is something to be coveted, even if the price of a too thin body may be malnutrition or, if it becomes anorexia, even death.

 

A few weeks ago I walked past a facility holding a fundraising event. What caught my attention was a group of extremely tall women wearing gowns that would have looked appropriate on someone’s red carpet. They must have been models; they had perfect features, either from genes or a plastic surgeon. I confess I stared at them, not just because they looked so exotic in my neighborhood but also because they were so THIN. They were not skeletal but just on the other side of being all bones and no flesh. Another woman stopped and looked with me. She said, “They don’t look quite real, do they? But it must be nice to be so thin.”

 

Somehow we don’t think of being model thin as associated with health issues. The warnings about the risks of eating too much or the wrong kinds of food are well known, they are hard to escape: Don’t eat too much, don’t eat too much sugar, exercise frequently, and get rid of belly fat.  But how many of us know what medical woes are awaiting the very thin? One has to go searching for them. And some can be as deadly as those associated with morbid obesity.

 

When very little food is eaten, as must be the case if someone is to maintain a weight 20 or so pounds less than normal, an inadequate consumption of nutrients can result. Calcium and vitamin D deficiencies are common, and can result in osteoporosis. This disease, which is mainly silent until the first of many bone fractures occurs, is characterized by the loss of bone mass. This disease usually shows itself around menopause, but the bone loss due to nutrient deficiencies may start decades earlier. Other symptoms of nutrient inadequacy such as thinning hair, fatigue, dry skin and bruising of the skin also may not show up for several years, but can be traced back to a very low nutrient sparse diet. A study of the nutritional adequacy of the Mediterranean Diet in Spain among thin women indicated that they were deficient in vitamins A, D, E, B2, B6 and folic acid, as well as several minerals such as iron. (Ortega, R, Lopez Sobaler, A, et al  Arch Latinoam Nutr. 2004 Jun54; 87-91.)

 

Even athletes, whom one assumes eat healthfully, may be nutrient deficient if they are dieting. Female volleyball players who play the game in the scantiest of uniforms were found to be deficient in a variety of vitamins and minerals, due to their dieting in order to reach a figure perfect weight. (Beals, K,  J Am Diet Assoc. 2002;102:1293–1296). And dancers who must maintain low weight and low body fat are particularly vulnerable to nutrient deficiencies ( Sousa, M, Carvalho, P et al ,Med Probl Perform Art 2013 28: 119-123).

 

Models, dancers and some athletes accept the necessity of maintaining an abnormally low weight as one of the demands of their profession. They may be able to compensate for their restricted calorie, and thus nutrient, intake with the use of supplements. However, supplements rarely provide all the nutrients they would get from food, if only they were allowed to eat more. 

 

Thinness is also prized among women whose weight is irrelevant to their profession but not to their social standing. And its potential nutritional toll and subsequent health problems may be ignored as thoroughly as by an obese individual who cannot stop overeating. A quasi-sociological analyses of the lifestyle of women who live in the rarified neighborhood of New York’s Upper East Side points this out. In her book, The Primates of the Upper East Side, Dr. Wednesday Martin describes the non-eating that takes place at social events. Women diet continually and subject their bodies to workouts that would make a Marine recruit weep in order to have a perfect body. So many foods are eliminated from their diet in order to achieve the desired thin state? It is a wonder that the residents of this neighborhood don’t suffer from scurvy, anemia and other nutrient deficiencies. They are not addicted to food, but rather they are addicted to their almost pathologically thin bodies.

 

And yet this bizarre eating behavior is not the subject of reality television, or urgent messages from health organizations warning about its long-term consequences of nutrient deficiency. We see the consequences of the massive overeating of the 600-pound individual and tsk tsk at what that person has done to his or her body. Maybe it is time to tsk tsk over the damage the too thin are also doing to their health.   

Are Reality Cooking Shows Really Fantasy Cooking Shows?

A group of us were chatting about a local restaurant whose chef was eliminated from the Food Network show, “Chopped.” The restaurant was popular; the show was not.

“The problem,” said someone, “is that the contestants are supposed to combine weird ingredients like Marshmallow Fluff and mushrooms into something edible and do it in 30 minutes or less.  How can of you make an entrée with side dishes in thirty minutes?  And using ingredients that are familiar, not Halloween candy and duck breast?”  We laughed but the question resonated and the group’s response was, “No way.”

As one person commented, it would be possible if we employed a full time assistant who would do all the basic prep work like chopping onions, peeling garlic, dicing carrots, and washing greens. And also making sure that water for pasta was always boiling, sauté pans were at the correct temperature and, we all chimed in, “Cleans up as the cooking goes along.”

“Watching the cooking shows, and then expecting to make the same dishes in 30 minutes or less, is like watching an international tennis match and then expecting to serve the same way,” said one of the women. “Even assuming I have all the ingredients on the counter before I start to cook—and that is a big assumption—it takes me twice as long, if not longer, to prepare the same meal.  And the shows are so deceptive. The cook will say something like, “…wilt the onions or beat the egg whites… and 3 seconds later it is done. Tell that to my onions! “

The women were of a certain age; that is, they had raised children, prepared thousands of meals, entertained, and had done this while working most, if not all, of these years. They may or may not have been good cooks, but they were experienced. And the consensus among us  was that cooking shows, whether competitive ones or in demonstrations by individual chefs, were deceptive. It looked too easy, too fast. Indeed, one woman said that she wondered if a younger generation, inexperienced in meal preparation, would end up serving undercooked food if they tried to imitate what they saw on television.

Wouldn’t it be useful to have one cooking program that was closer to reality? Onions would be burnt because the cook forgot to turn down the heat while answering the phone call from a telemarketer. The chicken would still be half frozen and dripping reddish chicken juice, the cat would leap onto the counter and poke around at the fish, the brownies would be overcooked around the edges and too moist in the center, and the food processor, used to puree the squash soup, would thrust its contents all over the floor like an erupting volcano.  But of course who needs to watch this on television when one can see it in one’s own kitchen?

Unrealistic menus or meal preparations are nothing new. During the 19th century and early 20th centuries, women studied and practiced a discipline called Home Economics, whose goals were to teach housewives basic nutritional requirements for their families and healthy cooking techniques on how to prepare food for the household. The goals were worthy, but some of the so-called nutritional meals were anything but. Cream sauces were poured over just about everything.  Salads consisting of Jell-O cubes, canned pineapple chunks and maraschino cherries were considered elegant enough for a luncheon. And, often disdain was shown toward ethnic dishes prepared by new immigrants, despite the fact that they were nourishing and familiar.  Women’s magazines often promoted recipes, not for their nutritional content, but because they used ingredients of their advertisers. The famous string bean dish in which the vegetable is drenched in canned cream of mushroom soup and sprinkled with canned fried onions rings certainly promoted the sales of these products.

But of course, in those far-off times in the last century, people were still cooking. Today one cannot assume that younger generations will or even want to cook at all.  Thus, if a non-cooking younger generation is to be weaned from supermarket or fast food take-out, prepackaged meals, or a diet of smoothies and shakes, they have to be shown, realistically, how to prepare a meal with more than two ingredients (salt and pepper).  Fortunately, the Internet is replacing the food channels in meeting this need. A little bit of searching will produce videos on how to prepare anything from baked potatoes to a soufflé.  And since they can be viewed as often as necessary, a refresher view is possible if it has been several months since the dish, say meatloaf or roast chicken, has been made.

Ingredients in a box that cook into a meal for two or more, delivered to your door, are becoming popular. Certainly the advertisements looks compelling, especially to cooks like this one who always seem to be lacking one or more ingredients essential to the recipe.  These could be considered starter meals. As they are more expensive than meals assembled from one’s own kitchen, they are unlikely to be a permanent substitute for reading a recipe, finding the ingredients, and cooking. Or maybe not.

Programs on the food channels are entertaining, which is their intent. If a recipe looks worth trying, it is always available on the website of the television personality who prepared it. But just don’t try making it in 30 minutes or less.

Should Santa Claus (and his wife) Stop Eating So Many Cookies?

Poor Santa, he certainly has not kept up with modern times. No internet, no computer, no 3-D printer assisted toy maker, and certainly no electric sleigh (or self driving one for that matter). And somehow Santa and his wife have not heard health professionals lament our excessive intake of sugar.

Consider this:

He used to be thin. Orginally, a long time ago, he started out life as a monk (and monks did not eat cookies) and eventually became a Bishop in a town in what is now Turkey. This was around 270, a time way before people thought much about the North Pole and its toy making factory. In his spare time, he gave away money he had inherited by throwing coins and gifts through the windows of homes in which children lived. But no one reciprocated by feeding him sweets.

Eventually, as St. Nicholas (this was long after his death) he became the patron saint of children. Still thin.

Then something happened several centuries later. St. Nicholas was transformed into a chubby (well more than chubby) jovial, cookie eating distributor of gifts because of a poem, meter and rhyme.

In l822, Clemet Clarke Moore, an Episcopal minister wrote the poem, The Night before Christmas, * and Santa lost his buff figure forever.  Others helped enlarge his figure; a cartoonist Thomas Nast drew Santa with a large belly in l890, and Washington Irving described him as a fat Dutch elf. And finally, Coca-Cola gave us the image we associate with him today by picturing St. Nick in a red suit with a white beard, of course.

Given the ubiquity of sugary snacks available to this now robust figure, it is really amazing that he does not grower fatter with every passing century or require a supply of insulin in his sleigh because surely he must have developed diabetes by now! Will he still eat cookies containing gluten, or might this affect his intestinal tract and mood?  Does he know about Grain Brain? We don’t want the presence of gluten to change his “HO HO HO!” into, “Oh, oh, oh….”

Why is he eating carbohydrates at all? That surely must be the reason he is still fat. If he followed the Paleo diet he might be thinner, and also be able to use wooly mammoths to drive his sleigh, rather than reindeer.

And really, what kind of example is he to our children? All year we try to get them to eat healthily, limit their snacks to baby carrots and plain yogurt, and make sure they eat nothing, or almost nothing, with sugar. We try to make sure they get enough exercise, and that they not depend on us to drive them everywhere. And then on Dec 24 along comes this guy who won’t even walk from house to house, no matter how close they are, but insists on riding to each one on a sleigh. He goes down a chimney (how much exercise is there in that? It is all downhill!) and his sleigh is waiting for him at the door. And there are those cookies. Does he even bring them home to his wife? Probably, because she is not exactly svelte herself.

Perhaps his focus on sweet carbohydrates means that like so many who live in northern part of the world, he is suffering from Winter Depression or Seasonal Affective Disorder (“SAD”). SAD suffers have an urgent need to consume sweets, especially in the late afternoon and evening. Maybe if he lived at the South Pole he would be not be so chunky and addicted to chunky chocolate chip cookies; seeing there it is summer in December, and the sun barely sets.

Of course none of us knows whether he and his spouse go on diets on January 2 like most of the world.  They may go the Weight Watchers equivalent at the North Pole, or endure a weeks-long cleanse or eat only meat (reindeer?).  But like most of the world, by next fall they will probably have gained back all the weight they lost, and Santa will be pudgy again. Should someone put out a diet book next to the cookies? Or at least some baby carrots?

But then again, if he loses masses of weight, his clothes will be too loose and worse yet, he will not be the Santa of Moore’s poem whose “little round belly laughed like a bowl full of jelly.”  So keep those cookies by the chimney. With care.

Will Preventing Male Baldness Cause Depression?

The symptoms sounded like a case of a male PMS: swelling in the hands or feet, swelling or tenderness in the breasts, dizziness, weakness, fatigue, cravings for carbohydrates, weight gain, depression, confusion, cold sweats, and sexual dysfunction. These are some of the side effects of a medication used to treat male pattern baldness. Finasteride, the generic name of the drug, was originally used to treat benign prostatic enlargement. During early clinical trials, however, researchers noticed that the volunteers were growing hair. It seemed too good to be true: finally, a solution to reverse age-related male baldness. The drug, known by the trade names Propecia and Proscar, seemed to be an effective treatment for the restoration of hair among men suffering from male baldness.

Finasteride’s effect on decreasing hair loss is related to its effect on a testosterone-like compound, dihydrotestosterone (DHT). DHT is an active form of testosterone and is responsible for prostate enlargement and the destruction of hair follicles on the top (but not the sides) of the scalp. Finasteride belongs to a group of compounds that inhibits, or slows this conversion of testosterone to DHT, thus making it an effective drug to slow prostate growth and, happily for many men, slow hair loss.

But unfortunately, getting a full head of hair comes with potential physiological and emotional costs. Soon after it was introduced to prevent male-patterned baldness, especially among young men (it works better among a younger population), anecdotal reports of depression and even suicidal thinking began to circulate. Even more disturbing, these critical changes in mood seem persistent even after the drug was discontinued. A small study to investigate the validity of these side effects was carried out by Dr. Michael Irwig of the George Washington University in Washington D.C.  He measured the moods of young men, average age 31, who had been treating their baldness with Propecia for an average of slightly more than two years. These men had developed persistent sexual dysfunction that continued for at least three months after they stopped taking the drug. He found 75 percent of those who had used the drug had symptoms of depression compared with 10 percent of controls who never took the drug. Over 30 percent reported having suicidal thoughts compared to only one from a control group. Were these young men depressed because they were experiencing sexual dysfunction or the converse? The study did not answer that question.

An increase in appetite, especially for sugary carbohydrates, and weight gain were two additional side effects that lasted well beyond discontinuing the drug. This was also unexpected, but reported as a side effect often enough to make the FDA add them to the list of side effects. And according to stories by men who used Finasteride, the weight does not come off after they stop using the drug. As one disgruntled user said,”I would rather be thin and bald than the way I am now, fat and hairy.”

What seems to be the link between Finasteride and depression? By altering the synthesis of the testosterone-like substance, it might be affecting two possible neurotransmitters in the brain involved with depression and anxiety. One is gamma-aminobutyric acid, commonly known as GABA, and the other is serotonin. Interestingly, serotonin activity also decreases when estrogen levels decline at the end of the menstrual cycle, and the resulting depression, anxiety, fatigue and overeating characterize PMS.

Evidence that the Finasteride-associated depression may be related to a change in serotonin activity comes mainly from animal studies looking at the effect of testosterone on certain serotonin receptors. But a hint that serotonin may be involved can also be found in reports of intense carbohydrate craving from men who have used the drug. PMS and Seasonal Affective Disorder (severe winter depression) are each characterized by carbohydrate cravings, depression, and decreased serotonin activity. And the consumption of carbohydrate by these groups seems to relieve their depression, anxiety and fatigue because of the resulting increase in brain serotonin synthesis.

Might men suffering from Finasteride-related mood changes also benefit from eating carbohydrates? Were they to consume 25-30 grams of a starchy, very low-protein carbohydrate snack two or three times a day, on an empty stomach, they will be increasing serotonin synthesis. The resulting improvement in mood may not dispel their depression entirely (after all, a cup of oatmeal is not an antidepressant), but at least will make it easier to cope with their negative moods and the possibility that they will now lose their hair.

A Stomach Drain: The New Level of Combatting Obesity

The FDA approved, in mid-June, a new obesity device that seems to come from a medieval concept of how to prevent overeating. A tube is inserted into the stomach and the outside end fitted with a valve that can be opened or closed, sort of like a faucet. After eating, the patient opens the valve or faucet so the contents of the stomach can empty into the toilet (or a bucket or some container that can be washed out). The procedure is like throwing up to get rid of the contents of the stomach, but with this device you don’t have to gag. Just open the valve.

When I saw an announcement of this device I thought it was a hoax or something thought up by people who compete in ‘all the hot dogs you can eat’ contests. But no, the device, called AspireAssist, is recommended for those who cannot control their food intake. Instructions for its use are quite specific: At least 20 or 30 minutes have to elapse between the completion of a meal and the emptying of the stomach. This is to make sure that some nutrients and calories are passed into the intestines where they are absorbed into the body. If the stomach was emptied immediately, the result would be similar to starvation.  Moreover, the binge eaters and others with eating disorders such as anorexia are not to be allowed to use the device, as it would only enable such individuals to continue on with their disordered eating. And it is not to be used for a short period of time like a few weeks. It is not the modern day equivalent of the way Roman nobles would eat at one of their banquets when, if they had eaten to their full, they would disgorge the contents of their stomach (there really is no way of saying this euphemistically) so they could feast all over again. This means that you cannot take this device with you if you are going on a cruise, for example, and want to make sure that you are eating enough to justify the cost of the trip.

The FDA is limiting use of the device to patients who are obese with a body mass index of 35 to 55, and who are unable to lose or maintain their weight loss through non-surgical interventions.  In clinical trials of the device, it was very effective in supporting weight loss in this very obese population. After a year, patients using the stomach-emptying device lost 12 percent of their weight compared to control patients who lost 3.6 percent. The amount of weight loss is less than what is typically found among people who have had bariatric surgery such as the gastric sleeve. There are many obese patients who have too many health problems to risk having general anesthesia, yet their obesity is so severe that unless reversed it will shorten their life. An acquaintance who must be at least 250 pounds overweight can barely walk, and now has been diagnosed with a heart problem. She is unable to lose more than 10-15 pounds even when living in a residential weight-loss clinic and would be a candidate for bariatric surgery except for her cardiovascular problems. So perhaps a tube that empties partially digested food from the stomach into a pail might help her.

Safety features are built into the use of the AspireAssist device to make sure it is not abused by, for example, someone who sees it as a way of eating unlimited quantities of everything. It can only be used for a certain number of ‘drains’ and then will stop working. The patient must return to the physician who inserted it to get a replacement part and be evaluated for weigh-loss progress.

Aside from the mechanical disposal of food that otherwise would contribute unneeded calories, how will the patient benefit from this new obesity device? Ideally, food intake, or perhaps the frequency of eating, might decrease. Stopping for coffee and a pastry or piece of pizza while shopping is tempting, but the mechanics of draining the stomach in a small bathroom stall in a mall could be awkward. Also, there is the time factor. Does one go out to eat with friends and then on the way home, thirty minutes after dinner is over, look for a public restroom? Maybe there is a manual that comes with the device that answers these pesky questions.

But an obvious question remains: Why would a device, really a plumbing tool, that removes food from the stomach affect how the brain controls eating? If eating is an almost automatic response to stress – and who doesn’t have stress – this response is not going to be altered by draining the stomach.  If eating is a response to lack of sleep, or boredom, or too much work, or too little relaxation time, how can a device that removes semi-digested food in the stomach change this?  In a sense, allowing the stomach to feel somewhat empty after the food is removed may promote another bout of eating as it did with the Romans.

There has to be a better way to allow fewer calories into the body. A tapeworm perhaps?

Is the Acai Berry a Superfood or a Super Scam?

A juice bar/health food restaurant located along my dog walking route is always crowded with diners sitting at sidewalk tables and eating large mounds of a mud colored food with the consistency of chocolate pudding. The mud, upon closer inspection, is dark purple and served with chunks of banana and sprinkles of granola. The diners are usually wearing yoga pants, running shorts or biking gear, and are so fully engaged in eating their bowl of purple stuff that they are not even looking at their cell phones.

“Do you know what they are eating?” I asked my dog walking companion.

“It is Acai,” she responded. “It comes from a berry that is found in Brazil,” she said. “It is supposed to be superfood healthy.”

“So that is how you say it,” I responded. “I had seen a sign on the restaurant door promoting it, but did not realize it was pronounced ah-sigh-ee. What does it taste like?”

“Tart… not very sweet. I actually had some in Brazil. It’s very refreshing. People eat it because it is advertised as a superfood. They say it is good for weight loss, decreasing inflammation, and preventing aging,” she told me.

I was not tempted to try it, not liking gloppy foods, but I did wonder if Acai really was a health wonder food. Certainly the people eating it all looked exceptionally healthy, most were thin, and when I asked two guys, about 33, in their bike shorts and tank tops what was so special about the Acai, they responded, almost in unison, that it was a superfood.

“It is full of energy,” said one. The other added that it was full of vitamins.

How could I have missed out on eating such a spectacularly nutritious food? I had seen some claims for the Acai berry headlined in the tabloid magazines for sale at the supermarket check-out counter, but discounted them.

“Berry from the South American rainforest cures diabetes, heart disease, obesity!” the headlines blared.

“Another nutrition scam,” I thought, and forgot about it. But now I was curious to know what was so special about the Acai berry. According to Wikipedia, a powder made from the purified pulp and skin of the berry contains mostly high-fiber carbohydrate, with low-sugar content. The protein content is small, only 8 grams in l00 grams of powder, about the same as in a glass of milk. The fat content was compromised of unsaturated fatty acids. Unlike other berries, its vitamin and mineral content is minimal.

Continuing my investigative nutrition a little further, I asked one of restaurant employees why Acai was so special. “Oh, it’s full of antioxidants,” she responded. “It has more than any other food.”

So apparently the Acai berry is special because of its extraordinary antioxidant content.

Sometime in the l990s, people who were not biological chemists (that is, the rest of us…) started to hear about something called antioxidants. Antioxidants are important because they destroy bad substances in our body called free radicals. Free radicals alter the structure of molecules by removing electrons, thereby weakening membranes and making them more vulnerable to destruction. They can damage artery walls, allowing cholesterol to be deposited which then form artery blocking plaques, they potentiate cataracts and age related macular degeneration, and may be involved in certain types of cancer. It had been known for some time that vitamins like beta-carotene (the plant form of vitamin A) and vitamin E have antioxidant power.

Studies involving thousands of people over many years were undertaken to see if supplementing the diet with large doses of these vitamins might decrease heart disease, cancer, diabetes, and other diseases. Unfortunately most of the results were inconclusive, negative (no effect) or dangerous. In one study, supplementing smokers with large amounts of beta carotene increased risk of lung cancer.

But the lack of positive results did not stop food and supplement companies from promoting the antioxidant content of whatever edibles they were selling. Magazines, newspaper articles, even media personalities offered lists foods that should be eaten because they contain large quantities of antioxidants. No longer were foods simply “Good for You.” They were antioxidant missiles aimed at those nasty free radicals that, if not thwarted, would cause you to degenerate into a crumbling mass of membranes by the time you were sixty.

So this brings us back to the purple glop. How did the Acai berry become anointed as the queen of antioxidants? The berry contains several chemicals that act as antioxidants, and the strength of their chemical reactions to counteract free radicals has been measured, mostly in test tubes but in a small number of animal and human studies as well. (J. Agric. Food Chem.2006,54,8604−8610 ; J. Agric. Food Chem., 2008, 56 (18), pp 8326-8333).

So yes, this Amazon rain forest berry does have potent antioxidant qualities. But one does not have to go to Brazil, or even the sidewalk restaurant in my neighborhood to eat foods with antioxidant power. Any local supermarket contains dozens of foods with antioxidant properties: kidney beans, pinto beans, blueberries, cranberries, strawberries, apples, prunes, plums, pomegranates, artichokes, cabbage, broccoli, asparagus, avocados, beets, spinach, and many spices as well. (The Journal of Agricultural and Food Chemistry, 9th edition, June 2004). There is little evidence that Acai contains substantially more antioxidants than a bowl of blueberries. And I suspect that the blueberries will cost considerably less than the $9.00 charged in my neighborhood for a small bowl of Acai pudding.

The downside of eating ordinary fruits and vegetables is that they are not associated with the astonishing, although totally unproven, claims made for Acai… such as reversing diabetes, weight loss, and increasing sexual virility. (Funny the two guys in bike shorts never mentioned this.) No one eats an ordinary apple, or a bowl of blueberries with the expectation of turning into a nutritional version of superman. But it is nice to know that it is not necessary to eat a berry imported from Brazil and pulverized into a powder to obtain antioxidants. We can go to a farmer’s market and buy locally grown strawberries in late spring, blueberries still warm from a summer sun at a farm stand in July, or apples picked at an orchard in the fall and enjoy the “magic” of eating locally grown foods, as well as benefiting from their antioxidant power.

At What Age Is It Alright To Act Old?

At a museum where I volunteer, a group of women and a handful of men came for a talk and a tour. They live in a retirement community, and ranged in age from their early seventies to mid-eighties. Most had difficulty walking, and gratefully sat down, even though they had been on a bus for two hours (traffic was bad). After hearing a talk and watching a video, many continued to sit even though visiting the exhibits required walking. The few who did stroll around the museum were conspicuous in their relative vigor despite, judging from their appearance, they did not look any younger than the rest of the group. Ninety minutes later, they climbed back on the bus, happy to be going off to lunch.

The reluctance of most of the group to walk around the museum they had come to visit may be typical of this age group. A review article by Drewnowski and Evans in the Journal of Gerontology pointed out that people 65 years of age and older significantly reduce the time they spend in voluntary physical activity. Some in this age group are unable to do any activity that requires muscular strength, such as getting up from a chair, carrying small items like dishes, or dressing themselves. Clearly the museum visitors have not fallen into dependency on others to assist them in what is called the activities of daily living, but if they had been forced to leave the museum quickly, say because of a fire alarm, I doubt most would have been able to walk, even in that circumstance, sufficiently fast enough to be safe.

Many of us take for granted that if we reach our ninth decade or even our eighth, we will be in a sense physically shackled by the decline of our bodies. And it is true that people who engaged in recreational sports such as skiing, tennis, running or biking when younger decide that they are too physically slow, their bones too fragile, their balance too uncertain to continue as they age. Indeed, I once had a weight-loss client who told me with great seriousness that, as she was soon to be forty, she was too old to exercise.

But does old age mean resigning oneself to a life of increasing frailty and limited mobility? Certainly joint and muscle pain or neurological degenerative diseases like Parkinson’s disease make movement difficult and often painful. But, as Drewnowski and Evans point out, the answer is no for the healthy elderly. If they engage in physical activities that improve muscular strength, endurance, and flexibility, they would find themselves walking more easily with improved balance and endurance. They would also decrease their risk of falling and fracturing their bones.

I wonder if people in this age group, like the museum visitors, consider themselves too old to be more physically fit? Perhaps they believe this, in part, because others reinforce that attitude by making it too easy for them to avoid walking or standing. When I asked one of the museum staff people why the visitors should be sitting for an hour of lecture and video after being on the bus for two hours, her reply was, “They are old. Let them sit.” Would she have said that if Jane Fonda,who is about to be 78, were in the group?

Do we make people behave old just because their age puts them in that category? Are we telling people that once they receive Social Security and Medicare, they can accept the inevitable deterioration of their bodies and should stop trying to slow it down by physical activity? Do we tell them, ‘You are old, so act your age!’?

And if they believe that they have the right to sit their way through their eighties, how are they going to fare as if they get into their nineties? If they enjoy reasonably good health now, they can expect to become part of the fastest growing group in the country–the ‘oldest old.’ The cohort of people 85 years of age and older is expected to triple between now and 2030. But if people 5-10 years younger than the oldest old are experiencing limited mobility and endurance, how will they manage as they age without needing to be dependent on others for their needs?

One problem is the absence of role models for this age group. There are too few like Jane Fonda, Lily Tomlin (76) and Morgan Freeman (78). Also, one can’t go to a newsstand or bookstore and find glossy magazines featuring exercise and healthy lifestyles for the over 70 crowd. Fitness facilities ignore this age group, who may feel uncomfortable with the density of twenty-something bodies in various states of uncover working out to blaring music. Even workout clothes are designed for the cellulite-free limbs of the younger cohorts. And exercise classes are rarely designed to protect aging knees or backs. If they are, they may be almost too protective and not push the participants hard enough.

The result is acceptance and complacency. I’ve heard the following: “If everyone around me is complaining of aches and pains and can’t walk far, or climb stairs, or lift packages, or do yoga stretches, why should I? If I go on a trip and the bus driver makes sure I don’t have to walk more than a few yards to a restaurant and I can sit down at the museum, why should I exert myself? I am too old.”

What is too old? Perhaps it time to tell the 75 year-old that if she wants to live a strong and healthy life into her 90′s, she better stop acting her age now.

Why Are Health Care Workers Unhealthy?

A friend of mine moved to a new city and obtained a new primary care doctor, along with a new hairdresser and gym. She writes, “I was somewhat appalled at the size of the receptionist and nurse in the doctor’s office. The doctor was a little pudgy, but the two others verged on morbidly obese. It was like going into a hair salon and seeing all the hairdressers with split ends and gray roots, or going to the gym to see the personal trainers sitting in the gym smoking and watching television.”

Her observations were not unique. I have been making weekly visits to a local VA hospital because of a research collaboration and noticed that many of the employees, both administrative and clinical, are also overweight or obese. The unhealthy weight of health care workers is now well documented in a research study published in 2014 in the American Journal of Preventive Medicine (vol 46: 237-248). The lead author, Sara Luckhaupt, analyzed data from the 2010 National Health Interview Survey and found that 35 percent of health care workers, both in medical offices as well as clinics and hospitals, are obese. The study was very careful to eliminate factors such as gender, race, smoking, and age as contributing to their excess weight.

Long hours, stress, limited access to healthy food, excessive commuting time, and sedentary jobs push us toward eating the wrong foods and/or eating too much and avoiding exercise. But all these factors operate across most work situations. And in some respects, health care workers who can stop working when their shifts are over are better off than the corporate worker, who is expected to be on call and meet work obligations 24/7.

Yet my friend wondered why the people working in her new doctor’s office were so overweight. Was it because there was a large container of Hersey’s Kisses on the counter where the patients check in and, in the small room where coffee was available for the staff and patients, a basket of highly caloric cookies stood next to the coffee machine?

“I feel as if I am receiving a dual message,” she told me. “I don’t need a medical degree to know that excess weight may affect my blood pressure and make me vulnerable to diabetes since I have a family history of that disease. So why the candy and the cookies? You wouldn’t expect a dentist to offer sticky sweet snacks to the patients unless business was poor. It was hard for me to resist eating the chocolate. It must be much harder for the office staff who stare at the container all day.”

Obviously my friend wasn’t going to cancel her appointment with her new physician because the person checking her in was overweight. As she told me, “I take full responsibility for my weight and I don’t need to be in a medical office with a skinny staff to motivate me to eat healthy foods.” But then she went on to wonder if someone who is struggling with her weight would decide that it is all right to be obese if surrounded by hospital and medical office employees who are also obese.

Seeing hospitals and medical offices filled with very overweight employees gives the impression that this profession is not taking care of its own. It is hard to understand how health care workers can see evidence of the medical consequences of obesity, and yet fail to maintain a healthy weight themselves.

Imagine going into the orthodontist’s office and seeing the dentists and office staff with pathologically bad teeth alignment. Or being examined by an optometrist who can’t read the figures on the machine because she needs glasses. What if the hospital staff never got flu shots and consequently they all come to work with fevers, bone aches and coughs?

No one in the health care profession has the right to impose weight standards on anyone else in the profession anymore than a dentist has the right to insist that the staff use dental floss. But given the multitude of health problems associated with obesity, it should not be necessary for the health care worker to become a patient, before his or her obesity is addressed.

It begs the question, this contradiction of obesity in the health care industry… Could changing the work environment help reduce the high incidence of obesity among health care workers? Do current work schedules contribute to overeating, stress, and too few healthy food choices, especially for evening and overnight shift workers? Should exercise facilities be made available on the premises, or at least a room for yoga, Pilates and relaxation techniques? Should employees who are morbidly obese be offered weight-loss strategies, including bariatric surgery?

Ironically, the health care profession is in the best position to implement a healthier work environment among its employees, because it is the health professionals who are telling the rest of us how to eat, exercise, decrease stress, and live more balanced lives. If they take care of their own by making it easier for them to maintain a healthy lifestyle, the health profession will be an example for the rest of us. But if they are not interested or fail, then the take-away message for the patient is, “Do what I say, not what I do.”

If You Eat Carbs When You Are in a Bad Mood?

Eating a dish of chocolate-sauced ice cream or a large bag of potato chips when feeling sad, angry, tense or worried is pretty standard behavior for people who turn to food rather than alcohol, nicotine or recreational drugs when their moods go south. Women with PMS know all too well the impulse to chow down a bag of chocolate chip cookies or half a sheet cake when the hormones are ‘raging,’ i.e. the end of the menstrual cycle.

But few of these eaters would put the blame for their bad moods on the carbohydrates they are inhaling. Rather, they know that a social disaster, financial problem, cranky mother-in-law, their teenager, or even the early sunsets of winter is driving them to food.  Chocolate cravings appear with great regularity among some premenstrual women, along with the feeling that all is wrong with the world. But few who may brave a blizzard to get a chocolate bar would blame their moods on the chocolate. (Of course, if the chocolate were unobtainable, their bad mood might worsen.) But now some scientists, and the carbohydrate overeaters themselves, are suggesting that the trigger to the bad moods is the carbohydrates themselves.

Isn’t it true? After all, what do depressed people eat and overeat? Not celery, kale, cottage cheese and boiled chicken. Not gobs of mayonnaise, lumps of butter or hunks of lard. Carbohydrates, either sweet/gooey or crunchy/salty, are the feel-good foods of choice. And of course, we all know where this type of eating leads: weight gain, obesity, a multitude of medical problems and depression because of the obesity. Certainly someone who looks at the empty quart-sized ice cream container, crumpled bag of potato chips or the crumbs of a depleted box of cookies feels remorse, depression, anger and even helplessness at the eating that just occurred: “Now I am really depressed,” thinks the overeater. “I probably just gained 10 pounds on top of the twenty I already need to lose.  It is all the fault of the carbohydrates. “

But is it? Does eating carbohydrates in association with negative mood mean that eating carbohydrates causes the negative mood states?  When we drink water in association with thirst, do we assume the water causes the thirst?  When we put food in our bodies in association with feeling hungry, do we assume that food causes hunger?  When we take a pain-relieving medication in association with back pain or a headache, do we assume that the medication is causing the pain?

Fortunately, we don’t have to rely on word play to answer this charge.

It is possible to test the carbohydrate-mood link in the laboratory.  The format for such research is to measure the moods of volunteers when they are not in particularly good moods, for example people who get grumpy every afternoon around 4pm or women with PMS. Volunteers fill out self-reports on their mood and then are asked to consume a beverage containing carbohydrate or protein. They don’t know what the beverages contain because the taste and textures are identical. An hour or so later, after the carbohydrate or protein has been digested, the volunteers fill out the same mood reports. We did such an experiments at MIT with people who always ate a carbohydrate snack late in the afternoon when they started to feel irritable, restless, impatient, distractible, tense, and even a little depressed. After they consumed the carbohydrate-containing beverage, their moods improved significantly. But their moods did not get any better after drinking the beverage containing protein.

Several years later we did a similar test with women whose carbohydrate intake (we measured this directly) increased enormously when they were in the throes of their mood-altering PMS symptoms. These women also consumed a carbohydrate or protein-containing beverage and, as in the earlier study, did not know what each beverage contained.  The carbohydrate beverage significantly decreased their anger, depression, tension, confusion, and even fatigue. None of these moods was altered after they drank the beverage containing protein.

There goes the ‘carbohydrates cause depression’ theory.

Was it the taste of the carbohydrates that put them in a better mood? Unlikely. Their moods were measured an hour and more after they finished the drink. Moreover, the drink had a mild fruity taste but would not be a contender for best tasting drink.  The reason for the improvement in mood was due to the increase in the ‘feel-good’ brain chemical, serotonin. The carbohydrates did not produce the serotonin, but their consumption triggered a series of biological events in the blood and brain that caused more serotonin to be made. And that produced a better mood.

What is wonderfully curious is how we know to eat carbohydrates when we are feeling blue, despondent, upset, stressed or anxious. It is not something we are taught and indeed, given the current anti-carbohydrate attitude of self-proclaimed nutrition experts, we have been told to avoid eating those dreadful foods. But (Thank you, Mother Nature!), there must be some sort of signal from the brain, to our emotional self, to our mouth and eyes that says: Now it is time to have some crackers, or an English muffin or a small bowl of oatmeal. I call it a ‘carbohydrate-thirst.’ Indeed, one of our early volunteers said, “My mouth is calling out for carbs.”

Whatever the signal, the outcome is the same. A small amount of carbohydrate, no more than 25 or 30 grams, is enough to perk up our serotonin and take the edge off whatever bad mood we are experiencing. Like thirst, or hunger, or the need for sleep, eventually the carbohydrate hunger will come back when, for a variety of reasons, mood begins to deteriorate.  But for several hours after eating the carbohydrate, we will feel a little less stressed, a little calmer, and even a little happy.  And that, fortunately, is not going to change.

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

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

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

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

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

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

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

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

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

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

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

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

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