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Eating When You Are Not Hungry: It’s Called Appetite

The woman who came to see me for weight loss, let’s call her Ann, was about 40 pounds overweight and frustrated, in her words, by, “…a lifetime of weight loss followed by weight gain.” Her problem, she thought, was that when she felt hungry she liked to eat protein because it filled her up. But then she still wanted to eat carbohydrates even though she was full from the protein.

“Why do I feel hungry all the time?” she asked. “Or, more to the point, why do I want to eat when I am not sure that I am really hungry? All the diet plans I have gone on promise to take away my hunger, but I still want to eat.”

“Perhaps you are feeling two different kinds of hunger,” I ventured. “One might be actual hunger and the other, appetite.”

Feeling as if I was wading into the quicksand of definitions of hunger and appetite, I gingerly offered my own explanation. “Being hungry is natural, and it means your body is telling you that you need calories and nutrients. It is a signal, like thirst, indicating that your body needs you to take action. If you are thirsty, you drink water. If you are hungry, you eat. Now appetite, on the other hand, is what you feel when you are not hungry but want to eat.  Perhaps not a very scientific definition, but I think it works.”

I told her that it we often think appetite is hunger, perhaps because we are so rarely really hungry. Hunger is often accompanied by symptoms such as a headache, fatigue, feeling faint or weak (as in weak from hunger), nausea, irritability, and emptiness in the stomach.  Most of us do not approach that dire state before being able to feed ourselves. Conversely, we often, perhaps too often, decide that we are hungry, and need to eat for reasons unrelated to our body’s need for calories.

The difference between hunger driven by the body’s need to sustenance and hunger, aka appetite driven by perhaps emotional or situational needs, can be seen by looking at the eating behavior of an infant, a young child and an adult.

A hungry infant will cry when his or her body demands to be fed. Once fed, the baby often relaxes and falls asleep. But consider the toddler, sitting in a stroller and whining. Mom takes out a sandwich bag of breakfast cereal, often Cheerios, and the toddler spends the next fifteen minutes eating, a distraction from whatever caused the whining. Is the toddler hungry? No. But the toddler has an appetite for Cheerios.

Jump ahead a few decades. The adult misses breakfast and lunch is delayed because of work or other demands. It is three o’clock and she finds it hard to work because lack of food is causing a headache, a growling stomach, and fatigue. An ancient protein bar stuck in the drawer is detected and, even though it tastes like pressed sawdust, is gobbled down. Hunger is at partially sated, and she is able to go back to work.

Two days later, the same adult has consumed breakfast and lunch, and is busily working on a complicated but teeth-gnashing boring document. The adult is grumpy, impatient, and distracted. “I need to get something to eat,” she thinks and leaves the office to go to the lobby snack shop. After buying and gobbling a large chocolate chip cookie, she goes back to her office and is able to resume work. It is no less boring, but she can deal with it more easily. The cookie was eaten because of appetite.

There seems to be a bias against giving in to appetite. We are told not to eat between meals, after supper, or when we are stressed, bored, tired, angry, lonely, anxious, and/or depressed. And yet the impulse to do so is often as great as the need to eat when we experience hunger. Indeed, many of us may experience genuine hunger, the kind that makes even a stale piece of bread desirable, much less frequently than we experience appetite, the kind of hunger that make us debate over what we feel like eating for dinner.

Isn’t it appetite rather than hunger that makes us consider eating dessert? Isn’t it appetite rather than hunger that causes us to polish off all the French fries or continue to nibble at the edges of the apple pie after we have eaten a large piece? Isn’t it appetite that suddenly makes getting an ice cream imperative after we see someone else eating one? Or, when we go to a street fair and smell sausages and onions grilling, isn’t it our appetite that makes our mouth water even though five minutes earlier we were not hungry?

Weight-loss programs promise to curb or eliminate hunger. None mentions appetite. Some say that their program allows the dieter to eat what she wants, so if a brownie is desired rather than cottage cheese? That is fine. But the program guidelines do not distinguish between wanting the brownie out of hunger or out of appetite.

Ann and I analyzed her eating habits to see when she ate out of hunger and when out of appetite. She had the option of trying to eliminate her appetite-associated eating but decided it was unrealistic. She wanted her carbohydrate snack in the afternoon and the option of having another in the evening, even though she wasn’t hungry when she ate these snacks. “If I am going to lose weight and keep it off this time… I have to allow myself to eat the way I want, not the way some diet plan wants me to eat.” She continued to eat protein when she was hungry and allocated a certain number of calories for the carbohydrate foods her appetite urged her to eat.

“I guess I can have my cake, eat it,” she told me paraphrasing a well-known French queen, “and lose weight!”

Should Cauliflower Be the Main Course at a Vegetarian Wedding?

I could have chosen the fish entrée at the wedding we went to a few weeks ago. But since we eat fish several times a week, and since the caterer was known for creative healthy main courses, I opted for the vegetarian choice. Maybe I would discover a novel way of preparing non-animal protein to add to my cooking repertoire.

But alas it was not to be. The mix of vegetables, grains, and lentils that were described in the printed menu was like a bait and switch. The plate arrived containing a mound of steamed cauliflower surrounded by two tiny pieces of sautéed mushrooms. I looked wistfully at the perfectly grilled fish my spouse was eating. Next time I will know better.

But why? Why shouldn’t a caterer prepare a vegetarian entrée with the same balance of protein, vegetables and starch that would appear on a traditional meat or fish dish? Why do caterers or chefs in general assume that vegetarians eat only vegetables? People who identify themselves as meat and potato eaters surely must eat other foods for breakfast or lunch. And why do caterers and chefs conflate vegetarian and vegan? They are not the same.

Indeed, the menu said “ vegetarian” entrée, not vegan. This meant that protein from dairy products and eggs could have been incorporated into a main course, thus allowing for a large variety of possible dishes. Moreover, if the entrée had been listed as vegan—meaning no dairy or eggs—then other protein sources such as beans, lentils, soy, and quinoa could have been used.
It is not necessary for the chef preparing a vegetarian meal to reinvent the wheel. Because animal protein has always been expensive and out of reach for much of the population, each culture has developed signature non-animal protein dishes from cheese blintzes to bok choy stir-fry with crispy tofu. Moreover, the Lenten season restricts the consumption of animal protein, and over the centuries many vegetarian dishes have also been developed to feed families unable to eat meat or chicken.

But none of this seems to be considered when the catering kitchen or many restaurants plans the components of a vegetarian meal. Unfortunately, despite the protein sources that could be incorporated into a vegetarian dish, the protein is usually omitted. Sometimes this is because the caterer simply takes the vegetables from other entrées and dumps them on the plate for the token vegetarian. But protein is often left off of the plate because the chef doesn’t take the time to learn how to include it.

Ironically, eating a vegetarian entrée at a catered affair that serves the main course often hours after one normally eats is a wise choice. Ingesting a slab of filet mignon or heavily sauced chicken at 9 or even 10 pm does not make for a sound sleep a few hours later. Digesting the fat in these animal protein dishes sometimes causes sleep disturbances or a lighter sleep than normal as well as a feeling of heaviness upon awakening the next morning. Vegetarian options tend to contain less fat (unless substantial amounts of cheese are used) and are less likely to demand heroic digestive function late at night.

Until the education of chefs at well-known culinary institutes includes an intensive education in preparing protein-rich vegetarian dishes, there is little hope that vegetarian entrée options at catered affairs will improve. And until cooking shows feature vegetarian dishes that provide at least 25-30 grams of protein and which seem “yummy” enough to be reproduced in the viewer’s kitchen, there is little hope that home cooks will find making a well-balanced vegetarian meal as desirable as grilling chicken or a hamburger. Fortunately, there are many excellent cookbooks and some gourmet cooking magazines that provide ample recipes for the vegetarian home chef. And in fairness to the caterers and restaurant chefs who have developed nourishing vegetarian main courses that look and taste good, it is hoped that they will be able to stimulate others to provide nourishing meals for those who abstain from animal protein.

However, until this occurs, it may be necessary to plan on eating before going to a catered event or bringing protein bars to nibble, discreetly, along with that cauliflower. And if there is any benefit to being denied a substantial vegetarian meal at a catered affair… it is that you will be one of the few who don’t feel your wedding finery is getting snug.

Who Cares for the Caregivers?

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

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

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

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

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

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

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

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

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

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

She too would like some care.


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

Excessive Exercising: Is it About Fitness or a Compulsion?

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

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

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

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

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

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

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

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

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

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

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

Moods for Overeating: Good, Bad and Bored

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

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

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

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

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

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


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

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

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


Would Walkable Sidewalks Keep Us Thinner?

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

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

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

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

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

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

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

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

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

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

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

The Covert Bullying of Obese Adults

When I congratulated a friend on her promotion to the head of a non-profit organization, she smiled and then told me it almost did not happen. “I learned that someone on the board did not want me to get the position and campaigned actively against me,” she told me.

“Why?” I asked. “You were obviously the front-runner.”

“Because I am fat,” she replied. “He told everyone on the board that he would not hire anyone who was fat. At least he is not criticizing my competence, only my size.”

But she was wrong.

The board member was likely not rejecting her solely because he believed her size or shape might affect her stamina in wearing the hats of an administrator, fundraiser, and creative director of a mid-size organization. He may have believed that her obesity reflected a deficit in her overall ability. A review of many studies of employer attitudes toward obese workers presented evidence that obese people are thought to have less leadership potential than normal-weight individuals. The obese are viewed as lazy, undisciplined, slow, unmotivated, and incapable of advancing to positions of responsibility. Thus my friend, whose resume indicated an unusually strong record of leadership and creativity in a previous position, could have been judged as inferior on these traits simply because she was fat.

Had she been male and obese, her size may not have been considered a detriment unless the job required physical skills that were difficult to perform because of weight. But an obese woman whose job requires some visibility—while fundraising, representing the organization at meetings, or giving presentations—might be passed over because of her appearance.

Had she failed to win the position, a claim that she was being discriminated against would have had no legal impact in the state in which she worked. The state of Michigan and some cities, including San Francisco and the District of Columbia, have outlawed employment discrimination against the obese.

Proving that a job is not offered or advancement not received because of size discrimination is very difficult. The board member did not publicly announce the reason for his opposition to anyone, but secretly told other members of the search committee. Happily, there were leaks, and eventually everyone in the organization knew and so did she. But even though he wished to deprive her of the position because of her weight, there was little she could do about it. What real proof did she have?

Obese employees face the same type of discrimination that smokers do, although 29 states prohibit the non-hiring of smokers. However, one justification of the employment discrimination against smokers is based on health risks to the smoker and thus increased medical costs to the employer. Other reasons include leaving the work site to smoke in a designated area, although this is a weaker argument since breaks for everyone are often built into the workday.

Many assume that the smoker, or indeed the obese individual, could quit or lose weight if he or she wanted to. Thus discrimination against these groups is sometimes justified by the belief that it’s their fault.

An article in the New England Journal of Medicine refutes the argument that smokers irresponsibly raise healthcare costs because they don’t want to stop smoking. What is rarely understood, except by ex-smokers, is how hard it is to break the addiction to nicotine. Surveys have shown that 69 percent of smokers want to quit but are unable to do so.

Losing weight and maintaining weight loss is similarly difficult, and the same uninformed attitudes persist. “Just stop eating so much and start exercising!“ (As if they hadn’t tried to do so.) The reasons for gaining weight are so varied and often so psychologically complex that simplistic solutions make about as much sense as trying to prevent the oceans from rising by stacking sandbags on a beach. I have a neighbor who gained a substantial amount of weight while she was on large doses of prednisone to reduce inflammation, and a distant relative who gained 125 pounds on a combination of antidepressants and mood stabilizers. Would they be unemployable?

The laws protecting the obese from workplace discrimination are insufficient or nonexistent. Children bullied on the playground may have more protection, because sometimes there is a teacher who can intervene. No one is watching or reprimanding the adult bully who refuses to hire or promote someone who is overweight.

Meals in a Box: The Answer to Eating Your Vegetables?

More than a dozen companies will, for a price, send you the ingredients for a complete, relatively interesting dinner, or smoothie snacks even, if you choose that option. All you have to do is open the many large and small packages, read the instructions and in 30 minutes or so, eat your own freshly prepared entrée. The concept is practical for the many who do not have the time or energy after work to figure out what to prepare for dinner and then to make sure the ingredients are in the kitchen. Meal-in-the-box choices tend to be more imaginative than grilled chicken breast and frozen veggies because professional chefs devise the menus and make available the entire ingredient list from the main course protein to a tiniest pinch of some herb or spice that the customer probably never heard of and/or doesn’t have. No looking up recipes in a cookbook or on the Internet is needed, nor guess work about the cooking methods.  Detailed instructions are given, perishable foods are kept cold with icepacks, and preparation time is thirty minutes. The end product may not get you, the customer, a spot on the Food Network program “Chopped” in which professional chefs are given ingredients in a box and compete to make an original perfectly cooked entrée and sides in thirty minutes…But unlike the competitors who turn their food over to the judges? The customers of meals in a box get to eat their finished product.

However, making the meals from the ingredients in the box will cost about twice as much as making it from ingredients assembled yourself. According to Consumer Reports, one company’s blackened tilapia dish costs almost $12.00 per person, compared to a little more than $5.00 when put together oneself. A tofu and Chinese broccoli dish from another company costs over $11.00. These ingredients are very inexpensive and will cost approximately $3.50 if you buy the ingredients from the supermarket, and even less from a Chinese grocery store.  The prices for some of these dishes are less than in a restaurant (although perhaps not for the Chinese entrée) but add up quickly as the cost is per person. Moreover, unless the customers are small eaters, no leftovers for the next day’s lunch will remain. But it is also unlikely that there will be much wasted, thrown away, uneaten food. Nor will the refrigerator fill up with plastic containers full of tidbits from previous meals.

It is no surprise, given our current fixation of dietary restrictions that gluten-free, carbohydrate-free dairy-free, vegetarian, vegan, organic (of course) calorie-restricted meals are available depending on which company is providing the foods.

But are they healthy? Will eating a meal from a box provide you with some of the vegetable, fruit, grain, protein, and dairy servings you ought to be getting? It depends. Certainly compared to many takeout and restaurant meals that tend to be free of food groups containing nutrients your body needs, the boxed to-be-prepared meals often contain substantial amounts of vegetables, and sometimes whole grains. If you tend to ignore the vegetables in your refrigerator bin until they turn into a slimy green mass, then ordering meals with a substantial amount of vegetables will ensure that you are eating this essential food group.

Yet there is a possible nutritional caveat to some of the meals. The salt content may be higher than recommended, especially if some of the seasonings contain sodium, like garlic or onion powder, or if salt if added several times during preparation. Consumer Reports analyzed sodium content and found many dishes containing 30% more than recommended, and some dishes containing as much as 1 gram of salt per serving.

Are boxed meal ingredients a trend, or the beginning of a permanent shift in the way people prepare meals? Probably the latter because they appeal not only to those who don’t (and won’t) prepare meals from scratch, but also to a generation who have been preparing meals from scratch for decades. For those who have been afraid to boil water, learning how to cook from the boxes might eventually give them confidence to cook on their own. It is sort of comparable to shifting from paint-by-numbers to covering a blank canvas with one’s own creation. For those who are tired of figuring out what to cook for dinner and despair at the high prices and noise levels of most restaurants, boxed meals are an easy way of eating interesting food less expensively (and in a setting that doesn’t require either waiting or tipping.)

Many companies are selling meals for people on all sorts of diets and presumably are competing with portion-controlled, factory-prepared meals sold by some national weight-loss companies.  Since the meals in a box are portion and ingredient controlled, the dieter does not have to be concerned about going over a calorie limit. There is no guessing about whether the weight of the entrée or the teaspoons of olive oil will fit the calorie requirements for a particular meal. On the other hand, by requiring the dieter to get involved in food preparation, she may lose her fear of not being able to prepare a meal on her own that allows her to continue to lose weight and/or keep it off.

This trend is still relatively new, but its rapid growth indicates that it meets the lifestyles demands of large numbers of people. However, since spending a little time in meal preparation is still necessary, we should not be surprised if, a few years from now, some of the boxes will contain a robot that will do the cooking.

According to a 2016 Consumer Reports analyses, home delivery of meal ingredients is about a $400 million dollars a year industry. Although the major portion of the sales are focused along the coasts and in major urban areas, sales are projected to increase throughout the country. They may not be replacing all home delivered pizza and Chinese food, but certainly offer healthier and more varied options.

How Do You Know Whether Supplement Claims are Hype or True?

At a recent university-sponsored conference on innovations in nutritional and fitness products, there was a discussion about the increasing number of fraudulent claims associated with such products in the market. When one speaker, a principal in a firm investing in start-ups specializing in fitness and nutrition, was asked how to detect ineffective or fraudulent products, he was unable to give a useful answer.

“It’s very difficult because often the claims are made up or supported by faulty research published in company-owned or for-profit journals. If it works, it is probably not a fraud,” he concluded. Someone from the audience responded with, “Yes, but placebos work also.”

The Food and Drug Administration (“FDA”) can barely keep up with the proliferation of fraudulent health products. Some make claims that cannot possibly be produced by the ingredients; others contain substances which are not allowed to be sold due to serious side effects, or must be prescribed only by a physician. Oftentimes states, as well as the FDA, step in to expose the deceptive nature of claims made by supplement manufacturers. In a well-publicized case a few years ago the New York State Attorney General’s office tested the contents of several popular herbal supplements and found either none of the advertised active ingredients in the product or levels too low to be effective. This past winter, the New York State Attorney General and the Federal Trade Commission (“FTC”) charged a company that claimed its product was shown in clinical trials to improve memory and cognition with making, “false and unsubstantiated claims” because the study cited by the company actually showed the product not working any better than a placebo. Yet the advertisements, seen frequently on television, were so compelling that the sales topped $165 million.

The most common claims seen on the labels of such dubious products are for weight loss, sexual performance (erectile dysfunction), memory loss, and mood.  Some claims are almost magical in the sweep of their promises: A New York firm claimed its dietary supplement treated senile dementia, brain atrophy, atherosclerosis, kidney dysfunction, gangrene, depression and osteoarthritis along with lung, cervical and prostate cancer. Alas, for anyone now wanting to buy a product that will cure all that is wrong with you, it is no longer available. U.S Marshalls seized it after a request by the FDA in 2012.

Personal testimonials are often so compelling that they sell a product. Who hasn’t looked at the before and after pictures of someone who used a weight-loss product and marveled at the change? Statements like, “I am no longer hungry, depressed, diabetic, or bald!“ beckon to us from the Internet, tabloid magazines, newspaper advertisements and television spots. These people must be real, one thinks…and if he grows hair, maybe I will also.

Health products claiming a quick fix such as, “Cover your bald spot by next Tuesday!” or, “Lose your double chin by this afternoon!” are also hard to resist, but should be regarded with as much suspicion as someone trying to sell you a bridge. Glue is a quick fix; health products rarely are. The FDA tells us to beware of health products attempting to gain a marketing edge by claiming that they are all natural. By the way, snake venom is also natural.

One easy way to detect whether a claim is legitimate or not is whether the term, “Miracle” is used on the label. Look at it this way, if the words “miracle cure” are attached to the ad, consider it a miracle that anyone is foolish enough to buy the product.

But of course there are many over-the-counter (non-prescription) supplements that work, are safe, contain the dose of active ingredients printed on the label, and don’t hide drugs deemed illegal by the FDA. If a combination of vitamin D and calcium promises bone health in the amounts recommended by physicians, such a supplement will help to restore bone cell growth and decrease bone fragility.  Supplemental vitamins, minerals and protein will help restore depleted levels of these nutrients due to prolonged illness, chemotherapy, or gastrointestinal impairment. Again, it is imperative to check with a healthcare giver about quantities; more is not always better.

But what if you are not sure whether the claims are to be believed. What should you do?

Ask your health care provider. Take a picture of the ingredient label on a product you are thinking of buying, and ask whether any of the ingredients actually do what they are supposed to. Use the Internet to look up the ingredients to see what studies support the claims of the product. Write to the FDA.

Example:  A product relieving anxiety and stress claims that the ingredients, “…promote serotonin synthesis.” But the main ingredients are chamomile and valerian, herbal products that may cause drowsiness; these do not promote serotonin. A physician will know that the product is incapable of increasing serotonin synthesis.

Here’s another: A product containing saffron extract as its main ingredient claims, ”…Reduces cravings, boosts metabolism, blocks appetite, lowers blood pressure and increases energy.”  Investigating whether there are any studies linking saffron extract to all these wondrous health effects may seem like a nuisance, but will save money and possibly, ill side effects.

Signing up for the FDA Consumer Updates page is essential for anyone routinely buying supplements because of their weekly descriptions of products containing hidden drugs, fillers, or bits and pieces of insects or twigs. Recently, the agency has warned consumers about more than 100 products containing illegal drugs; most of these products are sold for sexual enhancement, weight loss and bodybuilding.

Avoiding supplements that may not work, may not contain the ingredients listed, or contain ingredients that are harmful cannot be ensured. But a little homework and help from the FDA make the odds better that what you buy is safe and effective.