Category Archives: Tips

Salting Your Way to Health Problems

A few months ago we dined with friends in a restaurant featuring small plates of ‘interesting food’ that were meant to be shared by everyone at the table. For the first time ever in a restaurant, we sent back a few of the meal items. They were so salty we had to spit them out (discreetly). A review of the restaurant read after our visit confirmed our impression that the dominant seasoning came from the salt shaker.

The excessive salt content of this restaurant’s food was apparent to anyone with taste buds, but could not be avoided unless we left the restaurant hungry. However it was not alone in supplying more salt than our body needed or should  be given. Restaurant food in general is a major source of excessive salt content; so much so that the Center for Science in the Public Interest (“CSPI”) gives unwelcome prizes to the fast food chains whose dishes contain the most egregious amounts of NaCl. Two of the prize winners this year were Chili’s Crispy Fiery Pepper Crispers (6,240 mg of sodium ), and Applebee’s New England Fish & Chips/Hand Battered Fish Fry (4,500 mg of sodium). To put the salt content of these meals in perspective, the American Heart Association  says that we should consume no  2,300 milligrams a day, and ideally less.  And for those with high blood pressure, salt intake should not exceed 1,500 milligrams per day.

But you don’t have to be a patron of these notable restaurants to have your cells swim in salt. According to the Center for Disease Control, the average American, regardless of where he is eating, eats too much salt. We eat on average  according to their 2014 report, 3,400 mg of salt each day; about a thousand milligrams above the ‘highest’ amount we should be eating.

About 61 percent of the salt we consumed each day comes from processed foods and restaurant meals, according to Zerleen Quader, an analyst from the CDC. However the top five saltiest foods may not be the ones we would think of: they are soups, pizza, bread, luncheon meats, and sandwiches ( presumably because of the bread and the meat filling). Potato chips and other salty crunchy are close contenders .

While we are managing to eat too much of the mineral sodium (half of the salt molecule) we don’t eat enough potassium, a mineral  that we should be eating in much greater amounts than sodium. The consequences can be serious: the results of a major study published in the Archives of Internal Medicine showed  “…a significant increase in the risk of cardiovascular disease with higher ratios of sodium to potassium…”  We should be eating about 4700 mg of potassium and of course only 2300 g or less of sodium.  Most of us fail miserably in reaching this balance. According to their survey, of almost 3000 participants, less than 5% reached their potassium goals and only 13%  did not eat too much  sodium.

This study was based on information gathered more than ten years ago. Might our current emphasis on low carbohydrate, high protein diets make us even more vulnerable? Bananas for example, which are very high in potassium , would be eliminated on a Paleo or Keto diet, along with many other fruits and vegetables.

Changing sodium consumption behavior is difficult because unless we read food labels carefully, avoid most processed foods and restaurants, and rein in our tendency to use spices that have high sodium content, e.g. garlic or onion powder, soy sauce and condiments in general. Many contain MSG, which of course has sodium.

New York City is making it easier to identify high sodium foods by requiring a restaurant chain with 15 or more locations nationally to list sodium contents of their menu selections. And just a few months ago, Philadelphia passed a law that requires restaurants to mark menu items that contain 2300 mg of sodium or more.

High salt intake has been linked to hypertension (high blood pressure) for decades. A recently published study of nutrient intake among more than 46,000 men and women in Japan has shown that both sodium intake alone and the sodium to potassium ratio are linked to hypertension and the diseases that can result such as strokes.

But just as it is with those television infomercials always say, “Wait! There is more!” A press release from the Alzheimer’s Association International Conference this week announced a significant relationship between blood pressure, impaired cognition, and dementia.  Professor Jeff Williamson and his colleagues at Wake Forest School of Medicine found a decrease in the number of new cases of mild cognitive impairment and dementia among individuals with normal systolic blood pressure (systolic is the higher amount and normal readings are 120 and below). Many medications are available, the anti-hypertensives, to reduce  blood pressure to normal levels. However life style changes, most obviously cutting back on salt intake, would support the effect of the drugs on returning blood pressure to normal readings.

As a friend who loves salt told me, “ It is worth giving up salty foods so I can remember what I just ate.”

References

Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the trials of hypertension follow-up study Cook N, Obarzanek E, Cutler J et al    Arch Intern Med. 2009;169(1):32-40.

Relation of Dietary Sodium (Salt) to Blood Pressure and Its Possible Modulation by Other Dietary Factors The INTERMAP Study   Stamler J, Chan  Q, Daviglus M,  Dyer A, et al Hypertension. 2018;71:631-637.

Too Little of a Good Thing: Carbohydrates

I was in charge of refreshments at a reception held for a guest lecturer and, aware of some of the attendees’ dietary limitations, selected gluten-free, sugar-free, dairy-free, and vegan cookies, as well as a large bowl of seasonal fruits.

“I am on the keto diet,” several of the guests told me as they avoided the cookies and fruit.

Where had I been?

I did not realize that the ketogenic diet had reappeared with such popularity, although I knew it never had really gone away since the days of Dr. Atkins. A few minutes on the internet made apparent the ubiquity of a diet that forces the body to switch from using glucose to fatty acids for energy. The diet seems to appeal to those who believe that total abstinence from sweet and starchy foods is the only way to control calorie intake. It also appeals to those who feel that carbohydrates are the source of physical and cognitive distress.

That adherence to such a diet has side effects ranging from unpleasant to worrisome is a small price to pay for those who follow a carbohydrate-free eating plan. Who cares about bad breath, constipation, “keto brain” (inability to concentrate and remember), difficulty sustaining strenuous exercise, and dangerously low electrolyte levels? As long as the weight comes off, it is worth it. Or so the thinking goes.

What happens after the diet ends can be dealt with after the diet ends, and if it seems impossible to maintain weight loss, well, why not go right back on the carbohydrate-free diet? Long-term effects? No one knows, so it could be good (or bad).

When someone is in ketosis, the body uses fat as a back-up energy system. Normally and naturally the body depends on glucose for all its energy needs. The glucose comes into the body as the end product of digestion of all carbohydrates, whether sucrose or brown rice, and is converted through a series of biochemical reactions into energy. In ketosis, the body uses fatty acids as its energy source. Once the body adapts to this alternate source of energy, it seems to run more or less the same (except for muscles which work longer and harder when using glucoose, the natural source of energy.) Exercise physiologists tell us that there is so little stored glucose in muscle on a carbohydrate-free diet, that muscles may fail to sustain strenuous movement after a few minutes of intense exercise. This means muscles used to sprint after a dog darting into the street, or a toddler about to climb up the rungs of a bookcase, will run out of energy reserves very quickly.

However, the body has a way of getting around the lack of carbohydrates for its glucose source by making its own. Certain amino acids in the protein we eat are converted to glucose in a process call gluconeogenesis. This occurs in the liver and kidneys and, according to advice given to wannabe ketotics, must be prevented. According to one Internet site, “Perfect Keto,” one should eat a specific ratio of fat to protein, because if too much protein and too little fat are consumed, the body will use the amino acids in protein as a source of self-made glucose. To prevent this, one should eat a very high fat diet, and only moderate amounts of protein, namely 75% fat, 20% protein, and a tiny amount of carbohydrate, 5%.

You will know whether or not you have achieved your goal of ketosis by testing levels of ketone bodies in your urine, blood or breath. Ketone bodies are three substances (acetoacetate, beta-hydroxybutyrate, and acetone) that the liver produces from fatty acids during periods of fasting, starvation, and very low or zero carbohydrate diets.

Although we tend to associate a carbohydrate-free or extremely low carbohydrate diet with dieting, it has long been seen as an effective treatment for controlling intractable pediatric epilepsy. Indeed, it is so important that the epileptic child not deviate from this diet that nutritional products have been developed containing flavored protein/fat liquid supplements that function as meal substitutes.

Moreover, avoiding carbohydrates used to be, prior to the availability of insulin, the only way someone with diabetes could handle this disease. And minimizing carbohydrate intake not only from sugary foods, but vegetables such as winter squash, corn on the cob, and carrots may help maintain a normal fasting blood sugar level.

Is it worth putting the body through a major physiological readjustment in order to lose weight?  What about the effect of carbohydrate deprivation on mood? Will there be any rebound eating of carbohydrates once the diet is switched back to including some carbohydrates? A definitive study comparing weight loss among 609 participants who were on a low carbohydrate or low-fat diet over a 12 month period was published this past winter in the Journal of the American Medical Association. The study did not support claims that avoiding carbohydrate produces a better weight-loss outcome. The difference in weight loss between the two groups was about l ½ pounds.

But perhaps the low carbohydrate diet is better for mood. Certainly anecdotal reports of the benefits of eliminating or drastically reducing carbohydrate intake would have you believe that clearer, sharper, focused, energetic minds result.  Here, also, the claim was not borne out by results of another twelve month study comparing  a low-fat and low-carbohydrate diet.

That moods improve among those in the study not denied carbohydrate is not surprising, assuming that some of the mood effects such as energy, focus, calmness and a sense of well-being are associated with normal serotonin activity. The absence of carbohydrate over prolonged periods of time prevents the amino acid tryptophan from entering the brain where it is converted to serotonin. The result: a decrease in serotonin levels and the risk of mood changes associated with too little of this neurotransmitter.

What happens if and when carbohydrates are added back into the diet? Diminished serotonin levels may make the dieter vulnerable to overeating this food group.

Next time I am asked to bring refreshments, I will be sure to include some pork rinds.

References

“Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion,”  The DIETFITS Randomized Clinical Trial,  Gardner, C., Trepanowski, J., DelGobbo, L., et al,  JAMA 2018; 319:667-679

Long-term effects of a Very Low-Carbohydrate Diet and a Low-Fat Diet on Mood and Cognitive  Function .Brinkeworth, G, Buckley J, Noakes, M,  Arch Intern Med 2009 :169; 1880-1873

“Influence of tryptophan and serotonin on mood and cognition with a possible role of the gut-brain axis,” Jenkins. T., Nguyen, J., Polglaze, K.,, et al, Nutrients 2016 8(1): 56.

Working Toward Weight Gain

A few days ago, I was in the office of my ophthalmologist for my annual eye exam. The practice is huge, and the volume of patients is processed–so to speak–by a row of administrative personnel, each sitting in a cubicle. I checked in at one such space and later checked out with the same clerk. As I watched her scan the computer to then print out the appropriate paperwork, it occurred to me that her job was almost totally sedentary. She did not have to move more than a few inches to access her computer, and the printer was under her desk so she did not have to walk over to another area to retrieve a printout. She was not chained to her chair, yet I doubt she was able to leave it until lunch and then again when the office closed. Unless she had far to go for lunch, or exercised during that noon break, she was completely sedentary for hours.

Until robots take over many of the routine jobs now performed by humans, more and more employees will be working in occupations characterized by an absence of physical activity. About seven years ago, a report was published on changes in physical activity related to occupation over the past fifty years in the United States. The authors used data from the United States Bureau of Labor Statistics that analyzed the amount of energy expended for jobs in private industry from l960 on. When the data were first collected in the early l960s, almost half of non-government jobs required moderate to strenuous physical activity. 50 years later, this number dropped to 20 percent. The authors translated these figures into changes in the number of calories that are expended in work and stated, “We estimated a reduction of more than 100 calories per day in occupation-related energy expenditure over the last 50 years.”

50 years ago, the woman processing my eye doctor’s records would have been using a typewriter and thus expending more energy than tapping on a computer keyboard. She probably would have to get up from her chair and walk to the office copy machine to make a copy of my record rather than pushing a button on her computer and reaching under her desk to retrieve the paper from the printer. Multiply this by every patient, every five minutes or so, and her calorie output would have been considerably more than it is today.

The authors of this report discussed the implications of the decrease in work-related physical activity as a risk factor for obesity. They suggested that as we increase the use of labor-saving, we are promoting the increase in weight of the population in general.

They recommend physical activity to compensate for the sedentary nature of many occupations. According to them, if the woman processing my paperwork engages in 150 minutes of moderate activity a week, she will compensate for her lack of activity during her work hours. But, as they point out, only one in four Americans meets this goal. Given the long commuting time many workers face, as well as the unending tasks to be done at home, it is unlikely that the three out of four Americans who are not exercising will suddenly find the time to do so during their limited after work hours. And even if some physical activity occurs on weekends, unless it is prolonged it probably will not compensate for the inert workweek.

Chairs perched on bicycle pedals and mini treadmills, are now being used by many who otherwise might be stuck unmoving an office chair. Those who fear the consequences of prolonged inactivity welcome the opportunity to move the bottom half of the body while the head and hands are occupied in writing reports or code. The use of these devices could be expanded to a much larger population such as medical office workers or anyone else forced to spend most of the workday seated. However, this is unlikely to occur; in addition to the obvious cost of such devices, it might seem strange to check into a medical office for an appointment and find the medical secretary bouncing up and down on her under-desk pedals.

Another option is to schedule walking breaks for workers who otherwise have little opportunity to stand up, let alone walk. This requires time and attention to the employee’s schedule; five-minute walking breaks when patients are waiting in line to be checked in or out means having someone available to cover while the break occurs. This may be too much trouble logistically and too costly financially. Ironically, employees who still smoke and must leave the workplace to do so have a built-in opportunity to move. If they can take a break to smoke, why shouldn’t others be allowed to take a break to move?

Another solution is to rotate the sitting employee into positions that require walking so that for some of the work day he or she is released from the chair. In the office I have referenced, another employee takes the patient to the area where the doctor’s office is located. (The practice is so large one almost needs a GPS system to find the appropriate office by oneself.) If the person checking people in and out were to be a patient escort for part of the day, or some other job that required walking, then the sedentary routine would be broken.

But these are rather weak solutions to a major problem confronting most occupations: How do all of us whose work is associated with being relatively inert get enough physical activity without sacrificing sleep, family, social obligations, and financial goals? Perhaps the answer is for workplaces to offer brief opportunities to stretch and to move, even if it is only for 15 to 20 minutes a day.

It may not be enough to compensate for all those hours of sitting, but it is a start.

Distinguishing Fact from Fiction in Supplement Claims

The June issue of Women’s Health ran an article describing several relatively new supplements that have been making news because they are supposed to confer a large variety of health benefits upon their users.  All of them are derived from parts of plants that are pulverized into a powder or mixed into a solution. The prices were mentioned; they are not inexpensive but if the claims made for them are true, then they should be able to replace very costly drugs now being used to treat the disorders these supplements are able to prevent/treat.

But how does one know whether they do what they are supposed to do? How do we go from brief descriptions of these supplements and suggestions as to how to ingest them, to using them to treat our health problems?

One answer is to spend many hours searching the Internet for valid information about the efficacy of the supplements in doing what they are supposed to be doing. However, even after doing so, there is no guarantee that a particular supplement will replace a well-researched drug for a particular disease.

Curcumin, a yellow spice derived from turmeric, is described in the article and elsewhere as able to decrease the symptoms of certain diseases like arthritis and intestinal disorders. A distant relative who has had an autoimmune disease of the intestinal tract, Crohn’s Disease, was so convinced by published research on ability of this spice to relieve her symptoms that she stopped her treatment with a drug she had been using for years.  Two symptom-filled months later, she returned to the drug; the curcumin did not work for her. But it may work for others and only large clinical trials comparing curcumin with a conventional treatment will provide the answer. The magazine suggested trying it by sprinkling the spice over eggs.  But, of course, the article did not say who should try it, for what disorder and how often to take it. And at $27.00 for 100 grams, it might be cheaper to use the spice, turmeric, from which it is derived instead.

Another featured supplement, Schisandra, is a berry that has the unique property of producing five taste sensations: sweet, sour, salty, bitter, and spicy. Used as a medicine in Asia and Russia for centuries, it is thought to activate enzymes in the liver that break down many compounds and making them available to the body or destroying their functionality.   A short list of Schisandra’s therapeutic effects from several Internet sites include: preventing early aging, increasing lifespan, normalizing blood sugar and blood pressure, protecting against inflammation, chronic night sweats, excessive urination, insomnia, depression, fatigue and treating high cholesterol, pneumonia, asthma, and premenstrual syndrome (PMS).  The magazine highlighted one of its functions: it has been found to enhance short-term memory, especially spatial memory, but so far only among rats. (For those of us who get lost easily, this might be useful.)

But it is hard to find a scientific basis for these claims, nor any specific information on whether we should be ingesting this herb for its prevention abilities.  Like the other supplements, it is not cheap at $20.50 for 8 oz. The article suggested sprinkling a teaspoon over popcorn, but it wasn’t clear whether this would allow the eater to locate the exit from the movie theatre with less difficulty.

What one does not learn from the article is that the supplement can cause myriad side effects such as heartburn, upset stomach, decreased appetite, stomach pain, skin rash and itching. In addition, because it affects liver enzymes, it may alter the metabolism of many drugs. For example, a drug, Warfarin (coumadin), used to retard blood clotting, can be broken down more rapidly by the liver if the patient is taking Schisandra, thus reducing its efficacy. In the Journal of Ethnopharmacology, Panossian and Wikman published a comprehensive review of studies using Schisandra, including the use of this herb for mental illness, gastrointestinal disorders and infectious disease like the flu.  (“Pharmacology of Schisandra chinensis Bail: an overview of Russian research and uses in medicine,” Panossian1Wikman, G., J Ethnopharmacol. 2008 118(2):183-212)

According to their report, Schisandra has been used in Russia for decades as a medicinal herb, but it is frustratingly difficult to figure out whether we should follow the Russian experience and use it for diabetes or high blood pressure or to prevent normal aging. What dose should be taken for what disease, how long should it taken, how often each day, and how will it affect other medications being used?

Maca, also described in the article, comes from a tuberous root found in the Andes in Peru. A placebo-controlled study carried out the Massachusetts General Hospital in Boston found that  Maca restored sexual satisfaction in women whose libido had been suppressed by their antidepressants.  (A Double-Blind Placebo-Controlled Trial of Maca Root as Treatment for Antidepressant-Induced Sexual Dysfunction in Women Evid Based Complement Alternat Med., Dording, C., Schettler, P., Dalton, E., et al ,  2015)

According to their report, Schisandra has been used in Russia for decades as a medicinal herb, but it is frustratingly difficult to figure out whether we should follow the Russian experience and use it for diabetes or high blood pressure or to prevent normal aging. What dose should be taken for what disease, how long should it taken, how often each day, and how will it affect other medications being used?

Maca, also described in the article, comes from a tuberous root found in the Andes in Peru. A placebo-controlled study carried out the Massachusetts General Hospital in Boston found that  Maca restored sexual satisfaction in women whose libido had been suppressed by their antidepressants.  (A Double-Blind Placebo-Controlled Trial of Maca Root as Treatment for Antidepressant-Induced Sexual Dysfunction in Women Evid Based Complement Alternat Med., Dording, C., Schettler, P., Dalton, E., et al ,  2015)

The caveat, however, is that the only group that responded were the 12 post-menopausal women in the treatment group. Younger women did not have a positive response. The magazine article did not mention that the drug might only be useful for older women as suggested in the research report.  Moreover, the magazine suggested Maca might help insomnia, while the Internet is filled with reports about Maca actually causing sleep difficulty.

The caveat, however, is that the only group that responded were the 12 post-menopausal women in the treatment group. Younger women did not have a positive response. The magazine article did not mention that the drug might only be useful for older women as suggested in the research report.  Moreover, the magazine suggested Maca might help insomnia, while the Internet is filled with reports about Maca actually causing sleep difficulty.

One would not expect to find a comprehensive description of the functions and efficacy of any supplement in magazines, or on an Internet site selling the product or giving anecdotal information on what it did for the individual writing about it.  But it takes entirely too much effort to ferret out the information necessary to know how to use these supplements, whether they will work better than traditional interventions, if they might interact with other medications one is taking, how pure they are, what the dose is, and whether they are worth the cost. Unfortunately, there is little money to do the research necessary to show whether or not the claims made for these supplements are valid.

Until that occurs, let the user be cautious.

The Unfortunate Association Between Pain and Obesity

Anyone who suffers from chronic joint and/or muscular pain and is also struggling with obesity realizes how much each impacts the other.  The pain makes it hard to move to exercise without discomfort. The pain of fibromyalgia also makes it hard to deny oneself food that is pleasurable (and possibly fattening) because such eating is a source of pleasure. Pain makes it hard to be in a good mood, and not surprisingly, may potentiate depression. That, in turn, affects eating, sometimes causing weight gain, as do most antidepressants.

Thus more pain is experienced.

Another concern is that insomnia can result from pain; few people can sleep through the night because of the unrelenting disturbance. The fatigue from lack of sleep often leads to overeating, weight gain, and more pain.  And, just to make things worse, two of the drugs prescribed to help pain, especially that of fibromyalgia, can cause weight gain (Neurontin and Lyrica). And so more pain occurs.

Pain comes in many varieties: headaches, abdominal pain, joint and muscle pain, and fibromyalgia.  A review by Okifuji and Hare in the Journal of Pain Research details the ways pain and obesity interact; their review makes the reader feel grateful for every minute that is pain free. (“The association between chronic pain and obesity,” Okifuji, A., and Hare, B., J Pain Res. 2015; 8:399) When obese individuals claim that it “hurts to walk, to climb steps, to get up from a chair, to lift anything,” they are describing the way their weight affects their inability to move without pain.

According to Okifuji and Hare’s review, as BMI (a measurement of weight relative to height) increases, so too does chronic pain.  In one study, fewer than 3% of people with normal BMI reported low back pain, but almost 12% of morbidly obese individuals did so. Anyone who has watched the television series “My 600-lb Life” has seen the pain on the faces of these extremely obese people when they have had to stand or walk. It seems unbearable, yet even at a considerably lower weight, the body may respond to carrying around extra pounds with chronic pain.  The Arthritis Foundation has some compelling information about the relationship of excess weight and pressure on the knees: every extra pound carried puts 4 pounds of extra pressure on our knees. So if one is only ten pounds overweight, forty pounds of extra pressure is placed on those joints. This means that weight gain associated with a painful disease like fibromyalgia, typically more than twenty pounds, may put enough pressure on the knees to cause another source of pain.

If obesity is exacerbating chronic pain, such as that associated with arthritis or fibromyalagia, the solution is simple but not easy to achieve: lose weight.  Many studies that have shown relief of pain with weight loss.  In a typical study, when adults suffering from joint pain are put on a diet with or without the kind of exercise that their bodies can tolerate, they lose weight and their pain is diminished.  (“Diet and Exercise for Obese Adults with Knee Osteoarthritis,” Messier, S., Clin Geriatr Med, 2010;26:461; Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial,” Messier, S., Mihalko, S., Legault, C., Miller, G., JAMA, 2013 Sep 25; 310(12): 1263-73)

But anyone who has experienced even transient pain from, for example, an overly ambitious workout, the first long bike ride of the season, too much weeding and hauling a wheelbarrow, or some unexplained back pain that thankfully disappears a week or so after it mysteriously arrived… knows how hard it is to move without pain. Unfortunately, our appetite rarely disappears when the pain arrives.  A friend who is extremely active was transported through an airport in a wheelchair after a virus-like infection caused severe back pain. His agony prevented him from walking more than a few steps at a time. After he recovered, he told me how reluctant he was to move when he was in such pain.

“Unfortunately, I didn’t lose my appetite so I was eating as much as before,” he said.

Increasing mobility as a way of preventing weight gain and supporting weight loss is advised for almost all situations in which there is chronic pain, as long as there is no possibility of damage to joints or muscles. The best way to go about this is with guidance from a physical therapist who can advise on movements that either will not hurt, or cause too much discomfort. Swimming and/or aerobic exercises in warm water is less likely to cause pain than activities involving some impact on joints. Gentle yoga is also recommended with instructors who know how to protect the participants from movements that will hurt. Recumbent bikes tend to be more protective of joints and muscles than other pieces of equipment in a gym, but even this piece of equipment should only be used with the advice of a physical therapist. Walking, if not too painful, should be done where there are places to sit and rest, should the pain becomes too intense to continue.

Dieting is equally difficult. When pain restricts most physical activity, it is hard not to gain weight since the individual requires many fewer calories than when normal activity is taking place. Muscle weight may be lost due to the inactivity, but excess calories will continue to be turned into fat. A dietician can figure out how many calories should be consumed in relation to the degree of inactivity caused by the pain. And just as important, the dietician can develop a food plan to make sure that all essential nutrients are being consumed within the calorie limits. Pain and attempts to lose weight should not lead to a nutritionally inadequate diet.

Even small amounts of weight loss are beneficial. If every pound gained may make the pain worse, every pound lost should bring some relief.

Do Those With Psychiatric Diagnoses Get Enough Medical Care?

After a disturbing article about the side effects associated with withdrawing from antidepressants appeared in the New York Times (link is external), I asked a psychiatrist friend why patients were not being helped to avoid this problem.

“It is very labor intensive,” he answered me. “To taper someone off antidepressants very slowly, which is the only way to do this, the patient should be seeing the physician or nurse practitioner two or three times a week. The medical caregiver must spend enough time with the patient to evaluate the side effects, and adjust the withdrawal rate accordingly. “

“But certainly there would be time in a 30 or 60 minute appointment to do this,” I naively replied.

He looked at me, wondering where I had been the last few decades. “Many psychiatrists have to see four to six patients an hour,” he said. “Not all do this,” he went on, “but if their schedule is that crowded, they may not have time to fine-tune the withdrawal schedule and/or even hear about the side effects. “

Having absorbed that piece of unfortunate information, I asked whether such short visits would prevent the physician from having time to discuss other aspects of the patient’s health such as weight gain or loss, whether the patient was getting annual care like a flu shot, regular dental care or routine screening examinations like mammography. “If they are depressed, isn’t it possible that the only doctor they see is their psychiatrist?” I asked him.

He confirmed that this was so. He had worked for many years as an internist before specializing in psychiatry. He was particularly sensitive to other medical problems of his patients and was able to make sure his patients saw the appropriate medical specialist when necessary. But again, the short visits, and absence of internal medicine training might cause medical issues to go undetected by the therapist.

Certainly the weight gain so common with most antidepressants would receive little attention from the psychiatric professional in an abbreviated visit, but patients can find weight-loss programs to join without physician referral. The program may not address the reasons for the weight gain, for instance, a side effect of the medication, but at least organizations such as Weight Watchers offer sensible, healthy diets. But where does the severely depressed patient who stops eating for four or five weeks go to for help? Who will convince the patient that it is important to eat, even though the depression takes away all desire to do so? Who will make sure that nutrient needs are being met, and that the depressed patient who lies in bed for five weeks does not finally emerge from the depression with muscle wasting from inactivity?

If the patient has family or friends who will take responsibility for the health needs of the patients with depression, then they will make the phone calls and appointments necessary to get them medical care they need; whether it be it for a bad case of the flu, high blood pressure or poor nutrition. However, many people with depression are socially isolated and may be un- or underemployed, and not plugged into a comprehensive medical care system. Thus the only interaction the patients have with a medical care provider is during the scheduled appointment with the psychiatrist every six weeks, or three months, or even after longer intervals.

Of course, the absence of generalized medical scrutiny or support by a psychiatrist is hardly unique. If one goes to a dermatologist to make sure a freckle is not a melanoma, it would be rare indeed if the physician checks the patient’s blood pressure, blood sugar, or asks if the patient is eating four servings of vegetables every day. The issue is the freckle, and not the general state of health of the patient. Yet oftentimes seeing a dermatologist for that freckle-melanoma issue follows a visit with an internist. People with mental disorders who are, for example, in the throes of the depression or bipolar disease, may never get to see the internist.

Perhaps the solution is to combine the visit to the psychiatrist to get a prescription renewed with at least an annual visit to a primary care physician. So, if medical problems exist, they can be identified and treated. Better yet, frequent contact with a seriously depressed patient by a nurse practitioner or physician assistant would ensure that the patient is eating appropriately and not voluntarily confined to bed. Moreover, when the patient is in remission, follow-up medical care should be provided to accelerate the speed of recovering nutritional status, to increase muscle mass, and to identify any other medical issues that may have arisen while the patient was depressed.

Much attention has been given to providing preventive care and early identification of medical problems that can be resolved before they become very difficult, if not impossible to treat. For example, high blood pressure should and can be treated in order to decrease the risk of a stroke. Certainly, if a patient is rapidly gaining weight due to the side effects of an antidepressant or mood stabilizer, the weight gain should be halted before it potentiates diabetes or cardiovascular problems. But these “should do” suggestions are not being implicated for many suffering from mental disorders because of cost, logistical difficulties and probably, to some extent, inertia and reluctance on the part of the patient. Perhaps it is time to turn “should do” into “will do.”

Peak Physical Fitness as Protection Against Dementia

“Good news,” a friend in the gym said, waving her cell phone in my direction. She showed me a news release about a study on the positive effects of exercise in preventing dementia among women. The article published in Neurology (link is external) showed the somewhat startling relationship between being very fit and reducing by almost 90%, the chance of becoming demented.
An air of self-congratulation rippled through the treadmill walkers as the news passed from machine to machine, and there seemed to be a perceptible increase in the intensity of the exercise we were all doing.

Unfortunately, a closer reading of the study revealed that even those who went to the gym pretty regularly were not guaranteed a dementia-free future. Unless we were extremely physically fit we were still vulnerable to cognitive problems as we age.

The study was initiated in l968 when researchers tested the cardiovascular capacity of Swedish women ranging in age from 38 to 60.  The women exercised on an exercise bike that monitored their cardiovascular stamina, and they were told to exercise until exhaustion. One hundred and ninety-one women participated and, based on how well they did on this test, were divided into high, medium and low fitness levels. Some in the low fitness group were unable to complete the exercise because of cardiovascular problems. Forty placed in the high fitness group, ninety-two in the medium-fitness group and fifty-nine in the lowest group.  Those in the high fitness group were not competitive athletes, but their physical stamina and energy utilization measured during the initial testing period indicated their ability to endure strenuous exercise.

Women were tested six times over the subsequent 44 years of the study to determine if and when dementia appeared. The bad and good news is that 32% of the least fit developed dementia, as did 25% of the medium-fit. However, only 5% of the fittest group were affected.

Dementia is not the same as memory loss, although it can be associated with it. Dementia is not a specific disease, but instead describes a cluster of symptoms that affect intellectual functioning, emotional control, the ability to solve problems, maintain language skills, and carry out the functions of daily life. One example of the difference between memory loss and dementia is a person who cannot remember the name of a fork but can still use it to eat. This person has memory loss, but may not be demented. A person who doesn’t know the name of a fork nor its function would be considered to be suffering from dementia.

In the Swedish study, the most common cause of dementia was Alzheimer’s disease (eighty women), although twelve women developed vascular dementia. The latter is usually associated with strokes, some so small they are not even detected. The other causes of dementia were not described.

Before giving up one’s day job to spend more time in the gym to increase physical fitness, it is important to consider that the authors of the study were not sure how being especially fit protected the women from dementia. Nor did were they able to explain why the least fit women were so vulnerable. Moreover, the study did not record whether the women continued to be fit or not during the several decades that followed the initial assessment, and their physical fitness was never measured again.

This sort of study is frustrating on many levels. It is not a cause and effect study, i.e., exercise causes something that protects against dementia. Rather it shows the linkage of two conditions: peak fitness in middle age and significantly decreased incidence of dementia almost 50 years later.

So is it the exercise itself that may alter the brain to prevent cognitive decline? If so, how? Do women with outstanding stamina have different lifestyles? Do they also do crossword puzzles more often or speak several languages, activities that are supposed to improve brain function? The study was done in Sweden, but perhaps the high fitness subjects followed a Mediterranean diet eating mostly grains, fish, olive oil and vegetables. Such a diet has loosely been linked to lower rates of Alzheimer’s disease.

Was there a connection between the levels of their female hormones and their exercise activity? Maybe those who exercised so well didn’t suffer from menopausal hot flashes. Or maybe they did. Who knows?

Does their fitness at fifty result from a childhood and early adulthood spent in strenuous physical activity?  If so, might the positive change in their brain preventing dementia be a result of decades of peak exercise performance and perhaps, along with that, food intake designed to enhance this performance? Should we encourage our children and grandchildren to take on sustained high levels of physical activity, so by the time they are fifty, their brains may be protecting them against dementia?

This study probably took fifty or more years to carry out because of the time spent gathering and testing subjects before it began, and the time spent analyzing the data after it was over. Such studies are difficult to do, and certainly repeat, which is impossible to do in the lifetime of the original investigators. The results are tantalizing and sufficiently compelling to make some, perhaps with a family history of dementia, commit to more exercise, more frequently, and with greater intensity. And if it works to prevent Alzheimer’s disease and other causes of dementia, then regardless of why or how it will be worth doing.

References

“Midlife cardiovascular fitness and dementia,” Hörder, H., Johansson, L., Gu, X., et al, Neurology Mar 2018, 10:1212

If Your Valentine Sweetheart is on a Diet, Should You Gift Chocolates?

Valentine ‘s Day is a sweet (pun intended) holiday. It comes in the middle of the winter doldrums; Christmas is long past and spring is nowhere to be seen. But the problem is that it also comes about six weeks into the weight-loss program many started after New Year’s Day.

“Give something to show your love,” we are told in a doughnut shop advertisement featuring heart- shaped pink doughnuts covered with white icing and pink sprinkles. Shelves in gourmet chocolate stores are filled with pinky-red, heart-shaped boxes decorated with tiny flowers; the boxes contain melt-in-your-mouth creamy chocolate that should be guaranteed to melt the heart of the recipient.  Russell Stover chocolates that are filed with hidden flavors revealed only when bitten into are waiting to be bought and sent to the relatives who remember the candy with fondness. M&M’s sport pink chocolate shells, while heart-shaped sugar candies waiting to cause instant tooth decay call to the drug store shopper who came in only looking for shampoo.

Not to be left out, bakeries feature several-layered heart-shaped cakes to be consumed with a glass or two of champagne.

To be sure, commercial romance for Valentine’s Day is not limited to food. Flowers are a welcome brightness in the gloom of early February and jewelry, especially diamond engagement rings, do not contain calories. Gifts of self-indulgence that the recipient may not get for her or himself, such as a massage, spa treatments, pedicures, and/or manicures, are also calorie-free and thoughtful.

However, sweet foods, especially chocolate, seem to be the most persistent symbol of romantic thoughts or intentions. Perhaps because for centuries chocolate has been considered an aphrodisiac. There is no scientific evidence for this, and even if it were true, there would be no reason to assume that chocolate consumed on Valentine’s Day has a greater impact on sexual arousal than if it were consumed on any other day. Perhaps if chocolate is wrapped in a heart-shaped box, it has more of an impact; nonetheless, this certainly has not been tested.

Giving a gift of chocolate also has its perils. What if the message it conveys has less to do with romantic intentions and more to do with the body image of the recipient? Give a pound of chocolate to someone skinny and it may convey the thought, “You need to gain some weight.”  Present that heart-shaped box to a chubby recipient and it can unintentionally convey the thought that, “You are fat already, so what difference does another pound of chocolate make?” instead of, “I like you the way you are.” Can you give chocolate to someone in the older generation who may be overweight, developing diabetes, or dealing with orthopedic problems because of excess weight?

Then there is the dieter. The continuing popularity of low or zero carbohydrate diets puts chocolate on the forbidden food list. The butterfat would be fine, and the more expensive the chocolate, the more butterfat it contains. But the sugar content that makes chocolate edible (otherwise it would taste like bitter cooking chocolate) would ruin the diet of anyone who is following a ketogenic diet in which fat, not carbohydrate, is used by the brain and body for energy.

But for those who are counting calories or the equivalent in food exchanges, there is good news. Small amounts of chocolate have fewer calories than they seem to have, given their luxurious taste and mouthfeel. A quick scan of Godiva, a popular gourmet brand of chocolate, reveals a lower calorie count for their chocolate than one would assume. Admittedly the actual pieces of chocolate are not large, maybe one or two bites. Still, you can eat four dark chocolate truffles for about 180 calories, and three pieces of assorted Belgian chocolates for 190 calories. A Lindt chocolate ball has 75 calories. To put this in perspective, a glass of champagne has 95 calories, an eight-ounce serving of fat-free yogurt around 80-90 calories, and 10 almonds, 70 calories. So certainly presenting your Valentine gift of chocolate to a dieter should not be a problem; one or two pieces of chocolate will not retard weight loss or cause the diet to fail.

But of course that is the problem. You can’t buy prepackaged chocolates wrapped in the colors of Valentine’s Day in amounts smaller than twenty or so pieces. Thus the recipient has to confront the problem of how to manage the consumption of the rest of the chocolate after February 14.  A highly disciplined dieter will be able to restrict consumption of a luscious piece of chocolate to one or possibly two a day. But this kind of restriction is not easy to accomplish, especially in the middle of the diet. And the romantic associations with the chocolate will be quickly dissipated when the dieter finds a “gift” of pounds after devouring the rest of the package.

One solution is to buy only one or two pieces of gourmet chocolate from the store; the chocolate can be boxed in the same fancy wrapping as would be used for a larger amount. But in this time of online rather than in person shopping, locating such shops and having the time to go to one seems much too inconvenient. Moreover, the dieter may misinterpret intentions behind the gift thinking that the giver:

1) Is cheap;

2) Thinks I am fat;

3) Thinks I will gobble everything in a bigger box; and therefore

4) Wants me to stay fat.

Maybe people should stick to flowers or diamonds.

 

 

 

Don’t Avoid Exercise Because It Makes You Hungry

Among the many kinds of advice given to those who are trying to lose weight, exercise usually ranks just below diet. But just as weight-loss advice can be contradictory and confusing, so too are the recommendations for exercise. No one disputes the benefits of physical activity on everything from improved digestion to better cognition. The adverse effects of ignoring the prescription to move ones body are just as compelling: no exercise equates to bad sleep, bad bones, and bad mood, among other unpleasant symptoms.

But many dieters and weight maintainers are reluctant to exercise because they fear the effect on their hunger. Exercise seems like an ineffective, and indeed unworkable, way of losing weight when post-exercise appetite may lead to eating many more calories than those worked off. Anecdotal reports by dieters of feeling ravenous after a stint on the treadmill or weekly Zumba class supports the erroneous belief that exercise while dieting should be avoided to prevent overeating.

Curiously, highly-trained athletes (who, of course, don’t have to worry about their weight) are the least likely to want to eat after their highly intense exercise routines are completed. In a study published a few years ago on appetite among female athletes, the scientists found that intense exercise actually decreased subjective hunger. Moreover, ghrelin, the hormone in the gut and blood that regulates hunger, was decreased and another hormone that shuts off appetite, increased. (“No Effect of Exercise Intensity on Appetite in Highly-Trained Endurance Women,” Howe, S., Hand, T., Larson-Meyer, D., Austin, K. et al Nutrients, 2016; 8 ) The same effect had been found earlier in studies carried out with male endurance athletes.

Since most of us are not likely to devote a good portion of our lives to training for competitive athletic events, we cannot rely on this for suppressing appetite after exercise. However, it seems that even unfit obese men may also experience a decrease in hunger after intense exercise, at least for 30 minutes after the exercise session completed. Whether they overate several hours later was not reported. (“The Effects of Concurrent Resistance and Endurance Exercise on Hunger Feelings and PYY in Obese Men,” Asrami, A., Faraji, H., Jalali, S., International Journal of Sport Studies, 2014 4; 729-)

But one may ask: what is wrong with being hungry after physical activity? Isn’t hunger a natural and inevitable response of the body after calories are used up? A Food Network show featuring life on a ranch in some unnamed cattle-raising part of the country often features recipes for the “hungry” family and ranch hands after a day of especially hard work. It would be absurd for the workers to avoid physical labor just because they are very hungry when they return home to eat a substantial meal.

But most of us have traveled far from the natural progression of physical activity to hunger to eating to a return of energy, and thus being able to work again. The “I am so hungry that I could eat a horse” (or whatever animal comes to mind) statement after hours of manual labor or recreational physical activity seems to many like a prescription for weight gain, rather than the way nature intended us to feel.

But it is not. Hunger is natural. The hormones causing us to want to eat are there to make sure we do so in order to live. If hunger disappears, as is the case for some with late stage Alzheimer’s disease, the individual will not survive unless others make sure to feed the patient.
In short, we should stop being afraid of being hungry. Hunger means our bodies need food the way being thirsty means our bodies need water. How we satisfy our hunger is what we have to improve if we want to stop gaining weight and begin to lose it. Just as we could, but should not, satisfy our thirst by drinking gallons of champagne or sugary sodas; we should satisfy our hunger not by consuming junk food, but by eating foods that not only supply calories (to replace those used up in exercise) but also needed nutrients into our bodies.

Dieters are told to try to eat fewer calories than needed so the calories in their stored fat will be mobilized to make up the difference. But unless the dieter goes on a drastically low-calorie diet, or a diet that eliminates certain categories of foods, it is possible to eat less, satisfy hunger, and still lose weight. We often eat beyond feeling full, that is, beyond the cessation of hunger; this is why we eat dessert. If eating stops when hunger disappears—even if all the food has not—weight can be lost.
Should you eat before or after exercise? It depends on your body. Some cannot exercise after eating and will eat breakfast after, rather than before, working out in the morning. Others find that they don’t have the energy to play tennis or go hiking unless they have eaten. Therefore, they will eat enough to give their muscles fuel for their workout, but not so much that they feel too stuffed to move.

Sometimes during long bouts of exercise, such as a long bike ride or hike, the first sign that the body needs food is not hunger but fatigue. I remember once when I was cross-country skiing all day, I become too exhausted to move my skis up a hill to get back to the lodge. As I stepped outside the track to let a woman behind me pass, she handed me an energy bar. “You need food,” she said. “Eat this.“ She was right. Within a few minutes I felt my fatigue lift, and I was able to continue moving.

We are told to be in touch with our bodies. Exercising, being hungry, and eating healthfully are excellent ways of communicating with ourselves.

 

 

 

Will Reducing Your Dress Size Reduce Your Bone Size?

“She got so thin!” a friend whispered to me, pointing to a mutual friend we had not seen for several months. The thin friend came over, and when complimented on her size, she told us she had lost weight following a diet than eliminated most food groups. “It was easy to lose weight,” she said, “because all I could eat were lean proteins and vegetables. I think I will stay on this diet forever!”

“You might want to add some dairy products to your diet,” I murmured. “You know, osteoporosis and all that.”

“Oh, I get plenty of calcium from vegetables,” she answered, “and anyway, dairy is fattening.”

Feeling like the bad witch who predicts dire consequences, I restrained myself from pointing out that she was a perfect storm for losing bone mass and breaking bones. She was beyond her menopause, which meant that the protective effect of estrogen on bone density was no longer functioning. It was unlikely that she did weight-bearing exercise to increase muscle mass and subsequently bone mass. Her arms and legs showed no obvious muscular development; they were visually just skinny tubes. Vitamin D intake, the last piece of the triad of interventions that support bone density, was probably also lacking, as the foods she ate were not fortified with vitamin D.

At her age—she was almost seventy—she should have been consuming about 1200 mg of calcium a day and 600 IU (international units) of vitamin D to maintain her bone mass.  But because of her weight-loss diet, she wasn’t.

After a several month struggle to lose weight, it seems unfair that my now thinner friend is vulnerable to this debilitating disease. But she fits the profile of people likely to develop osteoporosis even without her weight loss. (Osteoporosis can occur in both men and women but women are more likely to have it. White and Asian women are most at risk that also increases with age.) If she had a family history of osteoporosis, smoked, consumed excessive amounts of alcohol, and had been severely underweight as an adolescent when bone mass is rapidly expanding, she would be facing an even greater chance of developing the disease.

It is not possible to diagnosis osteoporosis without a bone density scan. Despite her skinny appearance, her bones may have been fine. But the only way to tell is to have a type of x-ray called dual-energy x-ray absorptiometry (DXA or DEXA). Many women ten years or so beyond menopause will have the test so their physician can have a base line measurement of their bone strength. If the results indicate that osteoporosis may be developing, then the patient will be told to consume calcium-rich foods like milk, cottage cheese, yogurt or some vegetables such as kale…and also may be told to take a vitamin D supplement. Exercise is also important to promote bone density.

There are several drugs now available prescribed for osteoporosis but they have substantial side effects. The drugs are called bisphosphonates. Fosamax and Actonel are taken daily or weekly and another, Boniva, is taken monthly. One, Reclast, is given intravenously once a year; for those who have the early signs of the disease, once every two years. Most of the side effects, i.e., nausea, are tolerable, but a minority may developed osteonecrosis of the jaw or jawdeath. Fosamax and Boniva have been associated with this problem in which the bones in the jaw don’t heal after a minor injury like having a tooth pulled. Another equally rare side effect is a particular kind of fracture in the femur, the long bone of the leg.

Why drugs that promote bone growth and density should have the opposite effect on specific bony areas in the body is not yet known.The incidence is 1 in 1,000. It happened to an acquaintance of mine who had been taking one of the bisphosphonates.  She had a dental procedure, and a few weeks later experienced severe jaw pain that was finally diagnosed as osteonecrosis. Now she was faced not only with osteoporosis, but also the fact that she could no longer take the drug that was supposed to halt it.

Preventing, or at least decreasing, the possibility of developing osteoporosis has to begin in adolescence but it is hard, if not impossible, to convince an 18 year-old to drink more or any milk or eat more, or any, yogurt or cottage cheese or kale. The American Academy of Pediatrics has warned that children are not consuming enough calcium during puberty when most bone growth occurs. Young women who are anorectic, or because of excessive exercise and low body fat stop menstruating, are at risk for developing bone loss at a young age. Teens should be getting 1000 to 1200 mg of calcium daily. This amount of calcium is not difficult to obtain with fat-free or low-fat dairy products, or calcium-fortified milk substitutes like soy or almond milk, which are also fortified with vitamin D.  Unfortunately, a diet drink, instead of milk, is often the beverage of choice.

It seems as if the most compelling motivation to consume enough calcium and vitamin D in an effort to prevent osteoporosis is having a relative who fractured a hip or wrist because of this disease. There has to be a better way of promoting concern about this problem than the broken hip of an aunt. Bone density tests are expensive, time consuming and rarely offered to patients before menopause. What is needed is a simple, inexpensive test that detects the early stages of the disease, so nutritional intervention can start decades before the disorder develops—and perhaps an ad campaign showing that life can be “magical” after drinking milk.