Category Archives: Tips

Are Sugary Foods Less Unhealthy During the Holidays ?

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

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

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

But wait. They will be around in January.

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

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

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

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

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

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

Do College Students Get Enough (Nutrients) to Eat?

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

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

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

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

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

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

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

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

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

The Guest with the Surgically Shrunk Stomach & Thanksgiving Dinner

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Medication-Linked Weight Gain & Clothing Discrimination

Until someone joins the ranks of the size 16 and over, she probably has no idea of the discrimination from the fashion industry and department stores that awaits her when she needs to buy clothes. For you who were wearing “chubby“ sizes as children, and forced into wearing clothes designed for a woman when you were still an adolescent girl, shopping as an overweight or obese adult is an indignity and discomfort that you know all too well.

However, if you are someone whose size has migrated upward as a result of weight gain from antidepressants, mood stabilizers, low dose steroids, or other medications, you will probably be shocked at what awaits you on the racks of the larger size clothes in department stores. And if you loved fashion, or at least wanted to wear something other than oversized tops and stretch bottoms, you will be dismayed at the paucity of designers and designs for someone who does not fit into what the industry calls “normal“ size.

Once, while talking with a weight-loss client whose obesity was a result of her antidepressant treatment, I asked her how she shopped for clothes. She had been a competitive athlete during her young adulthood, and her body could have been on the cover of Shape or Self magazine. Now she was struggling to lose the fifty or so pounds she had gained on her medication.

“I don’t shop unless I absolutely have to, and then I go to stores like Old Navy where the sizes are more generous. A size large in a store like Banana Republic or Madewell would be a medium in a store like Old Navy, so I didn’t feel so bad about my body when I shopped there. And there were enough shoppers who wear large sizes to support a pretty good selection. It isn’t like going to a regular department store and being sent to a plus-size department behind housewares or pet supplies, and where there were relatively few styles and none I would consider wearable,” she told me. She went on to say that, like many women (and some men), she had found clothes shopping to be a pleasurable distraction from training and her college studies. “It was fun going to the mall with my friends and trying on clothes. But after I gained weight, the selection was so limited, and in many cases so ghastly, I hated to shop. It is as if fashion stopped with size 12.”

She was right.

A few weeks ago my persistent channel surfing on the TV attached to the treadmill at my gym brought up an old episode of “Project Runway.” What made this episode different was that the models were the mothers and sisters of the fashion designer contestants. Thus, they were told to design clothes for models whose bodies looked much different than the industry’s norm. Indeed, several of the moms were in the larger than “normal” size category, a fact that made the designers not very happy. Several seemed incapable of making clothes that were not burka-like; others covered most of the upper body with a voluminous poncho or jackets. The objective, it seemed, was to pretend that the women did not have body parts with bumps and curves.

Tim Gunn, who had been the taskmaster of this show, now many seasons old, confirmed my impression in an article published in the Washington Post in September 2016. He said that even though the average American woman is a size 16 or 18, and is willing to outspend her thinner sisters on clothes, “many designers—dripping with disdain, lacking imagination or simply too cowardly to take a risk—still refuse to make clothes for them.”

This past June, Steve Dennis, writing for Forbes, confirmed what Gunn stated. Dennis described much of the fashion industry as being biased against any image of women that did not conform to an unrealistically thin body. Yet according to Plunkett Research, a market research firm, 68 percent of American women today wear size 14 or above.

Women’s sizes may be getting larger, but the amount of space in a department store selling clothes to fit their bodies is not expanding. And the clothes are certainly not front and center when the shopper exits the escalator onto the floor featuring women’s clothes. The “cute stuff,” size 2, is on the mannequins; the plus-size department is a hike away.

The answer proposed to the frustrated larger shopper is to shop online. Of course, buying clothes, along with everything we need or want online, is done by almost everyone regardless of size. Indeed, some manufacturers of plus-size clothes that only sell online promote the advantages of trying clothes on in the privacy of one’s home, and will accept returns of clothes that do not fit.

But according to an insightful article by Sara Tatyana Bernstein, not being able to try clothes on at a store is frustrating. Not everyone who is size 14 or 18 or 22 has the same shape, and not everyone carries the excess weight in the same areas of the body, she tells us. And the woman who has had a slimmer body prior to gaining weight on antidepressants might need the help of an experienced saleswoman to figure out what looks best on her new larger shape. However, Bernstein did report her own positive experience going into a couple of stores (Torrid and Lane Bryant) where, in her words, “the larger shopper feels comfortable and supported by other shoppers of the same size.”

She also has an interesting observation about the lack of quality in many clothes made for the larger woman. Even though market surveys show that often the larger woman is willing to spend more on clothes than her smaller counterpart, according to Bernstein, clothes of good quality, made to last, are very hard to find. She suggests that manufacturers make cheap (in regards to the items’ durability) plus-size clothes in the belief that no woman wants to remain a large size. Thus she doesn’t want to invest money in clothes worn only temporarily—i.e. until she loses weight. Why, the thinking goes, would a woman want to buy expensive “staples” that sooner or later will be too big to wear?

Since many who have gained weight on medication now find it impossible to lose weight months, and even years, after the drugs are discontinued, they don’t know whether they will ever lose that weight. And there are many others who for a variety of reasons may not be able to reduce to a “normal” size without great difficulty. Isn’t it time to manufacture larger-size clothes that flatter and endure? If Peter Paul Rubens could make the larger woman look desirable, cannot today’s fashion designers do the same?

References

“A Plus In The Sun: The Spatial Politics Of Selling Plus-Size Clothes To Women,” Body Politics, Fashion July 31, 2017.

Should a Personal Trainer Be Present at a Wellness Exam?

Several years ago, wellness examinations were introduced into medical practices as a way of detecting possible health risks, especially among an older population. It made and makes sense. Detecting high blood pressure, elevated cholesterol or blood glucose, and too low levels of essential nutrients meant that interventions could be started to prevent a worsening of the individual’s health and quality of life. But do these assessments really measure the wellness of the individual?

Consider falling. Falling is a common risk factor for older people, and now that the Baby Boomer population is in that category of older Americans the incidence of falling will predictably increase. The loss of bone and muscle mass and balance that accompany aging certainly increase the risk of tripping over obstacles that might not even register a slight stumble in a younger individual. And unfortunately 30 to 40 percent of people 65 and older may trip and fall. The effect of a fall is not a tumble and, “Don’t worry, I am not hurt.” About half of these falls cause injury that becomes more serious the older the individual.

Thus the wellness assessment should include detection of physical deficits that might make the patient vulnerable to falling. If a decline in balance or uneven gait is detected before injury from falling occurs, a “prescription” for therapeutic exercises can be offered so these conditions can be helped. This would be similar to a physician making sure a patient received nutritional advice if blood tests showed pre-diabetes or early signs of iron deficiency. But according to guidelines from American and British Geriatric societies, no assessment of risk from falling will be made unless the patient has already fallen or complains of feeling unsteady while walking. If one is lucky or unlucky enough to have fallen (excuse the pun) into this category, then he or she is sent to someone for evaluation of walking and balance.

But why wait until there is a problem? If a patient was pre-diabetic based on fasting blood sugar levels, should a doctor wait until the symptoms of diabetes appears before starting treatment?

Your physician does not have to be a physical therapist or certified personal trainer to assess whether you have poor balance or impaired walking and need help to improve these functions.

The test to measure balance is simple. For example:

  • Can you stand on one leg and bend the other 45 degrees or place it against the calf of the standing leg? Can you do this on each leg for 30 seconds?
  • Can you walk ten steps with the heel of your front foot touching the toe of your back foot? (This is harder than it seems…)
  • Step to the right with your weight on your right foot. Bring your left foot next to your right foot. Then do the same with the opposite feet. Slowly.

There are other similar balance tests that are also used as exercises to improve balance.

The results of a balance test can be surprising. A friend who had an ankle operation found that even though her ankle had healed and the muscle mass of her leg restored, she had much more trouble balancing on the operated leg than the other years after the operation. Another who had stopped going to yoga classes because of scheduling conflicts and who could stand on one foot seemingly forever was horrified to find that after a couple of years not doing balance exercises she had trouble standing on one foot for less than a minute.

Gait is a fancy term for moving your feet while walking. Gait speed is a measure of how quickly someone can walk from a specific point to another specific point. Measurements of gait needs a bit more space than a balance test, and if problems are detected, a thorough evaluation, including walking on a treadmill and the walking videoed for later analysis by a physical therapist. In the initial test, a distance is measured out and the individual asked to walk at a normal gait /speed to the end point. This is timed and often repeated to get an accurate result. Gait speed is then calculated by dividing the distance by the time it takes to cover it.

So, if you walked 12 meters (one meter equals three feet) in 12 seconds, than you would walk one meter (or three feet) per second. Although gait certainly can slow down simply with aging—a 90 year-old probably walks more slowly than a 50 year-old—other factors such as being unable to pick up one’s feet (shuffling), perceptual problems, poor balance and muscle weakness can slow down the pace of walking in an otherwise healthy person.

These measurements of balance and gait do not require the services of a personal trainer or physical therapist. They can even be made at home. They don’t take time. Indeed, they probably require less time than one typically spends in the waiting room when the doctor is behind in his or her appointments.  But they should be made under medical supervision because they can reveal problems that are more medically complex than aging or lack of exercise.  Loss of balance and abnormally slow gait can be due to inflammation or other inner ear problems, nerve damage to the legs, vision problems, muscle weakness, side effects of some medications and neurological diseases like Parkinson’s. The underlying causes must be addressed.

Balance is something we don’t notice we have lost until we do. All of us must find out how vulnerable we are before that first fall.

References

“Assessment and Management of Fall Risk in Primary Care Settings,” Phelan, E., Mahoney, J., Voit, P., and Stevens, J., Med Clin North Am. 2015 Mar; 99(2): 281–293.

“Gait Speed as a Measure in Geriatric Assessment in Clinical Settings: A Systematic Review,” Peel, N., Kuys, S., Klein, K., The Journals of Gerontology: 68; 2013: 39-46.

Should Unhealthy Foods Become a New Food Allergy?

After we made our reservations at the bed and breakfast in a charming New England town, we received, along with our confirmation email, a form asking us to list any food allergies or food restrictions. The inn served a full breakfast, indeed, the gourmet quality of the breakfast was mentioned in several reviews and the couple running the inn obviously wanted to make sure that the culinary needs of their guests were noted.  We couldn’t think of any except the unthinkable, i.e. a breakfast without caffeine, and assumed that we would be able to eat the foods traditionally served at inn breakfasts: an assortment of bread, pastries, yogurt, fruit, cereals, and a hot egg-cheese casserole. We made a mistake. We should have said something about our food needs.

Her breakfast menu, the morning we were there, offered foods incompatible with what we normally eat for breakfast (or indeed ever.) The first course was a nectarine poached in syrup, coated with chopped nuts and seated on a bed of sour cream. The main course was a large slice of cheese quiche and a sour cream biscuit. The quiche was mainly egg, cream, butter and a great deal of cheese. The biscuit seemed to be mostly butter, sour cream and flour. To someone accustomed to eating a high-fiber cereal, fat-free milk and fruit, or yogurt and whole grain toast early in the morning, the inn’s breakfast was too high in fat to eat. But it was embarrassing. Other guests at the long table at which we all sat cleaned their plates. How to explain our nearly full ones? The face-saving one was that we usually were not very hungry in the morning.

Perhaps it was our fault. Perhaps we should have mentioned that for a variety of reasons, including a history of serious heart disease in our families, we tried to limit our saturated fat consumption. Or that we were going to be spending many hours that day driving home and would feel more comfortable eating lightly rather than digesting several ounces of almost pure fat. But we said nothing. We overheard the innkeeper explain to another guest that she liked to serve everyone the same food because it enabled her to control her food supplies and decreased waste. “If I put out a variety of foods like yogurt or fruit,” she said, “then I may have to throw some food away and I hate doing that.”  So we did not even ask if there was anything else to eat. We assumed that she was not prepared to offer anything but her own menu to her guests. Sadly, our food was wasted along with the labor she put into making it.

Could we have prevented this? She did ask us to list our food allergies and restrictions, but where would we have mentioned our desire to eat a low-fat, high-fiber, and vitamin-containing meal for breakfast?  Obviously we were not allergic to cheese, butter, eggs, and sugar, and it would have been dishonest to state that we suffered from diseases that prohibited eating these foods. (We simply did not want to develop these conditions.)

However, given the prevalence of medical conditions such as obesity, diabetes, heart disease, and gastrointestinal disorders that would benefit from a healthy diet, shouldn’t the potential guest be asked whether he or she preferred to limit consumption of high-salt, high-fat, and high-sugar foods? Shouldn’t the desire to serve a gourmet breakfast that featured high-fat ingredients be balanced against offering healthier options to the guests?  Or at the very least, offer them alternatives?

Our experience was not unique. Even with the greater sensitivity of the country as a whole to the restrictive food needs such as gluten, lactose, saturated fats, peanuts and other nuts, and all animal products of many people, it is still possible to be unable to find something to eat while traveling. A friend from India told us that when he arrived as a student in this country about 30 years ago and told people he was a vegetarian, they thought he was talking about what political party he belong to rather than his food restrictions. Fortunately, everyone now knows what a vegetarian is, although some still are not sure whether that is the same as being vegan (it is not).

Could the situation have had a different resolution? Should the website featuring the inn mention that gourmet breakfasts will be served, but those who need to restrict calories or fat or both should bring their own food?  Should we have mentioned before we arrived that we would be driving for hours that day and would have preferred eating lightly?  Was it her responsibility to make sure that her guests ate healthily or consumed calories in keeping with their day’s activities or their weight?  There are laws requiring inns to have sprinklers and well- marked fire exits in order to protect guests from fire, but so far no rules exist to protect guests from weight gain.

The answer in part is that we were guests, albeit paying ones, in her home.  The inn was not near any stores or restaurants so we were dependent on what came out of her kitchen for breakfast unless we wanted to travel for many miles to find a restaurant open in the morning.  If we had stated before we arrived that we wished to avoid unhealthy foods, this might have led to some confusion because there is so much disagreement among the public about what is healthy: bacon fat or olive oil, milk from cows, soybeans or almonds, egg yolks or tofu? So the solution (which other inns use) is to offer a variety of breakfast foods to which the guests could help themselves—at least to a couple of protein bars—even if it means throwing away an uneaten container of yogurt or an overly ripe banana.

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.