Category Archives: Tips

Excess Skin After Major Weight Loss: Might Removing It Prevent Weight Gain?

The financial officer of an organization to which I belong decided to have bariatric surgery. Bob (not his real name) needed to lose about 200 pounds and the operation, called the gastric sleeve, narrowed his stomach and decreased the production of ghrelin, a hormone that increases hunger. He lost about 190 pounds, significantly improved his food choices, and now exercises several times a week. But despite his success, and with it his improved health and energy, he told me that he was unhappy. “I had an image of myself as a thin person, which motivated me to always stick to the diet and work out. But now that I have lost all this weight, I feel encased in suit of loose skin. I have to force myself to go to the gym because I think everyone is staring at the skin hanging from arms and sagging down my thighs.  I have to buy clothing in a size too large. My loose flesh prevents me from getting my arms in the sleeves of my jacket and zipping up my pants unless my clothes are baggy.”

Bob’s problem is not unique.  Many patients who undergo bariatric surgery and are successful in losing very large amounts of weight are confronted with bodies distorted by excess skin. This is not a problem for those who lose much smaller amounts of weight. The skin regains its elasticity after being stretched, and regains its normal shape as it does, for example, after pregnancy. If large amounts of weight are lost very slowly, sometimes the skin regains its original shape, although this is less likely to occur in an older individual.

Surgery to promote rapid and massive weight loss, or extreme dieting and exercise, as seen in the television show program, “The Biggest Loser,” can leave pounds of skin behind.  Although those of us who have not gone through the massive gain and then loss of weight might view the problem as merely cosmetic and a small price to pay for the weight loss, the problem is not simply cosmetic. (“Surgical solutions to the problem of massive weight loss,” Spector J, Levine S, and Karp N, World J Gastroenterol. 2006 12: 6602–6607.) In their article describing surgical solutions to help the newly thin deal with their excess skin, Spector and his co-authors point out that patients who have large amounts of skin draped over their limbs and the torso may be in chronic pain and the skin can be easily infected.  Giodano reiterates their views in an article (“Removal of excess skin after massive weight loss: challenges and solutions,” Open Access Surgery 2015; 8: 51-60) and adds that physical impairment, including difficulty exercising or indeed even walking, and low self-esteem are some of the other problems caused by the excessive skin. Moreover, dieting and exercise are unable to bring the skin back to its original elasticity.

There is a solution. It is called body contouring, a plastic surgery that removes the skin, and by doing so, reveals the body shaped by the weight loss. Bob underwent several plastic surgical procedures over a period of many months but the results, giving him a body that finally revealed its nearly 200 pound weight loss, was attained only after a considerable cost in pain and money. He had to take time off from work, required a brief hospitalization for one procedure and, in his words, ‘”I won’t be taking a vacation for decades to pay for everything.” He justified going through this in part because he believed his professional appearance would be improved if he were able to wear clothes in the appropriate size for his weight and not to house his excess skin.  But he admitted another more personal reason: “I was afraid that I would gain back the weight because I was so disappointed in how I felt and looked. In fact, my body was so distorted that I think I looked worse than when I was obese. ”

The failure of patients undergoing bariatric surgery to maintain their weight loss beyond one year post-operatively has been reported. (“Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy,” Golomb I, Ben David M Glass A, et al JAMA Surg. 2015; 150:1051-1057.) According to the Golomb et al report, a significant amount of weight is gained relatively early, i.e., within the first few years, and many of the patients did not lose enough weight to reach their goals before they started to gain again.

However, for those who did reach their weight-loss goal like Bob, would having body-contouring surgery support their efforts to maintain their weight loss?  There is no answer. Indeed, the way to provide an answer would be to carry out a study comparing weight maintenance of patients whose excess skin is removed with patients who do not get the body contouring surgery. Both groups would receive the same nutritional counseling, personal training and psychological help so the only difference between the groups would be the removal of excess skin. Of course, the problem with such a study is that the results may show a positive effect on weight maintenance of skin removal. And then what?  The cost of such operations is almost prohibitive for most people and rarely covered by health insurance.

But perhaps this will change. Bariatric surgery is paid for by many insurance plans because studies have shown that the medical costs of obesity are much higher in the long run than the cost of the surgery. If body contouring is shown to have a significant effect on preventing weight gain after bariatric surgery, then perhaps this too will be covered by health insurance.

The better solution, of course, is to prevent the excessive weight gain necessitating the surgery.

The Silent Cause of Tiredness

Too often the response to the question “How are you?” is, “Tired.” A list of reasons justifying the fatigue usually follows: working hard and late, a household of children and/or visitors, too many outside commitments with deadlines, school papers and exams, inadequate sleep, recovering from a cold, and, of course, stress. The list could go on. Missing from this list, however, is a silent but potent cause of tiredness: iron deficiency anemia.  Iron is needed by the body to make hemoglobin, the constituent of red blood cells that transports oxygen from the lungs through the blood and delivers it to the cells. If, over a period of time, too little iron is consumed to make hemoglobin in amounts necessary to meet the needs of the body, iron deficiency anemia results.

Extreme fatigue is one of the symptoms of iron deficiency anemia, along with decreased stamina, increased vulnerability to infections, sensitivity to cold, increased heart rate and dizziness. Pale skin is also a symptom, but like so many of these signs, especially fatigue, other reasons for their presence can easily be summoned.  Many of us assume that we are suffering from some yet identified virus if we feel dizzy or out of breath climbing stairs. And, for many people, being pale in the winter is hardly considered unusual. And we often respond to our tiredness by eating. “Maybe if I eat a snack, I will feel more energetic,” we tell ourselves as we reach for a cookie or bag of chips.  We are unlikely to consider that maybe our fatigue is caused by an insufficient amount of iron in our diets. Unnoticed and unchecked, the depletion of iron stores continues to cause persistent fatigue that does not respond to more sleep or getting over a viral infection.

The National Institutes of Health Office of Dietary Supplements recommends that men and women of non-childbearing years obtain 8 mg of iron daily and 18 mg for premenopausal women. The larger requirement for women of childbearing age is based on monthly blood loss from menstruation.  Blood losses from medical conditions may also decrease iron stores. I had a neighbor who had a silent bleeding ulcer for months and was found to be severely anemic.

Iron deficiency anemia is not uncommon.  (“Iron Deficiency Anemia,” Killip S, Bennett J, Chambers M, Am Fam Physician 2007 1: 75: 671-678) According to a recent publication in the American Family Physician, “ The prevalence of iron deficiency anemia is 2 percent in adult men, 9 to 12 percent in non-Hispanic white women, and nearly 20 percent in black and Mexican-American women.” The trend toward intermittent fasting or cleanse diets may increase these numbers as a one or two-day fast cleanse diets, has been shown to rapidly deplete iron. (“Effect of short-term food restriction on iron metabolism relative well-being and depression in healthy women,” Wojciak R, Eat Weight Disord. 2014; 19:21-327)

Obtaining the necessary amount of iron from the diet is not as easy as, for example, getting enough vitamin C.  Although many foods contain iron, not all the iron in the food gets into the body. There are two types of iron: heme iron and non-heme iron. Heme iron comes from animal sources and is considered more “bioavailable” than non-heme iron. This means that the iron in the food is more able to get into the body from the intestinal tract than non-heme iron.

Liver is a good source of heme iron, but this food is not universally enjoyed (except, perhaps, by cats).  Lean meat and seafood, especially octopus, are also good sources, although the latter is also not particularly popular. Indeed, for most non-vegetarians as well as vegetarians and vegans, more of our iron comes from plant sources than animal foods.  According to the Office of Dietary Supplement report, about half of the iron we eat comes from fortified bread, cereal and other grains. In fact, cereal is a good source of iron:  one cup of bran flakes contains 4.5 mg of iron which is about half the amount men and post-menopausal women need each day. An avoidance of grain products means that the vegetarian and vegan eater must depend on obtaining iron from vegetables, lentils, dried beans, soy products like tofu, and nuts and seeds. The amount of iron in plant foods that are not fortified is low so that large quantities must be eaten each day to meet iron intake requirements, especially for women of childbearing age.  Moreover, there often is a misperception of how much iron is in the foods we think of as good sources of this mineral.

“I eat plenty of spinach and nuts,” a friend will say, “so I am not worried about getting enough iron even if I try to avoid eating meat.“  But an entire cup of cooked spinach (which is a large amount raw since it shrinks when cooked) has only 6 mg of iron. A cup of cashew nuts has 4 mg and lots of calories. Two large eggs have less than 2 mg of iron and one would have to eat an entire cup of hummus to get 5 mg of iron.

Iron in plant foods is also less “bioavailable” than the iron in animal foods. There are phytates and other substances in plant foods that grab hold of the iron and prevent much of it from being absorbed into the body from the intestinal tract. In fact, studies on the iron status of vegetarians have shown that they tend to have lower iron stores than non-vegetarians.   (“The effect of vegetarian diets on iron status in adults: A systematic review and meta-analysis,” Haider L, Schwingshackl L2, Hoffmann G3, Ekmekcioglu C ,  Crit Rev Food Sci Nutr. 2018; 58(8):1359-1374)

Fortunately, eating foods that are high in Vitamin C counteracts the effect of phytates on preventing iron from entering the body. Eating a vitamin C-rich food such as citrus fruits or juice, strawberries, broccoli, cauliflower, Brussels sprouts, and peppers including chili peppers, with an iron-containing food like oatmeal or tofu, significantly increases the absorption of iron, especially for people with low iron reserves.

However, if blood tests show that iron deficiency or iron deficiency anemia is present, it may be necessary to take an iron supplement and doing so should be under the care of a physician.  For many, this may be an easier solution than eating chopped liver or grilled octopus.  Once the problem is resolved and iron stores are back to normal, fatigue and the other symptoms of the anemia should disappear.

Chronic Lack of Sleep May Have Serious Consequences

Insomnia is a lonely and often neglected problem. This disorder may be found in 10-30 percent of the population, and perhaps higher among the elderly, females, and people with medical and mental disorders, according to the review by Bhaskar, Hemavathy and Prasad. But chronic insomnia may be neglected by family practitioners or treated inadequately. The insomniac cannot call their medical care provider at 2 or 3 a.m. after (once more) lying awake for hours and ask for the doctor for help the way one would if experiencing a medical problem during the day. Nor is waking someone up to relieve the 3 a.m. loneliness a good idea; it’s likely that the person awakened would not be good company. Moreover, since almost everyone has faced sleepiness at some point due to muscle pain, jet lag, a barking dog, or worry, we who suffer from insomnia sporadically may not realize how debilitating this condition can be when it is chronic.

Some occupations are vulnerable to sleep deprivation, either because their jobs don’t give them enough time to sleep, or because they have trouble falling asleep. Shift workers are prone to insomnia, and it may worsen when their sleep-wake cycle changes on their days off or when moving into a new work cycle. One consequence is a significantly greater occurrence of depression among shift workers compared to other groups, according to an analysis published a few years ago.

Despite the many symptoms associated with insomnia, the consensus seems to be that it is a disorder which is under-recognized and under-treated. This may be because sleep habits are not queried by the health provider, and complaints are not offered by the patient unless linked to an obvious cause for sleeplessness, such as pain, hot flushes, reflux, sleep apnea, or medication. Health providers may have neither the time nor the expertise to treat the disorder, assuming it is not related to an obvious cause . . . such as sleep apnea. Or, they may rely on pharmacological interventions to induce sleep, even though these drugs have side effects and/or limited efficacy. Sleep clinics may detect the underlying cause(s) of the sleep disturbances, but usually do not offer long-term therapeutic help.

Support groups for insomniacs exist and may provide information and help if this is not available from health providers. A.W.A.K.E., which stands for “alert well and keeping energetic,” is a national organization started years ago by the American Sleep Apnea Association to provide support for people using a new device, the PAP (positive airways pressure) machine, for sleep apnea. Currently the A.W.A.K.E program has expanded its outreach to anyone in the community with sleep problems. Other support groups helping those with specific problems that interfere with sleep, such as restless legs, are also listed on Internet sites and found throughout the country. But these groups are only as good as the information offered. Someone with serious psychological side effects from lack of sleep probably won’t find anyone in these support groups with the expertise to deal with their problems. However, one benefit may be no longer feeling isolated and lonely when sleep is elusive. Perhaps these groups, at the very least, give the insomniac the name of someone to talk to at 3 a.m.

Medical residents are another group that has been identified as vulnerable to impairments in mood and performance because of sleep deprivation. Their sleep needs are not met, because their work schedules require being “on-call” all night, after working all day. The numerous television hospital dramas with their interpersonal catastrophes fail to mention that the hospital staff may be suffering from depression, impairment of performance, and difficulties with interpersonal relationships because of inadequate sleep. The cognitive deficits associated with restricted sleep are not emphasized in these programs either, but are also a well-researched side effect.

However, emotional, cognitive, and physical impairments potentiated by sleep deprivation are not restricted to these two groups. In an article describing the results of a multi-site study testing an intervention to improve sleep, Freeman and his co-workers link a lack of sleep to clinical depression and suggest that many insomniacs experience general mental distress at their continuing failure to achieve restful sleep. Their study targeted university students whose insomnia caused paranoia and hallucinations, side effects that are probably not well known as a consequence of insomnia. The authors used an online cognitive-behavioral intervention over several weeks and compared the effects to conventional treatments for insomnia, such as medication, and suggestions about avoiding caffeine, regular bedtimes, and relaxation techniques. Despite the fact that no therapist was present in the experimental intervention, the online treatment was effective. Their intervention significantly reduced insomnia, paranoia, and hallucinations after 10 weeks, decreased depression and anxiety, and improved general well-being. What is striking about their results is that the improvements in mental and cognitive function were accomplished without drugs, and the therapy and the educational and cognitive interventions were carried out online.

References

“Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities,” Bhaskar, S, Hemavathy D and Prasad S, J Family Med Prim Care, 2016 Oct-Dec; 5(4): 780–784.

“Night Shift Work and Risk of Depression: Meta-analysis of Observational Studies,”  Lee A, Myung S-K Cho J, et al, J Korean Med Sci, 2017 32(7): 1091-1096.

“Sleep Deprivation and Depression,”  Al-Abri M, Sultan Qaboos Univ Med J, 2015; 4: 4-6.

Valentine’s Day Chocolates: It Used to Be So Uncomplicated

When Richard Cadbury decided to package chocolates in heart-shaped boxes and sell them as gifts on Valentine’s Day in 1861, the most complicated result of his brilliant idea was difficulty in choosing a particular bonbon.  Should the chocolate be filled with chocolate or vanilla cream, chocolate truffle or a cherry in a cherry liquor? No one questioned the nutritional wisdom of eating a food whose ingredients included sugar, cocoa butter, full-cream milk powder, cocoa liquor, lecithin, vanilla and cocoa. Valentine’s Day was special and so was chocolate.

Jumping ahead many decades, chocolate Valentine’s Day gifts now have to be compatible with contemporary attitudes toward food. Chocolate itself has been clothed with health-giving properties; the darker, and often the more bitter, the better. Whatever ingredients chocolate contains to make it a health-giving food however, the amounts are really too small to make much of a difference (unless one eats a 3 ½ ounce chocolate bar containing a few hundred calories daily). But endowing chocolate with the same positive nutritional properties as say, kale…takes away the guilt at enjoying the delectable calories.

The most obvious nutritional hazard is the calories. Who should receive chocolates? Someone who is very thin? She or he probably wouldn’t eat them because it might cause weight gain. Someone who needs to lose weight? The gift conveys the message that the recipient is fat so what difference does it make if the gift makes her or him fatter. Is the giver saying, “I like you fat, so eat these chocolates?”

And then there are those whose personal eating profile makes eating a combination of sugar and fat problematic, so the type of chocolate edible presented as a gift might actually carry health risks. For example, there are many people these days with no tolerance for gluten or other chemicals found in grains, such as wheat and barley. There are others who cannot eat sugar, and still more who have embarked on a diet eliminating all carbohydrates.  None of these people can be the recipient of baked goods made with conventional wheat flour and, for some, sugar.

A friend of mine was in a quandary because she was making a special Valentine’s Day dinner for friends and learned that one of them was on a gluten-free regimen. However, he could eat small amounts of sugar. She searched the Internet for a flour-free chocolate cake and found a recipe with very positive reviews. Her only concern, as she told me later, was the combination of ingredients that made her wonder if she ought to have an EMT standing by when she served the cake.  She said, “I laid all the ingredients on the counter: two sticks of butter, six eggs, two cups of gourmet chocolate chips, sugar, and vanilla, and really thought aborting the recipe. I like this guy and didn’t want to send his cholesterol through the roof.”  She made the cake, which was delicious. She decided to serve such small portions that the heart-unfriendly ingredients couldn’t do much harm.

Since the gluten-sensitive guest could eat sugar and other carbohydrates, theoretically a Valentine’s dessert could have used ingredients like almond, rice or coconut flour. But what about those advocates of a totally carbohydrate-free way of eating? The so-called keto folk avoid carbohydrates entirely because they want their bodies to stop using glucose for energy and switch to using a byproduct of fat instead. Any morsel of carbohydrate that crosses their lips will cause the body to revert back to glucose. What is the giver of an edible Valentine gift going to do? Answer: Find or make foods that are mainly fat and sugar substitutes.

The popular keto diet limits the options, although not the calories. This diet forbids its users to eat carbohydrates in order to coerce the body into using a part of the fat molecule, fatty acids, for energy. These are converted into substances called ketones, and they supply energy formerly supplied by the natural source of energy in the body, glucose. The other half of the fat molecule, glycerol, is converted to glucose (don’t tell anyone) to be used for energy by the brain, which much prefers glucose to fat.  People on the keto diet may not know that this glucose is chemically identical to the glucose in chocolate or bran flakes or oatmeal when these foods are digested in the intestinal tract. What is worrisome about restricting intake to foods with little carbohydrate is that in addition to eliminating most of the fruits, vegetables, and high-fiber carbohydrates we should be eating, the foods can be extremely high in fat and calories. The Valentine Day’s keto edibles are a striking example.

Cheesecake sheathed in a chocolate shell, or drizzled with chocolate, is available commercially and as cheesecake itself is mainly cream cheese and sour cream (and in this case artificial sweetener), its high fat, sugar-free content makes it perfect for a keto Valentine food.  Peanut butter chocolate chip cookie dough works for all sorts of diets (raw, vegan, Paleo, gluten-free, sugar-free, grain-free) and looks like it would also be appropriate…but is not because it contains too much carbohydrate in the form coconut flour and almond flour. Most keto diet acceptable Valentine gifts have to be homemade and, like the flourless chocolate cake, may spread the waist while spreading love.  A chocolate truffle is made from cream cheese, cocoa powder and whipping cream. Chocolate hearts are made from coconut oil and cocoa powder, with artificial sweetener. Dipping bacon strips in chocolate makes a Valentine breakfast for your keto sweetheart’s breakfast or, if you live in England, you can buy a heart-shaped sausage from Marks and Spencer for the breakfast table.

Somehow these recipes don’t convey the traditional appeal of the old-fashioned Cadbury heart- shaped box and its many imitators.  Valentine’s Day was never meant to be celebrated by eating various cream cheese-based foods.

By definition, Valentine’ Day is a sweet holiday with a message of friendship, affection and love. Wouldn’t it be nice if we could take this day of uncomplicated messages to uncomplicate our dietary profiles as well? No one in 1861 receiving the first heart-shaped boxes of chocolate had to worry about whether eating the chocolates would throw the body into some sort of metabolic disaster. And why today should a person deciding what chocolate gift to buy for his or her sweetheart have to think about the food idiosyncrasies of the recipient?  Maybe, just as one hopes messages of friendship and love are not limited to February 14, one also hopes that a reasonable approach to eating can extend beyond the day as well.  Unless one has a medical reason to avoid certain foods, couldn’t we decide that foods that bring such pleasure and are associated with such positive emotions be allowed? After all, we don’t limit romance and love to one day. Why should we limit a piece of chocolate to one day either?

 

Getting Nutrients from Food is So Old-Fashioned: Try an Intravenous Drip Instead!

I looked at the remaining drugstore-brand vitamin pills in the container and wondered whether I ought to continue taking them. A few days ago, an advertisement from a local plastic surgery/wellness/anti-aging spa offered a reduced rate for a procedure in which I could get an intravenous of vitamins and minerals.  According to the blurb that accompanied the offer, the “drip” would allow these essential nutrients to bypass my stomach and intestinal tract, and go directly into my blood thus avoiding the risk of some nutrients not being fully absorbed or altered by the digestive process. The promotional material promised an enhanced glow to my skin, better sleep, and increased energy.

A quick search on the Internet revealed that the intravenous procedures offered by this spa will be the “new” health procedure this year and to expect to see these “drip” spas becoming as ubiquitous as nail salons.  The benefits of receiving a vitamin-mineral infusion a couple of times a week were compelling, according to the web site advertisements. One company calls its preparation a, “brain booster” and recommends its infusion before examinations (studying might help also). Improving immune function is a standard objective of most of the vitamin -mineral infusions, although none of these clinics said to skip getting the flu vaccine. What if someone with the flu comes into the spa to boost immunity?  Should they get the vitamin infusion or go home to bed? This was not addressed.

Someone who really hates vegetables, rarely eats fruits, and dislikes swallowing vitamin pills might welcome the chance to lie on a recliner, listen to soft music and have vitamins and minerals pumped into his or her body every few days. Throw in a pedicure and it is a perfect day of self-renewal.  But why would someone want another type of infusion offered by this spa, namely an infusion of amino acids?  Amino acids are in every protein we eat, and the only people who might need an extraneous source of amino acids are those whose medical condition such as stomach cancer or severe gastrointestinal disease makes digesting protein difficult.  Vegan diets limit protein to plant sources of protein, and some foods may lack adequate amounts of specific amino acids. But so far, vegans have not been advised to skip the quinoa, and instead get an infusion of amino acids.

On the other hand, getting essential nutrients without relying on food might appeal to someone attempting to maintain a pathologically low weight (models, for example). The infusions of vitamins, minerals and amino acids would be a big improvement over a diet of calorie-free soda and cigarettes.

But of course going to infusion spas rather than eating is not sustainable or sensible. There is no provision for an energy source; no infusions of glucose or fat are provided by these clinics.  And it is absurd to equate the nutritional value of a synthetic mixture of vitamins and minerals with the nutritional complexity of micronutrients in food.

But what is disturbing about these spas/clinics offering these nutrient drips is that they are making the same spurious claims that health food restaurants have been making for years.  There is a popular health food restaurant near me promising everything except immortality for their smoothies. A neighbor told us that he did not get the flu vaccine because of one of the smoothies claimed to confer resistance to the flu virus.

A quick scan of some Internet sites promoting nutrient infusions seem to be making similar claims.  Some intravenous clinics offer a seemingly random assortment of amino acids, minerals and vitamins to overcome depression, halt compulsive behavior, improve sleep, decrease the symptoms of mental disorders like bipolar disorder, prevent the symptoms of PMS, help smoking cessation, and of course, weight loss.

These infusion bags of health have about as much scientific validity as products sold by so-called snake oil hucksters who promised their powders and drinks would cure everything. One could shrug off the IV spas as harmless, but they aren’t. The client would not know whether the amounts of vitamins or specific amino acid or minerals are in the range of safe intake, the client would not know if any medication he or she is taking might be adversely affected by these infusions, and whether he or she might experience side effects. When vitamins, minerals and amino acids enter the body by mouth, they slowly enter the body and some of the nutrients may not make it out of the digestive tract into the blood stream. So the dose of vitamins, for example, that gets into the body by mouth tends to be smaller than when coming from an intravenous solution. Moreover, does the client know how much of the vitamins, minerals, and amino acids are retained by the body or eliminated through the urine?  Are the people formulating the solutions medically knowledgeable about the diseases they are supposedly treating? Would they offer medical care if the solutions have no benefit? Do these clinics use licensed personnel to administer the drip? Is the environment sterile to avoid contamination? If someone has an adverse response like a severe allergic response, is there a medical team to handle this?

The most serious aspect of these heathy drips is that there is no validity to their claims, and in some cases, may prevent people from seeking credible medical help. No one is going to lose weight or relieve the symptoms of obsessive-compulsive disorder or bipolar disorder with a drip of some vitamins and an amino acid. Relying on the “magic” of these drips, rather than interventions with scientific evidence supporting their utility, may work only because of a strong placebo effect. And if it does, that is fine. However, if we have truth in advertising, then the drips ought to be labeled “placebo” so the client knows what he or she is getting.

Give Yourself the Gift of Energy

Fatigue seems to be as ubiquitous as complaints about the weather. But it is especially prevalent during the holidays for obvious and not so obvious reasons. The obvious:  buying, wrapping and sending presents, food shopping and preparation, decorating the house, travel or hosting guests, and so forth.  The not so obvious is the inescapable darkness of this time of year. When the sun is gone by 4pm in some parts of the country (and certainly by 5:30 in other parts) it is hard not to feel that bedtime is not so very far away. In addition, an all-encompassing fatigue is one of the symptoms of the winter blues that many experience during the late fall and winter.

Regardless of its cause, fatigue diminishes our productivity and takes away the pleasure we might have in what we have produced. If after shopping, cooking, decorating, buying and sending gifts, the holiday event you have worked so hard to bring about is just ‘… one more thing to do’, then fatigue has taken away your pleasure.

Recognizing that you will probably be more tired than usual is the first step in reducing the fatigue. Getting enough sleep is not only an obvious way of preventing exhaustion, doing so has been shown in countless studies to enhance both physical and mental performance. You would not want a neurosurgeon to perform an operation on you, or have your pilot fly you across the Atlantic with inadequate sleep. Staying up later or waking up earlier than your body’s normal sleep timetable may not allow you to accomplish as much as you want, or as well as you want, because of diminished cognition.

Planning rest intervals of only a few minutes throughout a day of endless tasks will also relieve tiredness. These rest periods are sort of like sitting on a rock or log during a long hike, drinking water and looking at the scenery.  Time-outs from the endless doing will give you energy to continue, just as sitting for a few minutes during the hike gives you the stamina to continue.

Avoid eating high fat foods, as these may cause you to feel sluggish. A double bacon cheeseburger with a fat filled sauce and French fries may seem just the food to restore your energy. Unfortunately they will leave you with just about enough energy to crawl onto a sofa for a nap. Stick to vegetables, fruits, lean proteins like fish, chicken, low fat yogurt, and fiber filled carbohydrates like whole grain breads. These low and no fat foods will nourish you, and not leaving you feeling like a zombie.

Drink plenty of water.  Indoor heat can be dehydrating, and even though you may not feel thirsty the way you did during the summer, your body still needs water.  Not getting enough liquids will only add to your fatigue.

Late afternoon is perhaps the most fatiguing time of all. Many people experience a deterioration in their energy levels and mood around 4 or 5 pm, regardless of how busy they are, and this is particularly true if the sun has already set. Decreases in serotonin may be one cause of the fatigue, along with a decrease in blood caffeine when that cup of coffee was consumed hours earlier.  Eating a small starchy, low or fat-free snack such as pretzels, bagel thins, rice cakes or breakfast cereal increases serotonin within 30 or so minutes, restores mental energy and improves mood. The snack should contain about 30 grams of carbohydrate (read food label) and have no more than 2-3 grams of protein, as protein prevents serotonin from being made. If drinking a caffeinated beverage will not delay your sleep onset later on, then a cup of tea or coffee, along with carbohydrate, will give you an energy boost that should last for a few more hours. Think of this as an English tea.

Exercise has an amazing restorative power. The common excuse about not doing any physical activity is that is since one is already tired, how can becoming more tired (through exercise) make one less tired? It does seem paradoxical, but it works. Moving the blood more quickly through the body, heating up the body through vigorous movement, oxygenating the blood with deeper breathing; these all may contribute to the clearing of the head and invigorating the muscles.

But taking the time to go to a gym, exercise class or indoor swimming pool may seem totally incompatible with an overcommitted schedule. There are two ways of dealing with this: One is to put the word exercise on the ‘to do’ list or day’s calendar, and give it the same prominence as a dentist appointment or a meeting with your child’s teacher.  Go to the exercise class or meet a friend for a walk or take your dog for a long walk at least a few times a week. The second option is to incorporate short bouts of exercise into the day. Avoid elevators. Take the stairs even if you are loaded down with packages. Walk, don’t drive to do an errand several blocks away. Use an exercise app that puts your body through a workout in 7-10 minutes. This is a good option for those days (weeks) when the weather makes outdoor exercise unendurable.

Find a place where you can be alone, where you can withdraw from the demands around you. You may have to put a “Do not Disturb “ sign on the door or a “Back in 10“ sign on the outside of the room where you retreated. Use the room when you feel that you must have a respite from everything going on around you. Sit or lie down, meditate if you can, do some stretching exercises, listen to music, or the radio or television, read a magazine or a few pages of an engrossing book. When you emerge, you will notice that your energy has returned. Perhaps not as much as you want, but you will be able to continue getting through the rest of your list.

If your fatigue is exacerbated by the decreasing hours of daylight, consider using a sun or light box. These devices contain lights that mimic the spectrum of the sun.  Studies over the last thirty years have shown that early more exposure to these lights seems to decrease the symptoms of winter depression, including intense tiredness.

Finally? Laugh. There is nothing so energizing as being with friends or family and hearing a funny story. Failing that, try watching some of the home videos on television. They will also drive away your fatigue.

 

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.