Category Archives: Tips

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.

Distinguishing Fact from Fiction in Supplement Claims

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until that occurs, let the user be cautious.

The Unfortunate Association Between Pain and Obesity

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

Thus more pain is experienced.

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

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

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

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

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

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

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

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

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

Do Those With Psychiatric Diagnoses Get Enough Medical Care?

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

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

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

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

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

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

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

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

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

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

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