Category Archives: Bad mood

Opportunistic Eating and Eater’s Remorse

If we had a miniature camera mounted on our wrist or forehead that recorded every time we put food in our mouths, we probably would be shocked at the number of times we eat each day. To be sure, meal eating is usually remembered even if we can’t recall what we had for breakfast or lunch yesterday, or what vegetable, if any, we ate with dinner. But when we nibble food we had no intention of eating, but ate anyway simply because it was there, we rarely remember doing so.

A few weeks ago, I was sitting with a group of women at a luncheon listening to a panel discussion. At the beginning of the discussion, a platter of bakery cookies on the table was untouched by my largely weight-conscious table companions. But as time and boredom increased, one by one, the women reached for and ate the cookies. When the speeches were over, the cookies were gone, and probably the memory of eating them gone as well.

This cookie consumption is an example of opportunistic eating—that is, the unplanned consumption of food just because it is available. Anyone who has a dog or cat knows that if a tasty morsel falls on the floor, the opportunity to eat it is seized by one’s pet. We humans do the same, although the food is usually in a bowl or platter, and not on the floor. My doctor’s office has a large glass bowl filled with wrapped chocolates on the counter in front of the receptionist. It is very difficult to resist the temptation to reach in and take one while checking in or out for an appointment. Supermarkets set up tables to offer tiny morsels of a product the food manufacturer wants the shopper to buy. The food is rarely refused; the area near the table is congested with shopping carts as people stop their shopping in order to sample this free food. A local ice cream shop announces a two-for-one ice cream cone sale on the anniversary of its opening. Pedestrians stop and go inside, even though before they saw the sign they had no intention of having ice cream. But who can pass up the opportunity to get a free ice cream cone? Leftovers from a farewell party are left on the counter of the office kitchen, and the next morning are quickly eaten by people coming in to make their morning coffee. They hadn’t planned on having sheet cake for breakfast, but it was there to be eaten.

All of us who have fallen prey to opportunistic eating are on, albeit temporarily, the See Food Diet (I see it, I eat it). But our degree of vulnerability differs. This has been tested in a study that under the guise of testing a new consumer product, offered chocolates to subjects who recently finished a meal and were not hungry. Not surprisingly, subjects with less self-control ate more than those who exerted some restraint over their food intake.

A similar study was done, again with chocolate, in which subjects were asked to eat chocolate until they were so full they could not eat anymore and then…they were given the chance to start eating again. Those who did had a higher BMI and on psychological tests had a greater degree of impulsivity.

Dieters and non-dieters alike fall prey to opportunistic eating. Often the act of eating is more of a reflex than a conscious act. We walk past a bowl of nuts or chips and, grabbing a handful, munch on the food without perceiving what we are doing. Our mind is on something else. Stopping for fried dough or a sausage and pepper roll while strolling through the street fair becomes part of the total experience, and may be remembered only if some intestinal discomfort occurs afterward. Finding a ten-dollar bill on the sidewalk is memorable. Finding and then eating cookies left on a plate in the office kitchen is not.

Sometimes opportunistic eating takes the guise of being served larger portions than anticipated, especially in restaurants. Although some diners would view a soup tureen filled with pasta, or half a roasted chicken spread over a small hill of mashed potatoes, as cause for horror (“How can I possibly eat this? I’d better take most of it home; maybe someone will share it with me?”), others will justify eating the entire portion because of the opportunity to do so. There will be no guilt or attempt at self-restraint, because the humongous-size portion wasn’t requested, but came as a gift.

Tracking the unneeded calories from opportunistic eating is a challenge. If one is eating mindlessly, noticing and recording what is eaten is rarely done. Often the opportunistic eater is aware of having eaten more than intended only when on a scale.

Even though it is difficult, the only way to prevent weight from being gained or weight loss being slowed is to avoid, totally, opportunistic eating. “Out of sight, out of mouth” works to remove temptation at home and in the workplace.  Removing bowls of nuts or candy or plates of cookies or leftover cake or pie from sight prevents them from being eaten. But it is impossible to remove entirely from our environment the presence of food and the spontaneous chance to eat it. Thus, the only other recourse is to use self-discipline. It is hard, but there are many who exert this type of self-discipline all the time. They may need to avoid foods that might contain allergens, or are not allowed for medical, religious, or dietary reasons.

Avoiding opportunistic eating avoids eater’s remorse. You may not have noticed or remembered what you ate, but you can be sure the scale does.

References

“Unintentional eating. What determines Goal-incongruent chocolate consumption?” Allan J, Johnston M, Campbell N, Appetite 2010, 54:  422-425.

“Psychological predictors of opportunistic snacking in the absence of hunger,” Fay S, White M, Finlayson G, and King N, Eat Behav 2015; 18: 156-159.

The Unhappy Consequence of Not Being Able to Exercise

I knew she was going to become depressed. The email she sent said that her doctor said no tennis, swimming, golf, or rapid walking until the wound on her leg healed. She had fallen off her bike, the wound became infected, and a short healing time turned into weeks.

“I don’t know what to do with myself,” she  wrote.  “I am irritable, worried, depressed and anxious.  This is the longest I have gone without any physical activity.”

She exercised all her life, and has a master’s degree in exercise physiology. Her outside activity used to change with the seasons, but now that she had traded life in a cold European country for the warmth of Florida, she had been able to engage in outside physical activity year-round. But, for the time being, she could only prop up her leg and hope the healing would occur quickly .

My friend’s mood changes are well known among  committed exercisers who must stop exercising.  Magazines devoted to particular sports, such as running, devote columns to alternate types of exercise while recovering from an injury sustained during a race, for example. And the Internet is replete with articles, blogs and anecdotes written by those who find themselves unable to pursue their sport because some part of their body has been injured.   Moreover, many research studies have been carried out quantify, to some extent, the degree of mood changes brought on by experimentally-induced cessation of exercise.

In an experiment designed to see whether runners really do experience mood changes when they stop running, forty male runners who ran regularly were divided into two groups. One group was allowed to run during the six weeks of the study, and the other group was not allowed to run for two weeks in the middle of the study. Depression and other mood states were rated weekly and confirmed what my friend and others have experienced.  Depression, anxiety, insomnia and general stress were elevated during the non-running weeks among the runners. When they were allowed to go back to running during the last two weeks of the study, their moods were the same as the group that never stopped running.

Similar findings were reported among 40 women who engaged in aerobic exercise regularly and were told to stop their aerobic activity. Their moods were compared to a placebo group that had continued to exercise.  Those who abstained from exercise exhibited depressed mood and increased fatigue compared with those who did not stop their physical activity…And these below-listed studies are a small example of many that have been published.

And yet, exercise withdrawal due to injury, or other factors such as caring for a sick parent or child, overwhelming work obligations, prolonged adverse weather conditions, and numerous other life events, may be overlooked as a cause of significant changes in mood. Mental health professionals recognize exercise addiction and the mood changes that occur when the exercise is stopped, either due to injury or because the amount of exercise is pathological. But my friend exemplifies an individual who is not addicted to physical activity but does it, like brushing her teeth, as part of her daily routine. Indeed, soon after we spoke, another friend who had a surgical procedure on her leg called to tell me that she was “going crazy” because she was not allowed to swim until the surgical wound was healed.

“What am I going to do?” she almost wailed to me on the phone. “How can I survive without swimming?”

How many primary care physicians inquire about change in exercise patterns when investigating depressed or anxious mood, or increased fatigue in a patient?  Would it even occur to many (unless they also exercised regularly) to ask about changes in activity? Or when a physician tells a patient that he or she can’t run, or go to a gym, or play tennis, or walk quickly for several weeks, is there any thought given to the impact of such prohibition on the mood of the patient?

Conversations about exercise focus heavily on the benefit of physical activity on mood, weight loss, sleep, cognition, and on and on to convince those who would rather sit than walk on a treadmill to start to move for their health. But has enough attention been paid to helping patients deal with the mood and energy changes that occur when it must cease for a period of time?

One problem is understanding why stopping consistent exercise should have such a negative effect on general well-being.  Many who have experienced the inability to exercise for a period of time often cite an increase in stress and worry that no longer can be dampened by vigorous activity. Exercise allowed them to cope; without it, they must seek out alternatives and often don’t find them.  But what is it about running or biking or swimming or working out in a gym that allows our brains to increase their coping skills? Moreover, even when we find out the answer beyond such things as endorphins—which not everyone experiences, and certainly not all the time—the problem remains: what to do until exercise can begin again?

Magazine articles, Internet chatter and blogs offer some suggestions, but what about professional help? Shouldn’t a patient who is told, “No exercise for X weeks!” be referred to a physical therapist to learn what physical activity can be done? My non-swimming friend did learn from a physical therapist that she could do Yoga and Pilates; my other friend decided to do upper body strength training. When I last checked, both were considerably less grumpy.

 

 

 

“Effects of temporary withdrawal from regular running,” Morris, M, Steinberg, E , Syeks A et al,  J of Psychosomatic Res. 1990; 34: 493-500.

“Depressive mood symptoms and fatigue after exercise withdrawal: the potential role of decreased fitness,”  Berlin A,1, Kop W,, Deuster P,. Psychosom Med. 2006 Mar-Apr;68(2):224-30.

“Mental health consequences of exercise withdrawal: A systematic review,” Weinstein A, Koehmstedt C and Kop W,. General Hospital Psychiatry 2017; 49:11-18.

 

PMS Carbohydrate Craving and Personalized Weight Loss Plans

There is much talk these days about developing a personalized diet based on DNA analysis, lifestyle, food sensitivities, and the use of apps alerting a dieter to situations that might derail a diet. However, in developing an overeating profile, is enough attention being given to a condition that causes some women to eat foods that are expressively forbidden on their diets? Does the eating profile include the information that this condition occurs every month, often for five days or longer? Does the eating control app have in its database knowledge that if the dieter does not get the food she craves during that time she may become very angry, may even delete the app from her phone, or that cognitive changes may make her misplace the cell phone? This monthly change is premenstrual syndrome (“PMS”), and unfortunately, it may be overlooked or marginalized when planning an individualized food plan. Indeed, if the wrong foods are on the food plan, the dieter may find her symptoms worsening and her ability to stay on a diet eroded.

PMS is associated with a change in hormones that occurs in the luteal, or second half, of the menstrual cycle. Estrogen levels begin to decrease and progesterone to increase soon after day 14 or so of the cycle. PMS typically appears a few days before menstruation and can suddenly alter mood, sleep, energy, concentration, and food cravings. Not all women experience PMS; the severity of the symptoms vary from barely noticeable to hampering daily life. Women who experience PMS may not experience it every month and with the same degree of severity. The most severe form is called premenstrual dysphoric disorder and is similar to clinical depression except, unlike a typical depression, it goes away by the beginning of the next menstrual cycle. PMDD, as it is called, is often treated with anti-depressants.

Craving chocolate is commonly associated with PMS and is not to be taken lightly as anecdotes describe women braving blizzards to get a chocolate bar. However, the cravings encompass both sweet and salty crunchy carbohydrates. A weight-loss client told me, “I did not know I was premenstrual until I returned home from my weekly grocery shopping with bags of cookies, ice cream, chips, hot fudge sauce, and packaged cupcakes. My husband asked me why I hadn’t bought any real food, and I told him this was what I wanted to eat. I got my period the next day.”

Several years ago, we were able to admit normal weight women with PMS to our MIT clinical research center to evaluate their mood and directly measure what they were eating when they were at the beginning of their menstrual cycle. We then would evaluate three weeks later when they had PMS. Food was provided in pre-measured servings at meals, and a computerized vending machine allowed the women to obtain protein-rich snacks such as cold cuts and cheese, as well as sweet and starchy snacks such as cookies and potato chips between meals and in the evening. When these normal-weight women were premenstrual, their calorie intake increased by more than 1100 calories a day, compared to the first half of their menstrual cycle — and the calories came from carbohydrate meals and snack foods.

Because all of these women were active and did not overeat when they were not premenstrual, their weight remained stable. However, if they had been trying to lose weight, the obvious response in developing a personalized weight-loss plan would be to insist on cutting out carbohydrates. Indeed, it seems obvious that if they had been on a low-carbohydrate diet, PMS would not have affected their food intake, because carbs would not have been allowed.

Perhaps. But eliminating carbohydrates would have affected their mood, and done so negatively.

Our research team discovered that the deterioration in mood, energy, focus and control over carbohydrate intake was due to alternation in serotonin activity, probably caused by the shift in hormones at the end of the menstrual cycle. Our research was involved in the first use of an antidepressant (Sarafem) that increased serotonin activity to relieve the symptoms of severe PMS.

Women with PMS apparently crave both sweet and starchy carbohydrates because their consumption will increase the level of serotonin. Eating carbohydrates is a natural solution to easing the deterioration of mood, energy, and concentration. A two-year study on the effects of a carbohydrate-rich drink on these symptoms of PMS showed this to be the case. The small amount of carbohydrate in the drink decreased cravings for carbohydrate snack foods significantly. When the women were given a drink containing protein, the PMS symptoms were intense including alterations in cognitive function.

The test carbohydrate beverage used in our study was fat and protein-free, and thus its calories came only from a combination of a simple sugar, glucose, and a mixture of starchy carbohydrates. Some breakfast cereals could easily be substitutes for our drink with their sprinkling of sugar on a high-fiber, starchy crunchy square or flake.

Eliminating carbohydrates, as is still the fashion in many weight-loss plans, overlooks a significant connection between this nutrient and brain function. The brain needs carbohydrates to be consumed to maintain serotonin levels and activities, especially when hormonal changes decrease such activity. In short, to remove carbohydrates in the interest of weight loss may be akin to tampering with nature.

References

Wurtman J, Brzezinski A, Wurtman R, and LaFerrerre B, , “Effect of nutrient intake on premenstrual depression,” Am J of Obstetrics and Gynecology l989; 161(5): 1228-1234

Brzezinski, A, Wurtman J, Wurtman R, Gleason R, Greenfield J, and Nader T D, “Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression,” Obstetrics and Gynecology l990; 76: (2) 296-391

Sayegh R, Schiff I, Wurtman J, Spiers P, McDermott J, and Wurtman R, “The effect of a carbohydrate-rich beverage on mood, appetite and cognitive function in women with premenstrual syndrome,” Obstetrics and Gynecology 1995; 86: 520-528.

Might Physical Activity Be as Effective as Antidepressants?

The well-known recommendation to exercise in order to relieve and/or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and obesity, as well as decrease vulnerability to diabetes, heart disease, and cancer. That is an awful lot to ask of a daily bout of physical activity.

However, many studies over the past several decades have confirmed the positive relationship between exercise and an array of health effects. Exercise is not going to prevent anyone from eventually exiting this world, but engaging in physical activity may make us more healthy while we are still in it.

Studies over the past decade on exercise and mental disorders have added another benefit to consistent physical activity: Depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Craft and Perna published an extensive review of studies on whether or not exercise might have a therapeutic role in clinical depression. The ability of depressed patients to carry out physical work has been shown to be significantly impaired, and they are less fit than the general population, according to some studies cited in the article. It is not hard to find reasons for the diminished physical well-being. Depression is often accompanied by fatigue, social withdrawal, sleep disturbances, and the side effects of antidepressants include dizziness, nausea, and even weight gain. These factors may make engaging in routine physical activity difficult, unless there is outside support to do so.

In a typical study to see whether exercise might be beneficial not just in improving physical status but also in relieving the symptom of depression, the patients are enrolled in an exercise program, walking three or four times a week, for example, or doing resistance training. The severity of their depression is compared with a control group of patients who do not exercise but engage in some other type of intervention so they receive the same amount of care and attention from the research staff. The results have been consistent study after study: Exercise has a positive effect on depression.

In one particularly compelling study, the effect of exercise over 16 weeks was compared with the effect of an antidepressant (sertraline) alone and with sertraline and exercise. About two-thirds of the patients in each group went into remission after the four-month testing period. The results indicate that exercise alone was as effective as the medication alone or medication plus exercise in relieving the depression.

If exercise is treated like any other therapeutic intervention, it is important to determine the most effective dose, timing, and type, as one would with medication. Walking slowly on a treadmill versus jogging or resistance training once a week, or four times a week, are some of the variables that have to be examined. Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight, or does this make any difference? Might yoga or other group exercise be more beneficial than solitary workouts, or a walk, because they diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressant therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect; should the patient wait the same amount of time to see whether exercise relieves symptoms?

These questions can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat the patients? Therapists are rarely, if ever, also trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain, but how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help/motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Visits to a psychotherapist and medication may be paid for now in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness, and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness, in addition to relieving the symptoms of depression without the side effects of drugs, cannot be overestimated. Now is the time to figure out how to apply this knowledge.

References

“The Benefits of Exercise for the Clinically Depressed,” Craft L and Perna F, Prim Care Companion J Clin Psychiatry. 2004; 6(3): 104–111.

“Effects of exercise training on older patients with major depression,” Blumenthal JA, Babyak MA, and Moore KA. et al. Arch Intern Med. 1999 159:2349–2356

The Social Isolation of a Painful Disease

We visited B for the first time in three years because of our infrequent trips to the country in which she lives, thousands of miles and several time zones away from us. Emails and phone calls had informed us of her worsening fibromyalgia, but we were not prepared for the almost total isolation imposed by her chronic pain. She has trouble walking because of pain in her legs, and simple movements, such as getting up from a chair or climbing a flight of stairs, are difficult or on some days impossible. Plans to socialize with friends or attend a lecture at the university where she used to be a professor are often canceled, she told us, due to overwhelming fatigue.

Fibromyalgia is a disease that seemed to defy diagnosis or categorization for decades, because no objective measurements, such as blood tests or scans, revealed the source of the symptoms. An advertisement for a drug to relieve the pain of fibromyalgia demonstrates the hidden nature of the disease: A woman tells us that we might assume she is perfectly healthy, because there are no outward signs of her symptoms, yet she is in constant pain.

Fortunately, the medical community has now accepted fibromyalgia as a real disease with multiple symptoms. The most common is pain that seems to migrate almost randomly around the body, affecting soft tissue, tendons, ligaments, and muscle. However, patients may experience severe migraines, sleep disturbances, mood and cognitive disorders, gastrointestinal disturbances, and fatigue.

It is not clear what causes the disease or why pain is felt when there is no visible injury, inflammation, infection, or sign of any other cause, such as cancer. Now researchers are investigating whether the pain is not due to some injury or other disorder within the body, but rather to inappropriate messages from centers in the brain that signal the presence of pain.

One therapeutic approach has been the use of drugs which activate neurotransmitters such as serotonin and norepinephrine to see if they can counteract the pain signals from the brain. But the drugs are not always effective and have their own side effects. Presently, a multifaceted therapeutic approach is advised, incorporating psychological counseling, cognitive-behavioral therapy, meditation, exercise, and reducing sleep disturbances.

However, these interventions are not always successful. Our friend swam and did exercises in the water for two years with no improvement. Now an exercise physiologist trained to work with fibromyalgia patients is available to help her exercise twice a week, but the sessions are often canceled because the intensity of her pain makes any type of exercise too difficult.

Physicians and other health professionals have not been able to find any effective intervention to allow this once-vibrant woman to return to her former active life. She taught university-level courses, turned her research into highly regarded books, and was active in an organization that worked with disadvantaged children. Now, most of her days are spent alone in her apartment with a part-time caretaker. Her friends have dropped away, not because they don’t want to be with her, but because her pain makes it difficult for her to be social. Her hands hurt too much to text or email or engage in social media, and she finds it hard to carry on phone conversations. We don’t know how much our visit cost her in pain. Because we had traveled so far to see her, she never revealed to us, honestly, how she was feeling.

And yet it was apparent that having visitors who made a point of not focusing the entire conversation on her disease had a positive effect. We amused her with some interesting gossip, engaged her in a political discussion that we knew would animate her, shared memories of a time when we lived in the same city, and talked about her research.

Did her pain recede as a result? We never asked, but the energy she summoned several minutes into our visit seemed to indicate that perhaps her pain was not taking over her life at that time.

Sadly, we had to leave her and return home, promising not to wait so long before we made the trip again. But our visit pointed out how a chronically painful disease reduces the quality of life and in particular the loss of human contact. And it is not obvious what can be done. It is hard to spend time with someone who is in constant pain; we don’t know what to say, how to help, or how to understand what they are feeling unless we have had similar experiences. We fear that we may be causing the patient more stress by forcing her to put on a cheerful face and chitchat with us as if nothing is wrong when we all know that she is deeply distressed. Sometimes it’s easier to stay away.

But we shouldn’t stay away. We should not allow the pain and other symptoms, such as sleep disturbances, limit our visits with the patient. If we allow this to happen, then we are allowing the disease to replace our relationships.

When we saw our friend, it was apparent that once we stopped talking about her disease and switched to topics that have consumed our mutual interests for decades, she seemed to focus less on her pain and more on engaging with us in discussing the interests we had shared for many years. Indeed, at some point, we all forgot about the fibromyalgia and simply remembered how good it was to be with each other.

Perhaps social contact should be added to the top of the long list of interventions for this disease. Pain may be present, whether the patient is alone or with others. But when others are around, good conversations, laughter, stories, arguments, etc., may prove an invaluable distraction from the pain. It may not always work; pain may cause social interactions to be delayed or canceled. But it is important to try, because the rewards of seeing a friend or family member relieved of chronic pain, even temporarily, are immense.

References

Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. JAMA 1987; 257:2782.

Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health 2009; 9:402.

Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014; 311:1547.

Does Your Mood Fall Before the Leaves Do?

When fall officially arrives on September 22, the number of hours of daylight and darkness are equal. As we proceed further into fall and early winter, hours of darkness overtake those of light, and a well-rehearsed (because we sing this every year) chorus of “It is so dark in the afternoon!” will be heard.  By the end of November, the refrain of, “It’s so depressing!” is added to our song of complaint.

And every year, even before the leaves change color, we noticed changes in energy, appetite, sleep and mood. At first, these changes are hardly noticeable: sleeping a little longer, disinterest in new activities or commitments, feeling tired, craving for starchy comfort foods rather than large salad, and a bit of irritability, annoyance, impatience, and gloominess. That’s seasonal affective disorder, SAD or the winter blues,  arriving.

This seasonal disorder with its symptoms of overeating, fatigue, sleepiness, and grumpy mood is provoked by a decline in hours of daylight. Inhabitants of our northern states are more vulnerable than those in the south because the southern states have more daylight in the late fall and winter. For example, on  December 21, the first day of winter, Chicago has a little over 9 hours of daylight; Key West, Florida, 10 and a half hours.  The symptoms of SAD are not weather related (although there is a variant called summer SAD that seems to be linked to heat and humidity). Indeed, the early symptoms may begin during the early days of fall with its sunny crisp days, and naturally cool nights.

SAD was first described in the mid-l980s, but not much more is known today about how an environmental input like sunlight is able to bring about so many changes in our well-being.  The hormone that puts us to sleep, melatonin, has been implicated because daylight naturally reduces its levels in the blood. It was thought that the late sunrises of the fall and winter seasons delays melatonin destruction and leaves us sleepy, but how this would affect the other symptoms such as mood and overeating was (and is) not understood.

One of the first therapies offered to patients was exposure to artificial light that mimics the spectrum of sunlight. Sitting in front of a lightbox or “sunbox” for thirty minutes or so in the early morning upon awakening was shown to relieve the symptoms of SAD. Lightboxes are still used, and some who work in windowless offices often keep them on throughout the morning to brighten their mood. Treatment with antidepressants that increase serotonin activity is now an alternative treatment based on studies showing that serotonin activity seems to be reduced in patients with seasonal affective disorder.

However, many people fortunately never experience the clinical depression of SAD; rather they have milder symptoms which now have taken on the name “winter blues”. Although their weight, sleep, work productivity, and mood are all changed (not for the better), their symptoms may be relieved in part simply by using light therapy.

One of the problems with winter depression is that it creeps up silently, triggering an almost imperceptible change in behaviors that seem to have their own justification, rather than associated with diminishing daylight. Fresh fruit desserts are less appealing than the fruit baked in a cake or pie; fall activities make a good excuse for skipping the gym; new projects or commitments are better off delayed until spring because the holidays will be coming; the irritability, depressed mood, anger symptoms are justified because of work/kids back to school/ family or financial stress; and sleeping longer is necessary because of a persistent tiredness.

Recognizing the early symptoms of winter blues, such as cravings for sweet carbohydrates or increased fatigue, allows strategies to be put in place (like rakes before the leaves drop) to decrease their impact on quality of life.  For example, weight is often gained due to the dual effects of craving high-fat sugary foods (like chocolate and cookies) and drastically decreasing exercise because of fatigue. Recognizing this should lead to removing highly caloric carbohydrate snacks like chocolate and ice cream from the kitchen. Once the full blown carb cravings of winter blues hit, it will be difficult to resist eating cookies or ice cream or chocolate, especially when the sun sets by late afternoon.  Replacing these highly caloric foods with very low fat breakfast cereal—such as oat or wheat squares or cornflakes—will increase serotonin, turn off carbohydrate cravings, and increase satiety without doing damage to your weight.

Fatigue and disinterest in taking on new activities may shut down any commitment to frequent (if any) exercise. Plenty of excuses will be available as weather, early afternoon darkness, work, holiday, and family commitments erode time for a workout at home, at the gym, or outdoors. It is all too easy to stop going to a yoga or Pilates class or cancel a walk with a friend. One solution is to use an APP, or wearable exercise tracking device that will nag you into taking 10,000 steps a day, or indicate how many calories you are eating and how many you are using for energy. The APP doesn’t care what your excuses are for not moving, but if programmed correctly, will ping and alarm and buzz until you do move.

Better yet, be competitive with someone at work or in the family so that you have to display daily (or at least weekly) whether you met your exercise goals. If you start doing this before the fatigue of the winter blues sets in, it is possible that you will continue with the exercise even if one part of you is begging to lie down on the couch and watch Netflix. There is no cure for SAD or the winter blues other than moving to states where the days are longer. Fortunately, the days start to get longer on the second day of winter, and the symptoms will go into remission by mid-spring.

We can’t keep the leaves from falling, or snow, for that matter. But it should be possible with the right interventions to keep weight from rising, mood from falling, and energy levels intact until that happens.

References

Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy Rosenthal N, Sack D, Lewy A et al Archives of General Psychiatry  1984 ;41: 72-80

(β-CIT SPECT imaging shows reduced brain serotonin transporter availability in drug-free depressed patients with seasonal affective disorder  Willeit M, Praschak N, Rieder A et al Biological Psychiatry  2000 ; 47: 482-489

Can You Laugh Off a Few Pounds?

Most of us have a friend who, if invited to dinner, will make us laugh so much with an unending stream of funny stories that the food will get cold and neglected. The jokes may start soon after hunger has been dulled sufficiently to slow down eating and, if the jokes are well presented, laughter will prevent many from continuing to eat.  And indeed, what one remembers after this type of dining experience is not the food (regardless of how good it is) but the shared experiences of laughter.

Many people have tried to define the effects of laughing on the brain, attempted to analyze how structure of jokes activates laughter (there is a linguistic basis for this) and even have measured physiological responses to laughter. But it is not necessary to know what neurotransmitters in the brain are involved in the laughing response to know that it makes you feel better. The feeling may not last any longer than it takes to forget the punch line, but there is a sense of contentment after a good laugh, a feeling of relief because even if it is only for a few minutes, any negative emotions we are harboring seem silenced by the sounds of laughter we are making.

The idea that laughing releases tension is well understood by therapists who study the effect of laughter on behavior and mood. Moreover, even though we can laugh privately at something funny in a book or in a New Yorker cartoon, laughing is acknowledged as a way we communicate with others in the few minutes we all perceive the world of the funny story the same way. Indeed, if someone in a group mutters, “Why is that funny?” others view him or her temporarily as an outsider to a shared understanding of the story.

Laugh therapy has been used to reduce anxiety and depression among patients confronting illnesses like cancer and chronic diseases that have no apparent cure. Laughter is used as a tool to help people with social anxiety, according to Aaron O’Banion and Justin Bashore, who write about this on their website, Social Anxiety Institute.

Doctors rarely, if ever, prescribe laughter as a remedy for disease but one man, Norman Cousins, proved that it could be a powerful tool. Cousins, the editor-in-chief of the Saturday Review, developed a painful connective tissue disease with a very small chance of recovery.  His own treatment plan included watching reruns of humorous television programs and movies. His book, The Anatomy of an Illness, published in l979 after he recovered from his disease, described how, “…ten minutes of belly laughter allowed him two hours of pain-free sleep.” Of course, as some critics pointed out, he may have been misdiagnosed and whatever he had could have gotten better without the laughter, but the effect of laughing was immediate and the results, no pain, easily noticed.

Inducing laughter for therapeutic reasons, such as decreasing anxiety, is not left to the telling of jokes or watching a stand-up comedian. There are therapeutic laughter meet-up groups, laughter yoga (known as Hasya yoga) and laughter clubs. The objective is put an individual through a series of breathing and moving exercises that mimic, to some extent, the body movements when one is laughing. And sometimes laughing is induced just by having two people sit, stare at one another, and then force a laugh. It works as anyone who has giggled in response to someone else giggling knows.

It seems obvious that laughing should somehow find its way into a weight-loss program, especially for those whose excessive food intake is the primary, indeed only, pleasure they have. Eating is commonly done to reduce tension and anxiety, as a pleasurable way of reducing boredom, loneliness, the tedium of work or household tasks, and as a source of comfort that never fails. If laughter can decrease the negative moods often associated with overeating, the effect may be a painless, and indeed enjoyable, way of losing weight.

Laugh It Off! Weight Loss for the Fun of It by Katie Namrevo was published 14 years ago and describes the effect of laughing on the weight loss of the author. Unfortunately, her book has not spawned the equivalent of national weight-loss laughing groups that, unlike Weight Watchers, would allow clients to tell jokes rather than sad stories about how they overate the previous week. Moreover, might laughter therapy be used to relieve the intense loneliness of a morbidly obese shut-in individual who finds pleasure only when eating? If Norman Cousins could experience a few hours of reduced physical pain, might laughing also bring about a few hours of relief from emotional pain? Consider what might happen if someone attempting to lose weight was told that a meal could be consumed only after the individual watched 10 or 15 minutes of a funny movie or video or listened to a recording of a very funny writer like David Sedaris. What if an exercise-averse individual were told that a yoga group was focusing on movements related to laughter? A weight-loss group might be more fun if the attendees laughed together instead of describing events in which they overate, or the reasons they were provoked into doing so.

All of us, regardless of our weight, probably don’t spend enough time laughing. And yet, all of us have had the experience of repeating to ourselves a joke or funny observation we may have heard recently, just because it brings a smile to our face. Doing so makes us feel good. And feeling good is an effective way to support weight loss.

References

“Effects of laughter therapy on anxiety, stress, depression and quality of life in cancer patients,” Demir, M. J., Cancer Sci Ther 2015 7: 272-273.

An Afternoon Starbucks’ Drink May Be Great for Your Mood, but a Disaster for Your Weight

A full-page advertisement for an Ultra Caramel Frappuccino stopped me from turning the page in a magazine I was reading. The picture of this drink caused my mouth to water, and was one of several Starbucks drinks they are featuring to entice morning customers back into their stores for afternoon refreshment.  Hidden in small letters at the bottom of the page is the phrase “Find Your Happy.” Perhaps it refers to happy taste buds after drinking one of the Frappuccinos.  And for many, this may be the result. Moreover, I suspect that the marketing people at Starbucks who came up with the campaign did not know that an afternoon drink combining caffeine and carbohydrate are satisfying a need rooted in our brains, not our taste buds.

Collette Reitz describes how many of us feel around 3 or 4 pm when she writes on Elite Daily’s May 2018 web site”…you can’t decide what to order at Starbucks because you are craving both a giant piece of cake and a caffeine boost.“ What Ms. Reitz is describing is the phenomenon of a, “…universal afternoon carbohydrate craving and afternoon lack of caffeine fatigue.”

The flagging energy and blah feelings experienced around 3 or 4 pm is largely due in part to caffeine levels that have been declining since morning, when many of us drink our coffee or other caffeinated drinks. They can be quite low by mid-afternoon unless a caffeinated beverage was consumed with lunch.  But most of the mood changes in the afternoon seem to be associated with decreasing brain levels of serotonin. We don’t know why there should be a change in the level of this neurotransmitter, but its effects can be seen in the craving for carbohydrates along with the distractibility, grumpiness, irritability and restlessness many experience between 3 and 5 pm.

We discovered this in studies carried out at MIT almost thirty years ago with people who self-identified as carbohydrate cravers. At first we believed people were eating carbohydrates in the afternoon because they wanted something pleasurable to munch on when they took a break from work. But it turned that eating the carbohydrates was a kind of self-medication. Our subjects told us how they couldn’t concentrate or became irritable with their kids, or felt depressed or angry late in the afternoon. They said they needed to eat carbs at that time. They weren’t hungry, but they found it impossible not to eat a sweet or starchy snack and when they did so they felt better.

We tested their claim that eating a carbohydrate in the afternoon positively affected their moods by giving them a drinks containing carbohydrate or protein, and measuring their moods before and after the drinks. They didn’t know what was in the drinks. It turned out that the carbohydrate drink reversed their bad moods but the protein drink had no effect.   (“Changes in Mood after Carbohydrate Consumption may influence Snack Choices of Obese Individuals,” Leiberman, H.J., Wurtman, J., and Chew, B., Am. J. Clin. Nutr. 45:772-778, 1986)

Further tests in which they received either a drug that increased serotonin activity, or a placebo showed that when serotonin was more active, their carbohydrate craving disappeared.( D-fenfluramine selectively suppresses carbohydrate snacking by obese subjects.Wurtman, J.J., Wurtman, R.J., Mark, S., Tsay, R., Gilbert, W., Growdon, J. Int. J. Eating Disorders, 4(1):89-99, 1985.)

So it appeared that somehow serotonin was signaling them to eat carbohydrates. Why? The reason was actually discovered years earlier, also at MIT. Serotonin is made after insulin is released and changes the pattern of amino acids in the blood. When insulin does this, a particular amino acid, tryptophan, gets into the brain and instantly is converted to serotonin. Insulin is secreted only after sweet or starchy carbohydrates (with the exception of fructose) are eaten.  (“Brain serotonin content: physiological dependence on plasma tryptophan levels,” Fernstrom, J., and Wurtman, R., Science, 173:149-152, 1971) Perhaps the lack of serotonin sent a signal in the form of carbohydrate craving just as thirst is a signal that the body needs water.

Starbucks’ “afternoon made” drinks may be the solution to this serotonin-generated afternoon mood and energy slump. But it is also a problem. The heavily advertised Frappuccino contains so many calories that the elevation in energy and mood may be costly in added pounds.  A grande size of the Ultra Caramel Frappuccino contains 420 calories, 19 grams of fat, 59 grams of carbs and 5 grams of protein. The grande size Triple Mocha Frappuccino has 400 calories, 18 grams of fat, 55 grams of carbs and 5 grams of protein. One does not need to consume 55 grams of carbohydrate and 400 calories to increase serotonin levels. Twenty-five to thirty grams is sufficient and if the snack is very low in fat or fat-free like some breakfast cereals the calories rarely exceed 130. Moreover, the fat content of the drinks may actually have a negative impact on mood. Feeling logy or foggy or just tired after eating a load of fat is not uncommon. Drinking 18 or 19 grams of fat puts a “ball of fat” in your stomach, and when digested rarely leads to increased mental or physical energy. I would not want to have a surgical procedure if my doctor just finished drinking a Frappuccino. To add fat to the fire, as it were, the fat drastically slows down digestion so the beneficial effects of caffeine and carbohydrate on energy and mood take longer to be experienced.

Starbucks offers other options that refresh and rejuvenate with many fewer calories. Mango Dragon Fruit Lemonade has 110 calories and 26 grams of carbohydrate. Strawberry acai lemonade has a similar nutrient profile. Other low-calorie drinks such as lemonade do not have quite enough carbohydrate to activate serotonin synthesis in the tall size, but would if ordered in the next larger size.

Will you find your “happy” in these afternoon drinks? Yes—but only if your mood goes up without your weight doing the same.

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.

Night Eating Syndrome: Is It Just Sleep That Is Disturbed?

Waking up in the middle of the night is an annoying event that most of us experience. Usually we are able to fall asleep again quickly, perhaps after drinking some water and/or making a trip to the bathroom. But for some, waking up is a signal to go into the kitchen and eat: a bowl of cereal, a peanut butter sandwich, or a dish of ice cream. And unhappily, going back to bed after the night time snack does not ensure that the remainder of the night will be restful. Waking may occur once again, or even several times during the rest of the night, and is always accompanied by eating. The next morning, the night time eater has no appetite for breakfast and may not eat for hours.

When the pattern of awakening and eating occurs regularly, it is defined as a type of eating disorder called Night Eating Syndrome (“NES”) described first by Albert Stunkard in l955. Dr. Stunkard was a professor of psychiatry at the University of Pennsylvania when he first put forth the criteria for diagnosing this poorly understood behavior. Simply eating leftover pie or pizza at midnight is not sufficient to meet the diagnosis, because people with NES consume about 25% of their total daily calories after the evening meal. The food can be consumed in the evening before sleep and/or during nocturnal awakenings. Those with NES suffer from insomnia at least four or five times a week and believe that they will not be able to go back to sleep unless they eat. Finally, if they have mood disturbances like depression and anxiety, their moods will worsen as the evening progresses.

Interestingly, as Stunkard points out in a paper he wrote on the subject almost fifty years later, people who engage in frequent night time eating are not necessarily obese, although it is a risk factor for obesity. Because they are unlikely to eat during the early part of the day, (skipping breakfast and delaying lunch) their total daily intake may be appropriate. On the other hand, many who are seeking help for their obesity often fail to report nighttime eating episodes. Plus, they are rarely asked about it, so it is not known to what extent this type of eating contributes to weight gain.

The inability to sleep through the night, or to do so with only infrequent awakenings of short duration, is certainly associated with NES, but is it the cause? Many people have insomnia, but they do not eat their way through every period of nighttime wakefulness. If the food eaten helps put the eater back to sleep, this would explain their seeking food once they wake up. But it is hard to find studies that test whether the foods chosen in order to put the insomniac to sleep actually work. Moreover, in a study that examined sleep cycles of NES subjects and controls, no difference was found in the duration of sleep, although the former did awaken earlier in the night and more often.

Perhaps the syndrome is not caused by disordered sleep, but by something else. Current research suggests someone with NES is not eating to go back to sleep, but rather waking up because of hunger. The “hunger” hormone ghrelin, which normally is secreted during the day when we normally feel hungry, seems to peak late in the evening and into the night in NES sufferers. Thus they may be awakening because of ghrelin-potentiated hunger.

A solution has been to reset the pattern of ghrelin secretion back to normal by exposing the patient to light very early in the morning. Anyone who has traveled east across enough time zones to feel out of sync and out of sorts during the first couple of days, knows the feeling of being forced to sleep and eat on another time zone’s timetable. It is hard to be hungry for breakfast when it is only 3 am back home, and it is hard to find food when you wake up hungry at 2 am because it is now 7 pm back home. If you stay in the new time zone long enough, your eating and sleeping hormones adjust. This is what researchers hope to accomplish for the night eaters using bright lights to make ghrelin levels high during daylight rather than at night.

Melatonin is also being tried because some studies have found that this sleep hormone is not as high as it should be in the late evening, and perhaps this is why it is so easy for the night eaters to wake up. There is a time-released melatonin preparation containing the low recommended dose of melatonin (0.3 mg); whether it might prevent frequent awakenings has not yet been tested. Anxiety and depression are also linked with NES, but it is unclear if they are the cause or consequence of disrupted sleep.

It is not unusual to wake up at 3 am and be assaulted with the worries that were successfully repressed 12 hours earlier. If one were prone to depression and anxiety, would these mood disorders cause sleep disturbances leading to frequent awakenings or, if awake, prevent the individual from falling back asleep unless something is eaten? Stunkard recommended antidepressants that increase serotonin activity to decrease anxiety and depression and calm the individual back into sleep. But a remedy that would help the sleep, as well as hunger and mood disturbances, is more simple and natural: a cup of low-fat, mildly sweet breakfast cereal eaten upon nighttime awakening. The carbohydrate will increase serotonin thus inducing relaxation, satiety and a more tranquil mood.

If the cereal is in a cup by the bed, it can be eaten without leaving it (as long as there are no crumbs.)

References

“The night-eating syndrome; a pattern of food intake among certain obese patients,” Stunkard, A.J.; Grace, W.; Wolff, H.,The American Journal of Medicine. 1955: 19: 78–86

“Two forms of disordered eating in obesity: binge eating and night eating,” Stunkard, A. and Allison, K.. Int J Obes Relat Metab Disord 2003, 27: 1-12

“Circadian eating and sleeping patterns in the night eating syndrome,” O”Reardon, J., Ringel, B., Dinges, D., et al, Obes Res. 2004; 12:1789-96