Category Archives: Advice on how to Lose Weight

Eating Late: Will It Make Us Gain Weight?

Is it true that when we eat may influence our weight? For years, some nutritionists and diet consultants have told us “…not to eat dinner later than 6 pm,” or “…If you eat late at night you will gain a pound while you sleep,” or “…it is better to eat most of your calories early in the day.”  Now that daylight saving time has arrived, we may find ourselves eating dinner much later than we did a few months ago when it was dark by 5:30, or even much earlier. Indeed, as the hours of daylight extend into the evening, and the weather becomes benign, dinner may be pushed back even further as we are reluctant to go inside and settle down for the evening. If the timing of our meals does make a difference, might this have an impact on our weight? Should we stick to eating dinner no later than 7 pm because if we ignore this time limit, we will be gaining weight?

Compelling evidence supports the idea that the timing of meals may affect weight. A large study examining meal times among Seventh-Day Adventist church members in the United States and Canada suggests that we should consider rearranging our meal schedule. Researchers looked at food records of 50,660 adult Seventh-Day Adventists and their BMI ( body mass index), a measurement of their weight status. Would there be a relationship between the number of meals consumed, the timing of the major and smaller meals, which meals were usually skipped and their weight? Their results might make one reconsider when to eat.

People who ate breakfast had lower BMIs than those who habitually skipped this meal. Moreover, people who made breakfast their major meal of the day, rather than lunch or especially dinner, had a significantly lower weight than those who ate their largest meal at dinner. Eating a bigger lunch than dinner also produced lower body weight, although the differences were not as striking as between those who made breakfast their main meal of the day and those who ate their largest meal at night.  Snacks were counted as meals and, no surprise, people who ate more than three meals a day were in the heaviest category.

Breakfast consumption has also been linked to weight loss in a study in which dieting subjects ate most of their calories at breakfast or at dinner. Both groups ate the same number of calories but those who ate most of their calories at breakfast lost significantly more weight than the other group.

These results suggest that populations that traditionally eat tiny breakfasts and large evening meals might have a high rate of obesity. In two such countries, Spain and Argentina, breakfast is often only coffee and perhaps a roll or pastry, and dinner usually begins, at least in restaurants, no earlier than 10:30 pm. However, despite their late dining and inadequate breakfasts, the prevalence of obesity doesn’t even come to close to what we have in the States where we finish our dinners before they have picked up their forks to begin theirs. The prevalence of obesity in both Spain and Argentina is around 14%.

In contrast, one out of every four Americans is obese. Moreover, articles lamenting the increase in the numbers of overweight and obese individuals in these countries do not mention the lateness of the dinner hour, but instead focus on the same factors that are responsible in part for our rise in obesity: too many high calorie snacks, too little exercise, too much watching television, too little consumption of fruits and vegetables and too much fast food. Sound familiar?

Nevertheless, can we disregard the studies indicating that consuming the majority of our calories before sunset might help us in the obesity battle? Should we stop having people over for dinner or celebratory occasions involving food in the evening, and switch to brunch or breakfast instead? Should lunch be the default main meal and dinner limited to soup and a salad, or yogurt and fruit?

One problem with transferring information from studies with compelling results such as the one with the Seventh-Day Adventists is that life gets in the way of implementation. Early mornings, filled as they are with getting breakfast for the family, walking the dog, long commutes, getting the kids to daycare or school, and the myriad obligations that arise between waking up and being at work seem incompatible with preparing and consuming a large meal. Moreover, lunch, the other opportunity to eat the major meal of the day, is rarely a complete meal. Do people go home for a hot meal at lunchtime anymore? Most of us content ourselves with a salad or sandwich and consider ourselves lucky if we can eat it at a table rather than at our desk or sitting on a curb near a construction site.

Perhaps the real problem is being too hungry at dinner. If breakfast and lunch are skipped or skimpy, late afternoon-early evening hunger hijacks our control over eating while preparing dinner, at the meal itself, and afterward. We may justify our grabbing and gobbling because we have eaten so little earlier in the day. And we munch on cookies or ice cream after dinner because “they couldn’t have any more calories than the breakfast or lunch we skipped.”

It is unlikely that breakfast will become the new dinner, regardless of research on its impact on weight. But we should not minimize the importance of this meal as well as lunch in controlling our hunger late in the day. It really might work.

Antidepressants: The Hidden Contributor to Obesity

Years after weight gain was recognized as a side effect of antidepressant therapy, researchers have presented evidence of its contribution to the increase in obesity.  For those patients, who for years have described the devastating effect antidepressant have had on their weight, it is a ‘told you so’ moment. Last spring the British Medical Journal published a report by Rafael Gafoor, Helen Booth and Martin Gulliford, documenting the significant weight gain in Britain experienced by  patients on a variety of antidepressants, compared to the general population.  Using electronic medical records, they tracked weight status of the 53,000 British patients who had been prescribed antidepressants over ten years, and compared their weight to a similarly large group of untreated individuals.  Both groups gained weight, but a significantly larger number of those in the antidepressant-treated group increased their weight. Moreover, weight gain did not stop after the first year of treatment, but according to their findings continued, on average, for six more years.  The drug that caused the most weight gain was mirtazapine (Remeron).

Moreover, weight gain as a side effect of antidepressant treatment was not confined to those who were overweight or obese at the start of their therapy, but included patients who were of normal weight prior to treatment. The authors conclude that the impact of antidepressant drugs contributing to the increase in obesity in the UK has been overlooked, and should be considered a major risk factor. Their assessment of the impact of antidepressant therapy on generating obesity can be applied to the USA where, as in the UK, it has been almost entirely ignored as a risk factor.

That antidepressants and related drugs used for bipolar disorder and other mental  disorders cause weight gain is well known to patients and their mental health providers.  Several years ago, my associates and I were asked to develop a weight maintenance center at a Harvard associated psychiatric hospital to help patients lose the weight they gained (or were gaining) on psychotropic drugs.  What was so striking about our clients was that unlike those who have struggled with weight gain all their lives, they rarely had a problem with their weight prior to their treatment: eating a healthy diet and exercising characterized their lifestyle, and few had ever needed to be on a diet.

Because the data for the BMJ report was derived from electronic records, no information about alterations in food choice instigated by drug treatment was reported. However, several papers (as cited in the reviews below) have pointed to an increase in carbohydrate intake, and the absence of satiety associated with antidepressant use.

Those attending our clinic complained of an almost irresistible need to snack frequently on sweet or starchy foods and some (although usually those on mood stabilizers) would report eating a second meal an hour or so after the first, because they did not feel full. A professor of psychiatry at Boston area hospital shared the experience of a patient on Remeron who woke up every night to eat boxes of crackers and cookies.

The BMJ report did not offer information on whether weight was lost after withdrawal from antidepressants; presumably, after the psychotropic drug(s) is no longer in the body, appetite should return to normal. There have been reports of patients unable to lose weight despite dieting and exercising, sometimes for months and indeed years, after they have stopped their medication – but this information is largely anecdotal.

Recognizing the contribution of psychotropic drugs to the rising rate of obesity may lead to interventions to prevent or diminish weight gain. Ideally a patient should be advised on diet and exercise at the initiation of the drug therapy, but one wonders whether adhering to a regimen to prevent weight gain is practicable for a patient while still symptomatic. Moreover, often the dietary advice, although well intentioned, may be counterproductive if it includes restricting carbohydrates. Since the synthesis of serotonin depends on the consumption of carbohydrates, and since not only mood but satiety is dependent on serotonin activity, offering a low carbohydrate diet may only exacerbate the cravings and the absence of satiety.

Acknowledgment by practitioners of the real possibility of weight gain as a side effect of psychotropic drug treatment, and the availability of Individual and/or group weight loss support must be part of the treatment plan.  Obesity is not a benign side effect; it has well known health consequences, and may significantly affect the quality of life of the individual. Social isolation, employment discrimination, embarrassment at a body no longer recognizable are but a few of the consequences. Consideration of a patient’s weight status prior to treatment is also important;  a drug like Remeron known to cause uncontrolled eating may catapult an overweight individual into obesity.

Those who have gained weight as a consequence of their psychotopic medication have been invisible as a sub-group among the obesity community. One hopes that this report is the first step in making us notice and help them.

Monosodium Glutamate: Will It Make Us Eat More or Less?

In a recent study, female subjects consumed chicken broth with or without monosodium glutamine (“MSG”) to see if this flavoring ingredient might alter their appetite. State of the art electronic devices that could detect their interest in eating certain foods monitored their intake during a subsequent meal. For those of you who order wonton soup, a chicken soup that usually contains MSG, in a Chinese restaurant, you might be interested in the results. Subjects exhibited more control over their food intake and ate less saturated fat after ingesting the broth with the MSG than after consuming the non-MSG soup.

In practical terms, this may mean you will eat more steamed broccoli and less battered shrimp or chicken after a cup of Chinese chicken soup. The authors suggest that the glutamine, an amino acid that functions as a neurotransmitter in the brain, in monosodium glutamate may be responsible in part for the eating behavior seen in the study. But before going on an MSG diet to lose a few pounds, it might be worthwhile considering that opposite effects have been described as well.

In 1990, a paper published by Rogers and Blundell recounted that subjects consumed broth (it was beef in this experiment) containing different amounts of MSG, and their food intake was measured about thirty minutes later. Initially after consuming the soup, subjects reported feeling full and not interested in eating. However, thirty minutes later their motivation to eat was higher after they consumed the MSG-containing soup than after soup without the ingredient. But this was not reflected in what they actually ate. They ate the same amount after each soup.

Scientist Takashi Sasano and his colleagues at Tohoku University in Sendai, Japan, concerned about the inadequate food intake of the elderly, found that giving them kelp-enriched tea could enhance their appetite. As reported in an article in New Scientist by Jessica Hamzelou in January 2015, the kelp, which is exceedingly rich in monosodium glutamate (MSG), stimulated food intake. The scientists speculated that an increase in saliva secretion was the reason.

So does MSG change your food intake? This is still in dispute. What is not in dispute is that the glutamate in monosodium glutamate is the source of a taste called “umami” by the Japanese. Kikunae Ikeda, who coined the term, discovered umami in 1908. There is no English word synonymous with umami; the closest related terms are savory, meaty, and broth-like. Because umami was originally a Japanese term, it was thought to be a taste associated only with Asian foods, and not one detected by Western taste buds.  However, it has been now established as a fifth basic taste along with sweet, sour, bitter, and salty.

Although most of us would immediately associate the umami taste with soy sauce, other Asian sauces such as oyster sauce, and the flavor imparted by MSG to soup powders and other processed foods, the umami taste is naturally present in foods we commonly eat.  Tomatoes, mushrooms, hard cheeses such as Parmesan and Roquefort, and also green tea contain high quantities of monosodium glutamate. Anchovies, an often disdained fish (except by the few who love them), contain substantial amounts of monosodium glutamate and have been used for thousands of years to impart the savory umami flavor to food. Garum, a condiment used in the Roman Empire, was as costly as perfume according to an NPR report by Howard Yoon in August 2009, and was prized for its ability to make foods taste, in his words, irresistible.  Anchovies have imparted this fifth taste in Indonesian, Korean, Filipino, Vietnamese, and Thai cooking over many centuries, although presumably adding purified MSG these days would keep the anchovies in the ocean.

And, according to Mr. Yoon, we fall prey to this savory taste when we find it hard to stop eating Doritos or instant ramen noodles.

MSG is both good and bad for us. It has received decades of bad press because of the so-called Chinese restaurant syndrome, a cluster of symptoms such as headache, flushing, tingling, rapid heartbeat, sweating, nausea and burning sensations in the face. After years of extensive research, it has been found that a small percentage of people experience an acute short-lived reaction to MSG. But this is not why MSG is bad. It is bad because, as an additive to many highly processed foods as well as snacks, its umami taste causes us to fill up on foods that, at the very least, don’t really nourish us, and at worst, cause us to eat too many calories in the form of junk food.

But monosodium glutamate could also induce us to eat foods that are healthy, but are avoided because their taste is so boring. Think of how many people do not eat vegetables. They have made up their minds, perhaps as children being forced to eat them, that when they grow up, they will never eat a carrot or a serving of spinach again. What if they were presented with vegetables that have the savory taste of umami? What if the salads and vegetables they disdain had the “lip-smacking flavor“ of a Dorito or ramen noodles and were suddenly craved? An increase in vegetable consumption would certainly improve the quality of our nutrient intake and might even reduce calories.

The article by Yamaguchi and Ninomiya points out that Western foods traditionally rely on high-fat ingredients like butter, oil, and cream to deliver taste and carry the taste of other ingredients. This is why bacon fat or melted cheese or heavy cream bring a deliciousness to dishes that can’t be mimicked by skim milk and canola oil. But, as they point out, much pleasure in the taste of foods is also found in foods delivering that fifth taste—and without the caloric cost.

Regardless of whether MSG makes us eat more or less, what it can do through the fifth taste sense, umami, is to bring more nutritional sense to our diet.

References

“Neurocognitive effects of Umami: Association with eating behavior and food choice,” Magerowsski G Giacona G, Patriarca, et al Neuropsychopharmacology   2018; 43: 2009 -2016.

“Umami and appetite: Effects of monosodium glutamate on hunger and food intake in human subjects” Rogers P and Blundell J Physiol Behav. 1990 48:801-4.

“Umami and Food Palatability,” Yamaguchi S and Ninomiya K The Journal of Nutrition 2000; 130: 9212-9265s

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

When Mindless Eating Has a Function

Mindless eating is always trotted out as a significant factor in the increasing incidence of obesity. If we only paid attention to what we are eating, perhaps we would eat more 1) healthily and 2) frugally. We would never eat potato chips, butter-drenched popcorn, French fries, peanuts, M & M’s and nachos or, if we did, we would notice every peanut or M & M going into our mouths and would stop after eating only one or two (in our dreams, perhaps). We never would eat everything on our plates, unless the portion size was so small we noticed its reduced size.  When served the typical overly large serving, we would carefully portion out the amount we should be eating and leave the rest, or eat it at another meal.

But who eats this way?  Probably people during the early stages of a diet, or after bariatric surgery when they are left with a tiny stomach. Restaurant reviewers pay attention to what they are eating, as do judges on televised competitive cooking shows or at state fairs tasting pies.  Of course, pathological food restrictors are extremely mindful of what they put in their mouths (three slices of apple, two leaves of lettuce), as are toddlers who chase cereal bits around the trays on their strollers.  Picky eaters notice what they are eating in order not to risk putting anything in their mouths that is distasteful or has unacceptable mouth feel. But once they remove the offending food from their plates, they eat as mindlessly as the rest of us.

Stress is a significant trigger for mindless eating and is often cited as an obstacle to weight loss or its maintenance. Often the eating is so unnoticed that only the empty ice cream container or bag of chips signals that eating has actually occurred.

Some studies suggest that chewing and not the swallowing of food is what decreases stress. Supposedly the repetitive motion of chewing produces a decrease in physiological markers of stress such as blood cortisol levels. (“Mastication as a Stress-Coping Behavior,” Kubo K, Iinuma M, and Chen H Biomed Res Int. 2015; 2015:876)  Laboratory rats given wooden sticks to bite or chew will show lower levels of cortisol when stressed, than rats not allowed to chew. Humans may chew gum or gnaw on other objects (pencils, pipe stems, coffee stirrers, fingernails) when they are stressed and as with the rats, this chewing decreases levels of cortisol and other physiological indicators of stress. If chewing does easing worry and anxiety, then the chewed object should have few or no calories (for instance, gum or crushed ice).

Unfortunately, we usually swallow what we are consuming when stress-associated mindlessly eating. This, of course, may significantly affect our weight if the stress and the mindless eating are prolonged. But is mindless eating at a time of emotional distress all bad?

Recently, while dining with friends we had not seen for several weeks, we learned that the husband was scheduled for a medical test that would reveal whether his medical problem could be helped by a simple, safe procedure, or major surgery with considerable risks. We had ordered a variety of small dishes meant to be shared among us, including two types of pasta which were served in large bowls. One bowl of pasta happened to be set in front of the wife of the individual whose medical condition we were discussing. “I can’t believe I ate the entire bowl of pasta,” she exclaimed several minutes later when someone asked her to pass the now empty bowl.  I didn’t mean to eat so much,” she said. “I didn’t even realize I was eating it!”

Mindless eating? Yes. Might it have been related to her worry and anxiety that her spouse might not survive the more drastic medical procedure? Probably. Did it help ease her emotional distress? Perhaps.   Certainly the carbohydrate, the pasta, would have increased serotonin synthesis in her brain, and that, in turn, may have lessened her anxiety, helplessness at not being able to do anything but wait and worry, and maybe even increased her ability to cope with the unknown.

It wasn’t necessary for her to eat the entire bowl of pasta to ease her anxiety. Indeed, had she eaten a few skinny bread sticks, or a slice of crusty bread from the basket placed on the table as we sat down, she might have started to feel better before the pasta arrived. Once digested, the carbohydrate in the bread sticks would have initiated the physiological process leading to an elevation of her brain serotonin levels. The subsequent increase in serotonin activity and possible reduction in her anxiety and worry might have prevented her from consuming all the pasta without noticing what she was doing.

However, the mindless eating our friend experienced is not without some benefit in addition to an easing of her distress. It can be regarded as an early warning of her vulnerability to eating uncontrollably in order to feel better. Our friend should be asking herself: “ Why did I eat all that food without noticing?  Am I using food  to block out my emotional pain? Is it working?”

Positive answers do not mean that mindless eating should be continued. Rather, it should be replaced by mindful eating.  It is not necessary to eat large quantities of carbohydrates  to experience relief from stress. The stressed eater need consume only about 30 grams of a fat-free carbohydrate (i.e. rice crackers or oatmeal) that contains no more than 4-5 grams of protein to bring about an increase in serotonin and a decrease in stress.  (“Brain serotonin content: Physiological regulation by plasma neutral amino acids,” Fernstrom, J. and Wurtman, R. Science, 1972; 178:414-416). Eaten as a snack, or indeed in a meal, once the carbohydrate is digested, the increase in serotonin should bring about some emotional relief.

Stress happens to all of us, and usually when we are not prepared. A bowl of pasta or a few breadsticks is not going to take away the cause or offer a solution. But at least these carbohydrates may take the edge off of our emotional pain, and make the problem a little more bearable.

 

 

 

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.

Is the Gym the Place for Psychotherapy?

I was on the treadmill when the battery for my noise-canceling headphones died. As I took them off and hung them on the railing of the machine, I heard a personal trainer talking with some urgency to the woman walking on the machine next to me. She was in her late forties, more or less, and about forty pounds overweight. He questioned whether she had planned to cancel the training session because she had not lost any weight, and when she nodded in the affirmative, he went on for some minutes, describing her emotional problems and what she should do about them. The noise of the treadmills was not loud enough to block his voice. The trainee, a woman, was a little out of breath which may be why she did not respond to his lecture.

What to do?  “I really should not be hearing this,” I told myself.  As someone who has done weight counseling and clinical research, I know how important it is to protect the privacy of everyone with whom I have contact.  Having a therapeutic conversation with a client would be done in an office, and the information in my notes was protected against an invasion of privacy. And yet, this trainer was conversing in a sufficiently loud voice so that I, and perhaps someone on a nearby machine, could hear what he was saying. Should I have been hearing about her problems with her mother? Did I want to know what she eats when she is upset? I suppose we all would benefit from his advice to take better care of ourselves, but it was not necessary for me to hear that as a bystander.

Combining exercise and talk therapy is certainly a good idea, as it may amplify the benefits of both. Presumably both therapist and client are better off engaging in physical activity; we all sit more than we should.  And as a friend told me, you, the patient, know that your therapist isn’t sleeping while you are talking if you are walking together. Sometimes simply walking side by side with someone who is an empathetic listener makes it easier to talk about problems than sitting face to face. How many of us have taken a walk with a friend or family member to discuss a problem?

But the personal trainer is neither a friend nor a family member, much less a licensed therapist. Yet because his advice was being given in a professional capacity as a paid trainer, it is reasonable to assume it would be taken more seriously than if the advice came from a friend or another gym member on an adjacent treadmill.

It is very tempting to give advice even when it is outside the area of one’s expertise. I go to the gym; shouldn’t I be able to help a weight loss client plan a program of physical activity?  For example, when I see a client for a weight-loss consultation, I ask about the level of physical activity and usually suggest exercise as part of a weight-loss plan. Certainly I should be able to suggest even more: how much weight lifting should be done along with cardiovascular activity.  But I am not a certified personnel trainer and I would never give advice as to the kind of exercise that should be followed, beyond the obvious recommendation to walk. Instead, I recommend a consultation with a personal trainer or physical therapist to make sure that the physical activity is compatible with the client’s health, stamina and age.  Would I take the client to a gym to show her how to use the machines? Of course not.  I do spend time with clients helping them figure out when their schedules will permit them to exercise.  And once I discussed with a client what she could wear in the gym that would flatter her shape. (It is hard to find workout clothes in large sizes.)

However, I have overheard many trainers who have relatively little nutritional expertise giving advice about diets or nutritional supplements; sometimes their information is erroneous or based on little evidence that a particular supplement, for example, is safe and effective.  Too many times, I have been told that a friend is following the latest diet fad because his or her trainer recommended it.

Would we be taking financial advice from our trainer or listening to her about how to decorate our living room, buy a car, or deal with a troublesome teenager? Unlikely.  Would we take marital advice or suggestions on how to deal with an aging parent from the person who helps prepare our income tax?  Probably not. But as I kept glancing at the woman on the treadmill beside me, I wondered why she was allowing her trainer (and not a therapist) tell her how to handle the demands of her mother, or problems with her marriage. (I obviously heard too much.) Was it because she was a captive on the treadmill? Or maybe she believed that someone who is overseeing how your muscles are working is competent to advise her on her emotional state.

The trainer’s advice to exercise faithfully, eat frugally, and give her some time for herself are within the bounds of common sense; they are suggestions that any of us could give and receive.  But if he plans on continuing his gym psychotherapy, let him go through professional training and receive the credentials to do so. And then he should he want provide therapeutic consultations in the gym, go to a place where only the client is listening.

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.

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.

Accidental Weight Loss: A Gift for the Dieter

Three of my friends are suddenly thinner, and they are delighted because none of them was dieting.  One lost weight because work required her to travel across several time zones, and she found that she was sleepy, but not hungry, at mealtimes in the new time zone. Another had unexplained abdominal pain, was put in the hospital for tests, and did not eat for several days because of the tests and the pain.  When she returned home, she found that she had lost several pounds. The pain went away unexplained, but the weight loss remained. A third moved and was so busy unpacking, she ate when she remembered to eat, and that consumed were protein bars unearthed in one of the boxes. Because she couldn’t remember where anything she had unpacked was, she walked miles in her home trying to locate the stuff she needed, such as her cell phone.

None of these women was obese, but each wanted to lose between 15 and twenty pounds, but had not gotten around to doing so (one for several years). However now, after noticing their unexpected weight loss, they put themselves on a diet because as one of them told me, “My weight loss was a gift and I didn’t want to throw it away.”

Who knows what motivates someone to go on a diet at a particular moment? Sometimes it is done during a traditional dieting time, such as the first week in January. Diets are started because a special occasion is occurring several weeks or months hence and right now the article of clothing to be worn is tight. Or the occasion itself calls for appearing slimmer; weddings and reunions are noteworthy for being diet motivators. Medical reasons are often motivators for weight loss, too, but sadly are usually accompanied by the development of a medical problem like diabetes or painful orthopedic issues. Occasionally a picture of oneself from an unflattering angle strips away the ability to deny the excess pounds, or the inability to fit into the new season’s clothes that fit a year ago demand that either weight be lost, or a new wardrobe be purchased. But these reasons for starting a diet involve a conscious ‘before’ when the individual was not on a diet, and a conscious ‘now’, when the diet has been started. Accidental weight loss is just that; no conscious decision is involved, it just happens.

Perhaps the most positive aspect of accidental weight loss (in addition to the lost weight itself) is realizing that it is possible to drop pounds without even trying. Many who struggle to lose weight believe that they won’t be able to. The pounds appear to be stuck with permanent glue to various parts of the body. Diets are started and weight may be lost, but to do so requires a great deal of effort: meal planning, and preparation, and time for exercise. Of course this healthy way of life should be followed regardless of weight change, but we are human and unless weight loss is substantial, we may feel that losing weight is not worth the effort we are putting into doing so.

Accidental weight loss seems to produce a looser skirt or pants, a zipper that goes up easily, a shirt whose buttons close without any obvious effort.  “My unplanned weight loss proved to me that when I eat less and move more, the pounds came off, “said my friend, “and I didn’t have to follow any peculiar diet, or any specific kind of exercise.“

Accidental weight loss challenges the claims that the dieter must eat, or avoid eating, foods from specific food groups, must overcook the food, or eat it raw, must allow it to ferment to produce specific bacteria, must subject the body to fasting, cleanses, supplements made from herbs and twigs, injections of fat burning hormones, hypnosis, packaged foods made in an industrial plant, or the latest tabloid ‘miracle’ diet, in order to lose weight. When weight is lost accidentally, it seems that the body wasn’t paying attention to all these diet remedies. It just responded to less food coming in, and in some cases more energy was being used up by your body, and that simply equates to that your physiology used up some of its fat stores, for energy.

The realization that the body is capable of losing weight without formal dieting should be transformed into a strategy for continuing to lose weight. The first step should be reviewing in a non-judgmental way, the eating and physical activity habits that caused the weight gain, and next figuring out what acceptable changes can be made to sustain the weight that has already been lost. With a suddenly slightly lighter body, eating smaller portions, or going for walk rather than sitting on the sofa, may become easier. Throwing away high fat, high sugar, and high sodium snacks that have been an obstacle to weight loss, might seem sensible rather than a culinary sacrifice and exploring alternate methods of decreasing stress other than eating.

After accidental weight loss, you are unlikely to continue to lose weight without consciously making an attempt to do so, but you will be able to. Your body has shown you that it is able to remove a few of those pounds you once felt would never be lost. Now your body is just waiting for you to continue to lose more.