Losing Your Sense of Smell to Lose Weight

A friend who went through an intense treatment of chemotherapy two years ago is still unable to smell, and thereby taste, most foods. She was warned this might be a treatment side effect, and when it would disappear was unknowable.  She used to eat chocolate, any kind of chocolate, as long as it was chocolate. “I don’t eat chocolate anymore,” she told me. “It tastes funny.”

That chocolate tastes funny to her is more likely to be from a loss of a sense of smell than taste.  According to Nancy E. Rawson, Ph.D. who is on the staff at the Monell Chemical Senses Center, Philadelphia, and Scientific Advisor to the Anosmia Foundation, it is our sense of smell, our olfactory system that gives us our taste sensitivity.  When people loss this olfactory function, when they have anosmia, they may not be able to taste the difference between an orange and a piece of chocolate.

As she and others explain, our ability to taste is almost totally dependent on our ability to smell. Of course, we can detect the basic tastes: sweet, salty, sour, bitter and umami, a savory taste sometimes associated with the taste of protein, even if we lose our sense of smell. But smell is the conduit to taste; without it the tastes of most foods are unrecognizable. We have cells high inside the nose, the olfactory sensory neurons, that connect directly to the brain. When we smell coffee brewing or popcorn popping, the microscopic “odor” molecules released by the food stimulate these neurons, and they message the brain, which then identifies the odor for us. (Dogs are much better at this than humans.) Interestingly, the smells come in not only through our nose, but also through a neuronal path connecting the roof of the throat to the nose. So when we chew our food, odors are also released that are picked up by the olfactory sensory neurons and sent to the brain.

A stuffy nose makes us aware of how important smell is in tasting what we are eating, and influences how much we enjoy or reject a particular food (think smelly cheese). But although it is frustrating to be unable to taste food when we have a cold, we know that once our stuffy nose disappears, we will be able to smell and enjoy eating once again.

It is this aspect of eating, enjoying the taste of food brought about by our ability to smell it, that has spawned interest in preventing the dieter from doing so.  If the food is tasteless, might the dieter eat less? Would the dieter stop eating when full, rather than continue to eat beyond fullness because the food tastes so good? Would impulsive eating of freshly baked chocolate chip cookies or French fries be thwarted because, without their scent, they lose their irresistible taste?

Apparently this occurred among subjects participating in a study in which they wore a nasal insert designed to redirect airflow in the nose away from those sensory olfactory neurons that tell the brain what we are smelling. Dror Dicker, MD, Rabin Medical Center, Israel, at the European Congress of Obesity a few weeks ago, described the device called Noznoz. The 65 subjects who wore the device while following a calorie-controlled diet lost significant weight; they especially reduced their consumption of sweet foods. In a sense, they had a perpetually stuffed nose.

Although the use of a custom-fitted nose device to reduce food intake is new,  the link between loss of the olfactory sense and altered food intake is well known. (“Olfactory Dysfunction Is Associated with the Intake of Macronutrients in Korean Adults,” Kong, Il, Kim, So, Kim, Min-Su et al, PLoS One 2016 ;11: 0164495)  Food intake among more than 1300 participants who had olfactory dysfunction (or inability to smell) was altered, compared to those who did not have this problem. Protein intake was reduced among males, the intake of sweet foods among young women, and consumption of high-fat food among young and middle-aged women. How the loss of the sense of smell differentially affected what was eaten or rejected was not explained in the paper.

Loss of the ability to smell odors may be one of the unwelcome aspects of aging. (“Effects of aging on smell and taste,”  Boyce, J. and Shone, G., Postgrad Med J. 2006 Apr; 82(966): 239–241)  The effect of aging on the deterioration of the sense of smell is so prevalent that one wonders if there ought to be generational-based recipes; foods made for an older population might have ingredients such as vinegar or lemon that can be tasted without a good sense of smell. Boyce and Shone state that in a recent survey almost 65% of 80-97 year olds have an impaired sense of smell.  The effects can be far ranging from the addition of too much salt and other spices to food in order to taste it, to malnutrition. Just as the loss of the sense of smell affects food intake among a younger population and decreases their food intake, so too the very old may eat less indiscriminately. They not only might avoid sweet or fat-rich foods, but food in general, thus causing them to be at risk for malnutrition. This is especially worrisome if their food intake is not sufficient to provide essential nutrients like protein, vitamins and minerals.

Fortunately the NozNoz and other interventions like a nasal spray that numbs the nose to smells, do not permanently eradicate this important sense. Indeed, its greatest utility might be putting them on when passing by sources of enticing food odors like sausages and onions cooking at a street fair that might tempt one into eating. It remains to be seen whether weight will be regained when and if the dieter removes the nose plugs. And of course, they may be helpful in cleaning up after a baby or dog.

 

 

Working Toward Weight Gain

A few days ago, I was in the office of my ophthalmologist for my annual eye exam. The practice is huge, and the volume of patients is processed–so to speak–by a row of administrative personnel, each sitting in a cubicle. I checked in at one such space and later checked out with the same clerk. As I watched her scan the computer to then print out the appropriate paperwork, it occurred to me that her job was almost totally sedentary. She did not have to move more than a few inches to access her computer, and the printer was under her desk so she did not have to walk over to another area to retrieve a printout. She was not chained to her chair, yet I doubt she was able to leave it until lunch and then again when the office closed. Unless she had far to go for lunch, or exercised during that noon break, she was completely sedentary for hours.

Until robots take over many of the routine jobs now performed by humans, more and more employees will be working in occupations characterized by an absence of physical activity. About seven years ago, a report was published on changes in physical activity related to occupation over the past fifty years in the United States. The authors used data from the United States Bureau of Labor Statistics that analyzed the amount of energy expended for jobs in private industry from l960 on. When the data were first collected in the early l960s, almost half of non-government jobs required moderate to strenuous physical activity. 50 years later, this number dropped to 20 percent. The authors translated these figures into changes in the number of calories that are expended in work and stated, “We estimated a reduction of more than 100 calories per day in occupation-related energy expenditure over the last 50 years.”

50 years ago, the woman processing my eye doctor’s records would have been using a typewriter and thus expending more energy than tapping on a computer keyboard. She probably would have to get up from her chair and walk to the office copy machine to make a copy of my record rather than pushing a button on her computer and reaching under her desk to retrieve the paper from the printer. Multiply this by every patient, every five minutes or so, and her calorie output would have been considerably more than it is today.

The authors of this report discussed the implications of the decrease in work-related physical activity as a risk factor for obesity. They suggested that as we increase the use of labor-saving, we are promoting the increase in weight of the population in general.

They recommend physical activity to compensate for the sedentary nature of many occupations. According to them, if the woman processing my paperwork engages in 150 minutes of moderate activity a week, she will compensate for her lack of activity during her work hours. But, as they point out, only one in four Americans meets this goal. Given the long commuting time many workers face, as well as the unending tasks to be done at home, it is unlikely that the three out of four Americans who are not exercising will suddenly find the time to do so during their limited after work hours. And even if some physical activity occurs on weekends, unless it is prolonged it probably will not compensate for the inert workweek.

Chairs perched on bicycle pedals and mini treadmills, are now being used by many who otherwise might be stuck unmoving an office chair. Those who fear the consequences of prolonged inactivity welcome the opportunity to move the bottom half of the body while the head and hands are occupied in writing reports or code. The use of these devices could be expanded to a much larger population such as medical office workers or anyone else forced to spend most of the workday seated. However, this is unlikely to occur; in addition to the obvious cost of such devices, it might seem strange to check into a medical office for an appointment and find the medical secretary bouncing up and down on her under-desk pedals.

Another option is to schedule walking breaks for workers who otherwise have little opportunity to stand up, let alone walk. This requires time and attention to the employee’s schedule; five-minute walking breaks when patients are waiting in line to be checked in or out means having someone available to cover while the break occurs. This may be too much trouble logistically and too costly financially. Ironically, employees who still smoke and must leave the workplace to do so have a built-in opportunity to move. If they can take a break to smoke, why shouldn’t others be allowed to take a break to move?

Another solution is to rotate the sitting employee into positions that require walking so that for some of the work day he or she is released from the chair. In the office I have referenced, another employee takes the patient to the area where the doctor’s office is located. (The practice is so large one almost needs a GPS system to find the appropriate office by oneself.) If the person checking people in and out were to be a patient escort for part of the day, or some other job that required walking, then the sedentary routine would be broken.

But these are rather weak solutions to a major problem confronting most occupations: How do all of us whose work is associated with being relatively inert get enough physical activity without sacrificing sleep, family, social obligations, and financial goals? Perhaps the answer is for workplaces to offer brief opportunities to stretch and to move, even if it is only for 15 to 20 minutes a day.

It may not be enough to compensate for all those hours of sitting, but it is a start.

Distinguishing Fact from Fiction in Supplement Claims

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until that occurs, let the user be cautious.

The Unfortunate Association Between Pain and Obesity

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

Thus more pain is experienced.

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

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

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

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

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

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

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

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

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

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.

Do Those With Psychiatric Diagnoses Get Enough Medical Care?

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

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

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

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

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

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

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

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

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

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

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

Funeral Potatoes Comfort, But At A Caloric Cost

What are funeral potatoes? People were asking this after an advertisement from Walmart for a packaged version of this dish appeared on their web site. Funeral potatoes are a well known dish in Mormon communities in Utah and Idaho, although it is popular as a cheesy potato casserole in many areas in the mid-west. Funeral potatoes is the name of a casserole traditionally brought to the home of the bereaved to be served at the after funeral lunch. The appearance of an instant version of this dish in Walmart may simply be evidence that in our busy lives, some do not have time to buy and assemble the ingredients. It is easier to find them all in a bag.

The ubiquity of this dish in homes of the newly bereaved, whether it comes from a package or is made from scratch, indicates that it may have an important function during the mourning process. The dish is considered the premier comfort food for after funeral repasts. One reason is that when made correctly, and probably not from a box, it tastes wonderful. Anyone who loves the combination of a creamy, cheesy, and crispy potato dish will have satisfied taste buds after eating funeral potatoes. (See below for generic recipe)  But long minutes after the food is consumed, the eater may experience a feeling of calmness, comfort, and decreased stress. The taste of the dish has disappeared from the mouth, but the effect on the emotions continues to grow.

Why?

The brain, not the gut, i.e., the intestinal tract, is involved in producing this emotional change. Twenty minutes or so after the last mouthful of the funeral potatoes are swallowed and digestion is in full swing, changes begin to occur leading to perceptible improvements in mood. Feelings of calm begin to take the edge off the sorrow and distress felt after the funeral. This occurs because of an increase in the synthesis and activity of the ‘feel-good‘ brain chemical, serotonin.

Funeral potatoes do not contain serotonin. (Indeed, even if one could eat something with serotonin in it, this very large molecule never, ever gets into the brain.) But potatoes are a starchy carbohydrate, and as happens when any starchy carbohydrate is digested, insulin is released. This sets in motion a process that allows an amino acid, tryptophan, to get into the brain . And as soon as tryptophan arrives, serotonin is made and one’s mood improves.

In the interests of good nutrition, or bringing food for a bereaved individual who may be on a Paleo or ketogenic diet, or any adherent to the, “Carbohydrates are Terrible Foods and Should be Avoided!’ diets, shouldn’t the traditional funeral potatoes be replaced by something else? Funeral potatoes may taste wonderful and make everyone feel better, but a dish of chopped egg whites is certainly a preferable dish for people avoiding carbohydrates. Or if not egg whites, perhaps roast chicken or baked fish or a smoked ham? These high protein foods certainly seem more nutritious than hash brown potatoes soaked in cream of chicken soup and covered with melted cheese, butter and crumbled cornflakes.

However, as important as eating protein is for our nutritional well-being, it has no effect on our emotional well-being. The carbohydrate, this funeral potato will nourish the mind, soothe the emotions. Potatoes are not an antidepressant, and of course cannot take away the pain and sorrow of a death of a family member or friend. But the synthesis of serotonin after eating carbohydrate is nature’s gift to us. It allows us to console and comfort ourselves simply by eating the right foods.

Eating protein prevents serotonin from being made. This is due to the absence of insulin secretion after protein foods are digested. The blood stream is flooded with amino acids that come from the digested protein, and although tryptophan is among the amino acids coming into the body, it is unable to get into the brain since the other amino acids crowd entry points to the brain. Eating protein does not truly comfort or console.

There is a problem, however. If going to an after-funeral lunch is something that is thankfully rare, eating funeral potatoes should have no lasting effects on weight and longevity. But if based on the traditions of your community or the ages of the people with whom you spend most of your time, and you are making frequent condolence calls? Eating funeral potatoes may deposit extra pounds you do not want. It is a very fattening dish mainly because of the number of high fat ingredients, e.g. sour cream, cheese, and butter.

Does this mean that you should eat egg whites instead, despite the lack of comfort bestowed by protein consumption?

Fortunately no.

Your brain does not care whether the carbohydrate that will ultimately lead to more serotonin is loaded with sour cream and shredded Cheddar cheese, or is a dry rice cake, bowl of bran flakes, or a boiled potato. Indeed the absence of fat as in a plain boiled potato will lead to a more rapid digestion, more rapid serotonin synthesis, and more rapid feeling of comfort.

Funeral potatoes are a great comfort. But for the sake of a healthy weight and avoidance of one’s own funeral, a plain baked potato (no butter or sourcream) should be eaten instead.

Generic recipe for Funeral Potatoes
Can Cream of Chicken soup
1 ½ – 2 cups shredded Cheddar cheese
2 cups sour cream
2 pounds package of frozen hash brown potatoes
1 stick butter
Chopped onions-1/2 cup
1-2 cups crushed corn flakes

Why Weight Loss Is Rarely Permanent

Many years ago at a meeting that addressed the usefulness of prescribing appetite suppressants for weight loss, one of the speakers (whose name will not be mentioned in case my memory is incorrect) said,

Obesity is a chronic disease.  Don’t think that allowing a patient to use weight-loss drugs will produce a permanent weight loss, or that other weight-loss intervention will also stop future weight gain. Obesity, like depression, alcoholism or autoimmune diseases, is chronic, and chronic diseases may go into remission because of medication and/or effective behavioral changes….So while sometimes one treatment is sufficient, the depression or skin rash never reappears after the initial intervention. The alcoholic stays abstinent.  Rarely is it that the diet plan or diet drug or surgery produces a permanent, positive change and weight stays normal. More commonly? The disorder reappears, more than once, and requires repeated behavioral, and/or medical interventions. Indeed, chronic treatment may be the only way to prevent flare-ups, a return of drinking, or depression.”

He went on to say that there is a bias toward people who gain weight again and again. We all know this…From the cruel remarks we make when someone is on a diet (Another one? Not again!) or gaining back the weight lost from the previous one (See, I knew she would never keep the weight off! ) to the hopeless attitude of physicians who give up helping a patient deal with constant diet failures (There’s no point wasting time talking about losing weight; he/she never listens.)

Weight-loss advice ranges from suggesting the most ridiculous or severe diets, to the simplistic mantra of portion control and exercise. Or else we keep quiet and shake our heads. “See,” we say to each other, “she has gained back all the weight she lost last year.“ And then we judge the currently popular diet with the comment, “Too bad this didn’t work, either.”

Yet so many of us have friends, colleagues, relatives, and acquaintances who have been abstinent and suddenly are found drinking again, perhaps after years of not doing so. When they are able to resume their AA meetings or come out of rehab, we don’t berate them with, “You failed. What is the point of helping when you will fail again? “ Rather, we support their effects to succeed.

If we treat obesity as a disease with a high probability of reoccurrence, as is the case with depression or alcoholism, then our entire approach to treatment can differ. All interventions will be presented honestly as a means of bringing the patient into remission, which may last weeks, months, or years. Still, the interventions will not be presented as a permanent cure. Taking out a diseased appendix is a permanent cure for a diseased appendix. Staying abstinent, if not a cure for alcoholism, is remission one day at a time.  Losing weight is not a permanent cure for obesity. Rather, it is remission from overeating and underexercising, one day at a time.

Treating obesity as a chronic disease allows a variety of interventions to be tried without blaming the patient if he or she fails to succeed at one or the other. Depressed patients are often switched from drug to drug, and the patient is not blamed when the depression doesn’t respond to a particular medication. Just as talk therapy is considered as important as drug treatment for depression and related mental illness, so too talk therapy should be part of the obesity treatment. Recognising what might erode control over eating is essential for success on a current diet, but also in delaying the onset of another weight gain flare-up. Semi-annual check-ups of weight status must be mandatory so the patient and care provider can identify emotional, situational, or even hormonal changes that might start the weight gain process. Such check-ups should remove the inevitability of weight gain in the minds of the patients.

For example, people who suffer from winter depression resign themselves to gaining weight over the dark months of late fall and winter, since weight gain is one of the symptoms of this particular type of depression. People also assume and anticipate gaining weight over the holidays. But why should this be? Would we assume that a friend, a recovering alcoholic, would start drinking over the winter, or that someone who is depressed every winter not be treated because the depression will come back the next year? If a patient had an intolerable flare-up of psoriasis, which can be maddeningly itchy, then every winter wouldn’t a dermatologist take steps to prevent it from occurring?

Because we don’t view obesity as a chronic disease, we simply do not treat it when we should. We don’t say to someone gaining weight, “You are experiencing a weight gain flare-up. It is important for you to be treated now before the situation becomes intolerable or hard to reverse.” A patient who has reoccurring depression should obviously be treated long before the symptoms become life-threatening. When the weight gain flare-ups occur, treatments also should be initiated. They include appetite suppressants, therapy, consultation with a physical therapist about exercise, use of calorie-controlled meals until control over eating is resumed, and participation in weight-loss support groups.

Of course, none of this will work if the weight-gaining patient refuses to acknowledge what is happening and/or resists treatment. Not all alcoholics who have failed to remain abstinent acknowledge what is happening or seek treatment; when they do, many are able to go back into remission. We must tell the obese individual to stop hoping for permanent weight loss. Keep the weight off today, and we will be there to help you if tomorrow is a problem.

Peak Physical Fitness as Protection Against Dementia

“Good news,” a friend in the gym said, waving her cell phone in my direction. She showed me a news release about a study on the positive effects of exercise in preventing dementia among women. The article published in Neurology (link is external) showed the somewhat startling relationship between being very fit and reducing by almost 90%, the chance of becoming demented.
An air of self-congratulation rippled through the treadmill walkers as the news passed from machine to machine, and there seemed to be a perceptible increase in the intensity of the exercise we were all doing.

Unfortunately, a closer reading of the study revealed that even those who went to the gym pretty regularly were not guaranteed a dementia-free future. Unless we were extremely physically fit we were still vulnerable to cognitive problems as we age.

The study was initiated in l968 when researchers tested the cardiovascular capacity of Swedish women ranging in age from 38 to 60.  The women exercised on an exercise bike that monitored their cardiovascular stamina, and they were told to exercise until exhaustion. One hundred and ninety-one women participated and, based on how well they did on this test, were divided into high, medium and low fitness levels. Some in the low fitness group were unable to complete the exercise because of cardiovascular problems. Forty placed in the high fitness group, ninety-two in the medium-fitness group and fifty-nine in the lowest group.  Those in the high fitness group were not competitive athletes, but their physical stamina and energy utilization measured during the initial testing period indicated their ability to endure strenuous exercise.

Women were tested six times over the subsequent 44 years of the study to determine if and when dementia appeared. The bad and good news is that 32% of the least fit developed dementia, as did 25% of the medium-fit. However, only 5% of the fittest group were affected.

Dementia is not the same as memory loss, although it can be associated with it. Dementia is not a specific disease, but instead describes a cluster of symptoms that affect intellectual functioning, emotional control, the ability to solve problems, maintain language skills, and carry out the functions of daily life. One example of the difference between memory loss and dementia is a person who cannot remember the name of a fork but can still use it to eat. This person has memory loss, but may not be demented. A person who doesn’t know the name of a fork nor its function would be considered to be suffering from dementia.

In the Swedish study, the most common cause of dementia was Alzheimer’s disease (eighty women), although twelve women developed vascular dementia. The latter is usually associated with strokes, some so small they are not even detected. The other causes of dementia were not described.

Before giving up one’s day job to spend more time in the gym to increase physical fitness, it is important to consider that the authors of the study were not sure how being especially fit protected the women from dementia. Nor did were they able to explain why the least fit women were so vulnerable. Moreover, the study did not record whether the women continued to be fit or not during the several decades that followed the initial assessment, and their physical fitness was never measured again.

This sort of study is frustrating on many levels. It is not a cause and effect study, i.e., exercise causes something that protects against dementia. Rather it shows the linkage of two conditions: peak fitness in middle age and significantly decreased incidence of dementia almost 50 years later.

So is it the exercise itself that may alter the brain to prevent cognitive decline? If so, how? Do women with outstanding stamina have different lifestyles? Do they also do crossword puzzles more often or speak several languages, activities that are supposed to improve brain function? The study was done in Sweden, but perhaps the high fitness subjects followed a Mediterranean diet eating mostly grains, fish, olive oil and vegetables. Such a diet has loosely been linked to lower rates of Alzheimer’s disease.

Was there a connection between the levels of their female hormones and their exercise activity? Maybe those who exercised so well didn’t suffer from menopausal hot flashes. Or maybe they did. Who knows?

Does their fitness at fifty result from a childhood and early adulthood spent in strenuous physical activity?  If so, might the positive change in their brain preventing dementia be a result of decades of peak exercise performance and perhaps, along with that, food intake designed to enhance this performance? Should we encourage our children and grandchildren to take on sustained high levels of physical activity, so by the time they are fifty, their brains may be protecting them against dementia?

This study probably took fifty or more years to carry out because of the time spent gathering and testing subjects before it began, and the time spent analyzing the data after it was over. Such studies are difficult to do, and certainly repeat, which is impossible to do in the lifetime of the original investigators. The results are tantalizing and sufficiently compelling to make some, perhaps with a family history of dementia, commit to more exercise, more frequently, and with greater intensity. And if it works to prevent Alzheimer’s disease and other causes of dementia, then regardless of why or how it will be worth doing.

References

“Midlife cardiovascular fitness and dementia,” Hörder, H., Johansson, L., Gu, X., et al, Neurology Mar 2018, 10:1212

Eating When You Are Not Hungry: It’s Called Appetite

The woman who came to see me for weight loss, let’s call her Ann, was about 40 pounds overweight and frustrated, in her words, by, “…a lifetime of weight loss followed by weight gain.” Her problem, she thought, was that when she felt hungry she liked to eat protein because it filled her up. But then she still wanted to eat carbohydrates even though she was full from the protein.

“Why do I feel hungry all the time?” she asked. “Or, more to the point, why do I want to eat when I am not sure that I am really hungry? All the diet plans I have gone on promise to take away my hunger, but I still want to eat.”

“Perhaps you are feeling two different kinds of hunger,” I ventured. “One might be actual hunger and the other, appetite.”

Feeling as if I was wading into the quicksand of definitions of hunger and appetite, I gingerly offered my own explanation. “Being hungry is natural, and it means your body is telling you that you need calories and nutrients. It is a signal, like thirst, indicating that your body needs you to take action. If you are thirsty, you drink water. If you are hungry, you eat. Now appetite, on the other hand, is what you feel when you are not hungry but want to eat.  Perhaps not a very scientific definition, but I think it works.”

I told her that it we often think appetite is hunger, perhaps because we are so rarely really hungry. Hunger is often accompanied by symptoms such as a headache, fatigue, feeling faint or weak (as in weak from hunger), nausea, irritability, and emptiness in the stomach.  Most of us do not approach that dire state before being able to feed ourselves. Conversely, we often, perhaps too often, decide that we are hungry, and need to eat for reasons unrelated to our body’s need for calories.

The difference between hunger driven by the body’s need to sustenance and hunger, aka appetite driven by perhaps emotional or situational needs, can be seen by looking at the eating behavior of an infant, a young child and an adult.

A hungry infant will cry when his or her body demands to be fed. Once fed, the baby often relaxes and falls asleep. But consider the toddler, sitting in a stroller and whining. Mom takes out a sandwich bag of breakfast cereal, often Cheerios, and the toddler spends the next fifteen minutes eating, a distraction from whatever caused the whining. Is the toddler hungry? No. But the toddler has an appetite for Cheerios.

Jump ahead a few decades. The adult misses breakfast and lunch is delayed because of work or other demands. It is three o’clock and she finds it hard to work because lack of food is causing a headache, a growling stomach, and fatigue. An ancient protein bar stuck in the drawer is detected and, even though it tastes like pressed sawdust, is gobbled down. Hunger is at partially sated, and she is able to go back to work.

Two days later, the same adult has consumed breakfast and lunch, and is busily working on a complicated but teeth-gnashing boring document. The adult is grumpy, impatient, and distracted. “I need to get something to eat,” she thinks and leaves the office to go to the lobby snack shop. After buying and gobbling a large chocolate chip cookie, she goes back to her office and is able to resume work. It is no less boring, but she can deal with it more easily. The cookie was eaten because of appetite.

There seems to be a bias against giving in to appetite. We are told not to eat between meals, after supper, or when we are stressed, bored, tired, angry, lonely, anxious, and/or depressed. And yet the impulse to do so is often as great as the need to eat when we experience hunger. Indeed, many of us may experience genuine hunger, the kind that makes even a stale piece of bread desirable, much less frequently than we experience appetite, the kind of hunger that make us debate over what we feel like eating for dinner.

Isn’t it appetite rather than hunger that makes us consider eating dessert? Isn’t it appetite rather than hunger that causes us to polish off all the French fries or continue to nibble at the edges of the apple pie after we have eaten a large piece? Isn’t it appetite that suddenly makes getting an ice cream imperative after we see someone else eating one? Or, when we go to a street fair and smell sausages and onions grilling, isn’t it our appetite that makes our mouth water even though five minutes earlier we were not hungry?

Weight-loss programs promise to curb or eliminate hunger. None mentions appetite. Some say that their program allows the dieter to eat what she wants, so if a brownie is desired rather than cottage cheese? That is fine. But the program guidelines do not distinguish between wanting the brownie out of hunger or out of appetite.

Ann and I analyzed her eating habits to see when she ate out of hunger and when out of appetite. She had the option of trying to eliminate her appetite-associated eating but decided it was unrealistic. She wanted her carbohydrate snack in the afternoon and the option of having another in the evening, even though she wasn’t hungry when she ate these snacks. “If I am going to lose weight and keep it off this time… I have to allow myself to eat the way I want, not the way some diet plan wants me to eat.” She continued to eat protein when she was hungry and allocated a certain number of calories for the carbohydrate foods her appetite urged her to eat.

“I guess I can have my cake, eat it,” she told me paraphrasing a well-known French queen, “and lose weight!”