Starting Antidepressants? About the Weight Gain…

Like hair loss during chemotherapy, weight gain while on antidepressants is not, fortunately, inevitable. And like hair loss, gaining weight should not be justification for refusing treatment with these drugs, as they may be very effective for a variety of mental disturbances, fibromyalgia, and even menopausal hot flushes. Unfortunately, for those who find themselves gaining weight within weeks of starting on their antidepressants or mood stabilizers, losing this weight is much harder than growing back hair after its loss from chemotherapy. Many find themselves struggling to dislodge from 15 or 50 pound months following the end of antidepressant treatment.

Recently, an email arrived from someone who found herself 35 pounds heavier six months after starting on a commonly used antidepressant. She wondered if it was too late to lose weight. Would those 35 pounds be a permanent side effect? Would she ever be able to go back to her original, normal weight?

My answer to her question, “It is never too late to lose weight!” was, I hope, reassuring, but I asked myself why she was not told to notice changes in her appetite and physical activity as she started on the drug. The signs are well-known by now: a new and persistent craving for carbohydrate, a sense of not feeling satisfied after the completion of a meal, increase in between-meal nibbling and possibly decreased physical activity due to fatigue. Had she been weighed before starting the treatment? Was there any record of her biweekly or monthly change in weight? Was she told to weigh herself since her physician may not have had a scale in the office? Was she asked if she is eating more and moving less? None of these measures may have prevented some weight from being gained, but if she and her physician were alerted to changes leading to the first five-pound weight gain, steps to halt additional gain might have been recommended.

As any dieter knows, as more and more weight is gained, the motivation and optimism that it can be shed disappears. After a certain point, a feeling of hopelessness in controlling the weight gain may make the dieter give up entirely. He or she concedes an inability to fit into clothes that were worn several weeks earlier and goes back into the larger pre-diet sizes still in the closet. Exercise programs are abandoned as it becomes more difficult to move those extra pounds.Eventually, when the weight gain becomes cosmetically or medically disastrous, he or she concedes that it is time to (finally) start dieting again.

But the previously normal weight person, now fat from the medication, doesn’t know any of this. Many of these weight gainers never dieted before starting on their antidepressant. Unlike the typical obese individual, their eating was controlled, emotional upheavals did not lead them to consume quarts of gourmet ice cream, and they did not feel compelled to eat even when full because there was still food on the plate. Physical activity was a part of their daily life. It was natural to take the stairs, or walk instead of drive, or go to the gym regularly. And their clothing size was stable.

Indeed, does it even require saying that when such individuals are started on a treatment, which may take away their control over eating and desire to exercise, some advice on how to deal with the weight gaining side effects should be offered? And soon, before much weight is gained?

Happily, doing something to stop antidepressant induced weight gain is easy.You and your doctor should keep track of changes in your eating, exercise, and even sleep, seeing that sleep disturbances also influence eating and activity. Typically, early signs of eating-going-out-of control include feeling strangely unsatisfied after eating an amount of food that from pre-drug treatment was more than enough to satisfy you. This may be accompanied by a new or increased desire to munch on sweet or starchy carbohydrates, urges to snack frequently during the day, or even awakening to do so during the night. is These appetite changes are stoppable. Normally, serotonin, acting on certain receptors on brain cells, produces a sense of satiation or fullness. It is the feeling that ‘I am satisfied, I really don’t want to eat anymore,‘ and analogous to the feeling we have when, after drinking enough water, our thirst is relieved. For reasons still not understood, antidepressants and related drugs, the mood stabilizers, may interfere with serotonin’s ability to bring about this sense of satisfaction. However it is not necessary to know how the drugs interfere with this function in order to do something about it.

The simple solution is to consume, on a relatively empty stomach, a small amount of carbohydrate, perhaps two or even three times a day. Doing so increases the brain’s production of serotonin. And from our clinical and research experience at MIT and a Harvard University associated psychiatric hospital, we found that increasing serotonin seemed to halt the relentless need to snack and the uncomfortable feeling of never feeing full after eating. Our weight management center at the hospital was able to help people successfully lose weight even though many were on two or three drugs, each with weight-gaining side effects. Serotonin also seemed to promote better sleep.

The amount of non-fruit carbohydrate that has to be eaten is really small, about ¾ of a cup of Cheerios, a cup of oatmeal, 6 small graham cracker squares or a slice of bakery-made multigrain bread. These and other nonfat (or very low-fat) carbohydrate foods should provide about 25 grams of carbohydrate (food labels have this information), and contain less than 2 or 3 grams of protein. Protein prevents an amino acid tryptophan from getting into the brain (even though protein contains tryptophan) and making new serotonin.

Exercise is also crucial to preventing weight gain. Your physician may not mention it so it is up to you to find a way to move: walk, take classes at a health club or Y, get a dog that is not house broken, and/or start some muscle building workouts. Tiredness may be a side effect of your medication but you will feel less, rather than more, tired after exercising. Strange but true.

And if you don’t have one, buy a scale. And if you feel generous, buy one for your doctor’s office as well.


Might the Fat Gene Make You Fat If You Were Born After 1942 and Received Penicillin as a Baby?

Born before 1942? If you were and also carry the gene for obesity, relax. The gene won’t make you fat. Born after 1943? Yes, the gene might have a definite impact on your size. A study using information from The Framingham Heart study looked at the link between the FTO gene for obesity and actual weight. The Framingham Heart study is an ongoing research project, started in the middle of the last century to monitor the health of people living in and around Framingham, a town about 30 miles from Boston. The study has been going on for so long that the adult children of the original participants and their children are part of the study. Although many of the original participants have died, their records are available so their health status for example, their weight, can be compared with measurements made on their children and grandchildren.

Researchers at the Massachusetts General Hospital in Boston wanted to see if people with the FTO gene became obese; what they found was unexpected. According to James Rosenquist, lead author on the study published in the Proceedings of the National Academy of Sciences, it depended on birth year. Those with the fat gene born before 1942 did not become obese. Those born after 1942 were likely to be fat. This is true even among siblings from the same family born before and after 1942. For the almost-baby-boomers and beyond, there was a strong relationship between having the fat gene and being fat.

The reasons for the difference pre and post 1942? It’s easy to find them. Packaged cake mixes, electric typewriters and then computers, TV remote controls, extension lines for the phone, drive-in services (so no walking is required to eat or bank), shopping malls, too much fast food, microwaves, clothes dryers, vending machines, super-sized portions, power lawn mowers and snow blowers, cheap food, automation, etc., etc., etc. The authors lump the reasons into one blame, and it’s technology, which arguably does cover just about everything, excluding too large food portions, too little time to exercise, and inadequate sleep.

However, there is one factor that they did not mention, probably because the research is new and has been carried out on mice, but not people. That factor is penicillin, and its effect on the intestinal tract.

Our intestinal tract is inhabited by trillions of microbes, a fact few of us think about until we have a tummy ache. But there are scientists who believe that some of those trillions of microbes might affect whether or not we become fat. It is not clear how these microbes influence how much fat ends up in fat cells, or whether metabolism is speeded up or slowed down, but something seems to be going on. In a recent article in the December 25 issue of the New England Journal of Medicine, a rather startling discovery was reported. Scientists could make baby male mice quite fat simply by giving their mothers while pregnant and then nursing, low doses of penicillin. The antibiotic altered the intestinal microbes of the baby mice which in turn changed their metabolism and how their bodies responded to food. The mice became so obese as adults, they looked like mouse pillows with a head, a tail and a cushion-like body. The power of the penicillin-exposed microbes to turn skinny mice into candidates for Weight Watchers was confirmed when the microbes were given to germ-free mice and those mice gained fat and weight at a rapid rate.

So what does this have do with the fat gene and birth date? Probably nothing. But consider this. Something may have happened in 1940s to make it more likely that babies born with the fat gene would indeed become fat. And that was, for the first time ever, the easy availability of penicillin.

The military had access to penicillin during the Second World War but the rest of the country did not. Production of penicillin was limited until early 1944. In 1943, 21 billion units of the drug were produced in the United States. One year later, the number jumped to 1,663 billion units and then to more than 6.8 trillion units in 1945. Unlike the earlier years, distribution of the antibiotic was no longer restricted and everyone had access to it. Production continued to rise so by 1949, the annual production of penicillin in the U.S. was 133,229 billion units per year and it was now cheap.

So here we have one study that says something happened after 1942 to increase the likelihood of being fat if one has the obesity gene. We have another study, done with mice (so its relevance may be limited), that says changing the microbes in the gut with low doses of penicillin may cause obesity. And from 1944 on, penicillin rapidly became available to everyone.

Coincidence? It will take much more research to know. But it does turn research on obesity in a new direction. If the fat gene slows down metabolism for example, and if antibiotic altered microbes in our intestinal tract also slows metabolism (or increases the absorption of fat), it may explain why some people seem to gain weight so much more easily than others. Now if only researchers can discover how to alter our intestinal microbes so we can lose weight!

How Many Pounds Did You Get for Christmas?

How can anyone not gain weight during the holiday season? Starting with the national binge day, Thanksgiving, the country seems to be in a whirlwind of feasting and drinking. Or at least it seems that way… Stores typically selling shoes or sheets now feature shelves full of imported cakes, candies, nuts, jams, processed meats and cheeses all seemingly encased in hard to remove plastic wrap, as well as fancy liquors whose bottles resembling perfume jars. Going into a home goods store the other day in search of a potato grater (mine seems to have disappeared), I had to avert my eyes from these food displays, feeling my blood cholesterol rising simply by walking past them. Healthy recipes featured on the Food Network, morning television shows and magazines will not appear until the beginning of the new year. Kale salads and quinoa somehow do not have the same appeal as sugar-coated pecans, pork roast wrapped with bacon, the ubiquitous sausage, egg and cheese casseroles, or spinach pureed with heavy cream. And as with the menu for Thanksgiving, the holiday tables, be they set for dinner or a party, must have more food than could possibly be consumed by the guests.

Eating special foods on holidays, and indeed eating much more than normal on holidays, is a very old tradition. The meals were special in large part because they were so different from the sparse and often nutritionally inadequate foods people ate during the rest of the year. Protein-rich foods such as meat, chicken, lamb, pork, and even eggs were simply too costly. Oftentimes foods such as eggs and cheese were sold, rather than eaten, so there would be money to buy the less expensive flour, corn, potatoes, beans and rice. Sweetening agents like honey and sugar were also excessively expensive and thus reserved for celebratory occasions. Fruits such as oranges and bananas, which for us are affordable and available throughout the year, were so rare that an orange took on the status of a Christmas gift.

In the countless books by people surviving in environments isolated by geography, weather, and war, Christmas day was usually a time for eating special foods hoarded for the occasion and made even more precious by previous deprivation. In diary kept by the explorer, Ernest Shackleton during his 1902 trip to the Antarctica with Captains Scott and Edward Wilson, he writes of the chronic hunger all of them experienced, and then records what he managed to make for Christmas:

Christmas breakfast:- a pannikin of seal’s liver, with bacon mixed with biscuits. Each; topped up with a spoonful of blackberry jam; then I set the camera, and we took our photographs with the Union Jack flying and our sledge flags, – I arranged this by connecting a piece of rope line to the lever. Then four hours march. Had a hot lunch. I was cook:- Bovril, chocolate and Plasmon biscuit, two spoonfuls of jam each – Grand!

Then another three hours march and we camped for the night. I was cook and took thirty-five minutes to cook two pannikins of N.A.O. ration and biscuit for the hoosh, boiled the plum pudding, and made cocoa. I must of coarse own up that I boiled the plum pudding in the water I boiled the cocoa in, for economys sake, but I think it was fairly quick time. The other two chaps did not know about the plum pudding. It only weighed six oz. And I had stowed away in my socks (clean ones) in my sleeping bag, with a little piece of holly. It was a glorious surprise to them – that plum pudding, when I produced it. They immediately got our emergency allowance of brandy so as to set it on fire in proper style. [1]

Shackleton saved food from the men’s daily intake so that there could be a special Christmas feast, even if the foods of the “feast” were meager and calorically inadequate. They did eat excessively, but of course they did so only because they typically were consuming so little. In contrast, because most of us are so well fed daily, (unless we are on a diet) in order for us to view a Christmas, Thanksgiving or any other celebratory meal as special, the meal must contain an excessive quantity and variety of food and drink. And alas for many the consequence of this overindulgence is taking home the gift of unwanted pounds.

For the homesteader trying to survive a brutal prairie winter or the sweat shop laborer earning barely enough to pay the rent, if in the unlikely event weight had been gained at a holiday meal, it was lost quickly. Once the holiday was over, people went back to their barely-calorically-adequate and unvaried diets. In her book 97 Orchard St about the lives of tenement dwellers in New York City in the late 19th century, Jane Ziegelman relates how some families eat as their only food for weeks a soup made out of potatoes, onions, and carrots along with stale bread (cheaper than fresh). Others lived on a soup made from lima beans, barley and a chunk of potatoes. No-one kept those pounds from the December feast season for long.

Alas, not so today. Typically by the first of the year, the pounds gathering on our bellies and hips from Thanksgiving are still around by the time we move into the New Year. Some of us attempt to dispose of these pounds by adopting the soups and meager diets of our great grandparents; others with cleanses of lemon juice and water, dinners of charred meat, and copious quantities of green leaves sprinkled with vinegar.

It makes no sense, this going from excessive feasting to self-imposed famine. How much better to make the excesses of the holidays those of generosity and friendship; these are “pounds” that one will gladly take into the new year.


One Order of Fried Chicken: Hold the Calories

Right before Thanksgiving, the FDA announced its new regulation requiring restaurant chains as well as those selling ready-to-eat food; from convenience stores to even movie theaters, to post the caloric contents of the food they are selling. It was not the most fortuitous time to do so, considering that people consuming at least 3,000 calories during the kickoff the holidays feast would not be worried about eating a measly 1,000 calories from a bucket of movie theater popcorn.

The regulations will not go into effect for a year, however, and might be delayed by the protests of some in the food business concerned with the difficulty of providing accurate calorie contents. Pizza chains are concerned with posting the calorie contents of their almost infinite combinations of toppings, and supermarkets announced that they might have to decrease the number of ready-to-eat foods because of the difficulty in calculating the calories in many of their dishes. Moreover, who is overseeing the actual calorie count? Is there to be a calorie inspector counting black olive slices on a piece of pizza or the number of drops of olive oil sprinkled on the cheese? Will the supermarket hire a portion control guard to make sure that customers serve themselves a portion size corresponding to the posted calorie count? Are there officials who will keep track of the chocolate sprinkles on a doughnut or raisins in a raisin bagel? The possibilities of calorie error, yea even calorie fraud, seem endless.

And will any of this have an impact on food choice and ultimately weight?

Those already alert to the pound elevating capacity of innocent-looking foods like whole-fat yogurt with granola or a grilled chicken sandwich with pesto and avocado, will no doubt use the calorie information to prevent themselves from gaining weight and/or continuing to lose it. Others who have a vague idea of the calories in ordinary breakfast or lunch foods may experience something akin to sticker shock.

A chain sandwich shop located down the street has posted calorie contents for its sandwiches, soups, and salads for a few years. A friend told me that several times she walked into the restaurant very hungry but then walked out without buying anything because she couldn’t decide between what she wanted to eat, that is, a tuna wrap, and what she felt she should eat, a kale and egg white salad. The salad contained two hundred fewer calories than the tuna wrap, but she hated kale and wasn’t crazy about egg whites. But she could not bring herself to eat the tuna fish salad sandwich once she knew how many calories it provided. Some, already obsessed with calories and reducing their already skeletal frames to a smaller size, will undoubtedly find that calorie information confirms their worst fears: everything is fattening. Others who want to get the most food for their dollar, like people on a cruise or a teenage boy, might opt for calorie dense food. Why not eat 3,000 calories rather than 500 for the same $5.95 price?

Moreover, how does one reconcile the FDA’s belief that knowledge about calories will affect our eating when a major international weight-loss organization, Weight Watchers, has not used calorie counting for years in their diet program? In fact, how many weight reduction programs ask the dieter to count calories, rather than concentrate on portion size and number of servings of various food groups? How many of us even know how many calories we should be eating?

A construction worker, a corporate lawyer, a mom with two toddlers and an infant, a senior citizen who plays 18 holes of golf daily and foregoes the cart to walk, a tuba player, a taxi driver: what should their calorie quota be? Charts of calorie quotas for different age groups and size are available, but rarely do these charts factor in daily calorie output, i.e. construction worker versus taxi driver. When the food truck comes to a construction site, it is doubtful that the guys buying their meatball subs really care about calories. They have been working for hours, are hungry, and need energy to continue working for several more hours.

The FDA and other agencies concerned with our nation’s weight should put its efforts into informing the public about their personal calorie requirements and how this is influenced by their current height, weight, size and usual energy expenditure. Does the construction worker understand that come Sunday, when he may spend hours in a recliner watching football, he does not and should not be eating as much as during the work week? Does the corporate lawyer who works at her desk for 12 or 14 hours a day know that she can eat more calories on the weekend after several hours of cross-country skiing or a long bike ride? Should a woman in her late seventies, who has shrunk two inches, be eating the same number of calories as she did twenty years earlier? She is shorter because of compression of her spinal cord. Does this mean she should eat less?

On the other hand, and there is always another hand, calorie information is useful for dieters and non-dieters. When we buy something, we obviously know the price. Very few (is there anyone?) would buy something without knowing how much the item costs. Except for the multi-billionaires in the world, almost no one has unlimited financial resources. The same is true for calories. Unless one is training for an Ironman triathlon or has an overactive thyroid, who can eat an unlimited amount of calories? Labeling restaurant food with its calorie content allows us, if we wish, to avoid foods that use up too quickly our limited calorie allotment. If you know that a ladle of blue cheese salad dressing has 500 calories and a light oil and vinegar salad dressing only 100, that information would allow you to save calories and spend them on another food item. The calorie differences between a baked potato even with a pat of butter and a heaping plate of French fries, or between fried clams and baked lobster, gives you the knowledge to decide whether to ‘spend or save’ the calories.

The FDA is not your mother attempting to make your food choices for you. You make choices all your life based on whatever information you have. Calorie content of restaurant foods is helping you makes informed choices. It is up to all of us to use the information wisely.

Should Couch Potatoes Wear Fitness Bracelets?

Looking for a gift for a runner in our family, I wandered into our nearby sports store and stopped by a large display of devices and gadgets that monitor activity: sleep, calories, heart rate, and perhaps in the near future, how well your investments are doing from minute to minute. The price, as well as the tendency of the gift recipient to lose anything not fixed to her body (she is a young teenager), made me look for something else, but it got me wondering who would get the most use out of such gadgets? I have seen the rubberized bracelets on the wrists of people going into spin class or lifting weights, and the ever-increasing variety of devices suggests an ever-increasing market for self-health monitoring. But like the proverbial preaching to the choir, are these fitness devices attractive primarily to the already fit? Or are they like scales, to be avoided if you know you are sedentary and have gained weight?

The relevance of devices that measure activity to those who shun it was pointed out to me by my dog, an exercise avoidant dachshund, who tends to combat me for every inch he walks. Worried that his already slothful ways would increase as the temperature dropped, I considered buying a canine fitness device that, like a human fitness bracelet, would measure his daily mileage or centimeters walked. I reconsidered when I realized that his walking was my walking as he was always on a leash. The free app, MOVES, would tell me how many steps I was taking and although I am too mathematically impaired to see how that corresponded to four footed steps, at least I would get some idea of how weather was changing activity for both of us. Indeed, on some exceptionally frigid days, we both were quite sedentary (except that I could go to the gym).

Everyone knows that we as a nation are growing fatter, and lack of physical activity still remains one of the most prominent causes. But how much physical activity do we not do? How sedentary are we?

Patients who come to see me for weight-loss counseling usually claim to exercise a few hours each week and only a few would acknowledge how little they actually do. Those with gym memberships are vague about how many times they worked out and walkers are equally vague about the frequency of their perambulations. In fact, their vagueness is matched only by their inability to recall with any accuracy what they eat every day, especially at non-meal times. And once on a diet, promises to increase their physical activity are made but unlike Robert Frost’s poem, rarely kept.

Measuring physical activity, either with a free APP or purchased device, might be extremely useful in helping my patients reach their weight-loss goal. Calorie intake is only one part of the weight-loss process, and if physical activity monitoring showed very little activity, it would explain why the pounds were coming off so slowly.

Conversely, most people on diets, or just those seeking to become fit, would respond positively to even a slight increase in the number of steps taken and miles walked each day. The MOVES app tells you, as soon as you turn on your cell phone in the morning, how much walking you did the day before. And sometimes the results are surprising in a good way. You the walker might think you did relatively little walking the previous day, and find that all that going and coming from the basement to the attic, shopping at the mall for holiday gifts or, in my case, walking the dog, adds up to a respectable number. Suddenly it doesn’t seem so hard to move off the couch and get moving. And the congratulations, “Today is an all-time personal best for you” message appearing on the phone is a virtual pat on the back, and must have some positive impact on continuing to move.

The days that show little activity are just as important. Why was there so little walking? Was it because you had to sit in meetings, at your desk, or in a plane all day? Were you stuck doing errands and chauffeuring kids around? Was it simply too cold or too hot to walk outside? Were you getting or getting over a cold? Some situations that prevent you from walking may be resistant to change; you can’t alter the polar vortex or stop a trial so you can go for a walk. But if your app or monitoring gadget shows about the same amount of activity as if a 200 year-old tortoise wore it, then this is a warning of transformation back into a couch potato. Even something as simple as walking rather than sitting if you are talking on the phone, or getting up from your desk chair rather than rolling it over to the printer add steps to your day, and therefore caloric burned.

It is not easy to get thin and fit, especially as we recover from Thanksgiving and head into the pudgy season of Christmas. But these monitors may help support you, each step along the way.

Hold the Gluten! Pass the Fat! The Contemporary Thanksgiving Meal

The Thanksgiving day menu from the Fall of 1621, when the Pilgrims and the Wampanoag Tribe feasted in gratitude for the newcomers first harvest, has gone through profound changes. Yes, turkey was on the menu but not the main dish. Turkeys in the early part of the 17th century were probably not unlike the drab, skinny, aggressive birds roaming the inner suburbs of Boston, terrorizing small dogs, children, and on occasion even postal workers.  These urban turkeys do not resemble the plump fowl we’ve come to expect for our contemporary Thanksgiving meal, and it is easy to see why duck, venison, lobster, oysters, and clams had pride of place, along with squashes, berries, and a baked cornmeal-like bread. They did not yet have wheat.

A century later, Alexander Hamilton proclaimed that turkeys should be eaten at Thanksgiving  (maybe the turkeys in his neighborhood were better looking) but it wasn’t until the mid-19th century, when Lincoln made Thanksgiving a national holiday, that turkey rather than lobster, venison or pot roast, for that matter, became the traditional dish.

Today’s Thanksgiving day menus barely resemble the foods eaten in the early 17th century:  the Pilgrims should be thankful that marshmallows had not yet been invented, and they might have been perplexed at how they could stuff those scrawny turkeys with a soggy mass of  bread , celery, apples, chestnuts, raisins, and sausage. If they had followed contemporary cooking fads and fried their turkey, Massachusetts might have been set on fire, and turkey made out of tofu would have sent many early settlers scrambling to get back to England, where birds were not made from soybeans.   

As our country became regionally and culturally diverse, so did the Thanksgiving menu. Years ago, I was invited to a Thanksgiving meal at the matriarch’s home of a large Sicilian family, and if there were turkey on the table, it was hidden by the bowls and platters of lasagna, sausage, escarole, meatballs, and fried eggplant. This one dish of stuffing, aka dressing, is our continental consistency, however, and its ingredients are a prime example of our regional and national diversity: in the South, cornbread is the main ingredient but in other areas stuffing came be made from white, wheat, or rye bread. Additional ingredients include oysters, apples, chestnuts, raisins, celery, sausage, and even cheese and raw eggs.  

Now home cooks are facing new challenges to their Thanksgiving Day meal that go beyond  whether to put marshmallows on the sweet potato casserole, or how to separate Aunt Mary from nephew Sam so they won’t spend the entire meal arguing politics.  These issues pale before the problem of: What can I serve to satisfy the never ending food issues of the guests? Should I have asked them to fill out a food preference list a few weeks ago so their specific needs will be addressed?  

Attending to the foods likes and dislikes of family members and friends is as probably old as Abraham serving goat (or maybe lamb?) to the three angels who appeared before his tent.  An older relative always had beef and chicken dishes available at any dinner party she hosted in case, as she always told me, “What if someone doesn’t like brisket?” My response, to serve them cornflakes, was ignored. But now, the needs of guests have expanded far beyond food allergies, low salt or low fat diets, and a persistent hatred of Brussel sprouts.  

Sensitivity to lactose, the sugar in dairy, must be noted before adding evaporated milk to the pumpkin pie, or butter (it contains milk solids) to mashed potatoes and string beans. Those adhering to the Paleo aka The Caveman Diet, should be given their turkey more or less raw with perhaps a hunk of wooly mammoth as dessert. The high fat advocates? They will want to skip the vegetables, unless they are saturated with butter and cream, but will ask that the layer of turkey fat on top of the gravy not be skimmed off before being poured over their meat. And of course the gluten-free folk will find foods compatible with their need to avoid this wheat protein, but only if the menu is kept as simple as that of the Pilgrims. Boiled squash, pumpkin, ground corn, and berries, along with the turkey should be a safe for them to ingest, and they must be warned away from touching the biscuits, cranberry bread or pies, as eating them will surely cause distress. (I suspect not eating those luscious pies should also cause them some distress.) The easiest guests to feed are those following the Cleanse Diet; just give them a glass of warm water and lemon juice.

Thanksgiving is a meal commemorating the survival of the plucky Pilgrims through the harsh winters, cold springs and uncertain summer harvest. They made it, thanks in large part to the help of the Native Americans with whom they shared this feast. Their meal, lavish in relation to what they had to eat daily, was a feast and they gave thanks to the abundance of food before them. Now, living in a society with a daily over abundance of food, it is not strange that for many, today’s Thanksgiving meal is a testimony to what we cannot eat rather, than being grateful for what we have been given? 

Chasing Away Insomnia With a Bowl of Oatmeal

Mike, the guy behind the desk at the gym, was yawning so much he could barely say good morning. “Late night?” I asked him. “No,” he yawned in reply. “I haven’t been sleeping well for days.”

“How long have you been on the high-protein diet?” I asked, knowing nothing about what he had been eating, but guessing he had fallen prey to the fitness hype about the benefits of avoiding carbohydrates.

I was right. Mike’s sleep problems started two weeks earlier because he had cut all starches and sugars from his diet. Now his sleep was like a yo-yo: asleep/awake/asleep/awake all night long.

“I go to sleep at midnight, and I wake up at 2 or 2:30. I then fall back asleep, and I’m up again in another hour. My mind is racing, and I feel agitated and simply can’t relax,” he told me.

If Mike had searched the Internet during those wakeful early morning hours, he would have read countless anecdotes from others describing similar sleepless nights. Whether the problem was failing to fall asleep easily, or get through the night without multiple awakenings, all the insomniacs had one thing in common: they were on high-protein, low or no-carbohydrate diets.

This is not to say that there are not many other causes of sleep disturbances from taking too long to fall asleep, trouble staying asleep, or waking up too early. Anxiety, age, sleep apnea (which awakens the sleeper many times during the night), drug side effects, some degenerative diseases, and even shift work are but a few of the obstacles preventing this most natural and wanted behavior. But if someone stops sleeping normally at the same time as he or she stops eating carbohydrates, it does not take a sleep disorder expert to figure why…too little serotonin is the cause.

Serotonin, the multi-functional brain neurotransmitter, normally soothes your brain into a calm and tranquil state so sleep comes easily. If you awaken, serotonin prevents the anxiety demons from leaping out and filling your brain with worries that prevent you from falling back asleep.

To some extent what we eat influences whether or not our brain is able to make serotonin. More than 30 years ago, research at MIT uncovered the connection between the consumption of any carbohydrate (except fructose) and serotonin synthesis. The release of insulin after carbohydrate is digested indirectly

helps an amino acid, tryptophan, get into the brain. Once there, tryptophan is converted through a biochemical process into serotonin. However, when more than small amounts of protein are eaten along with the carbohydrate, this process is blocked.

Serotonin synthesis was never in peril until recently. For most of our history, carbohydrates have been a staple of our diets, and being told to avoid them would have been as unimaginable as being told to walk on our fingers. Alas, the self-appointed nutrition gurus who are convincing us that the eating of carbohydrates will destroy our bodies, or at the very least, turn us into a human version of Humpty Dumpty, don’t understand that we have to eat carbohydrates if we are going to make serotonin.

When you are awake at 2AM searching the Internet for help with your insomnia, you will come across bland assurances that eating protein will give you the tryptophan you need to make serotonin. To borrow a phrase from the Gershwin’s Porgy and Bess,”… It ain’t necessarily so.”

Here are the facts: Eating protein prevents tryptophan from getting into the brain. Eating turkey does not increase the tryptophan in your brain (you are sleepy after the Thanksgiving Day dinner because of the fat you have just eaten). The research evidence conclusively shows that tryptophan is blocked from entering your brain after you eat protein.

So as you lie awake in your dark bedroom wondering whether you will fall asleep before the alarm goes off, contemplate your problem: sleep or a high-protein diet?

But good grief, you will say. If I eat carbohydrates, like the man in that Kafka novel, The Metamorphosis, I will wake up with my body horribly altered? (Kafka’s hero became an insect). Pounds will attach themselves to my body as I sleep, and I will need a tarpaulin to cover my now massive body!

Well, yes you might, if you eat croissants, doughnuts, mega-muffins, scones, French fries, potato chips, tortilla chips, baked potatoes leaking butter, and crackers covered with 80% fat cheese. Oh, and of course, weight gain is to be expected from consuming too much chocolate, ice cream, cookies, cake and piecrust. These foods are not just carbohydrate but full of fat, too. And since fat contains more than twice as many calories as carbohydrates, if you eat copious quantities of any high-fat foods, you will gain weight.

But you can get a decent night’s sleep, and leave the tarpaulin outside, if you eat very low-fat or fat-free carbohydrates like ¾ of a cup of plain Cheerios or Rice Chex, a small bowl of oatmeal, toast with strawberry jam (the sucrose supercedes the trace amount of fructose), or a graham cracker square. Don’t wait until the middle of the night before consuming the carbohydrate. Instead, eat a small, 120-calorie carbohydrate snack twice a day, before or several hours after you eat protein. This will help increase serotonin synthesis before you go to bed. If you have been on a low or no-carbohydrate diet for several weeks, it may take some time to restore your serotonin levels. So don’t worry if you still wake up during the night for a few more days. Eat another small snack. You will be back to sleep in about 20 minutes.

Try this. You have nothing to lose but your insomnia.

When Kids Grow Fat From Medication, Who Protects Them From Being Bullied?

The good news is that the increase in obesity in kids seems to be leveling off. Perhaps this is due, in part, to healthier school lunches and/or an attempt to get kids to exercise more. It’s a good thing, because fat kids are likely to be a verbal and physical punching bag at school, in their neighborhoods, and often at the family dinner table.

That obese adults are targets of verbal abuse, often from strangers as well as from officious relatives and nasty co-workers, is well known. Their ability to defend themselves is limited. Unlike hate speech, there is no legal penalty for laughing at the body of someone else, and it is hard to prove that obesity is involved in job discrimination. But adults sometimes have the option of escaping from situations in which they are victims. They don’t have to see offensive relatives or spend time with puny-brained fellow employees who feel good by making others feel bad.

Children don’t have escape routes from bullying, even when parents and school officials get involved. What happens on the walk home from school, or on the playground away from the eyes of a monitor, in the school bathrooms, or on Facebook, is often not preventable no matter how many meetings of school officials and declaration of no-bullying policies.

Obese children are the most likely to be bullied.

The National Education Association (School Psych Rev 2013; 42:280-297) reported weight-based bullying to be the most prevalent of all causes of bullying, and not just among younger children but among obese teens as well. Sadly, criticism and worse about their weight seems to come from parents and teachers as well (Pediatrics 2013; 131 abstract).

Now imagine a kid, formerly thin, who gains 50-75 pounds from medication he is taking to control uncontrollable rages or impulsive behavior or anxiety or depression. A pediatrician at one of Boston’s leading pediatric departments told me that such kids who are put on anti-psychotic medications to control severe behavioral problems might be able to be mainstreamed in school. But now the 7-year-old who weighs as much as a 13-year-old is the victim of bullying. He is still fragile emotionally, and perhaps not well socialized into his peer group because of his mental problems or autism or Asperger’s syndrome. He no longer can run fast, bend down to pick up a ball, do gymnastics, or climb a rope. He is alone in the proverbial school yard or bathroom. Who is protecting him from the inevitable teasing? These children are supposed to be helped and supported en route to being integrated into conventional schoolrooms, but bullying presents a barricade that many may not be able to overcome.

Putting such kids on a diet seems like an obvious solution, except that these kids can’t prevent themselves from overeating. Their medication is making them constantly hungry and unsatisfied with food portion levels that kept them full before going on their meds. And like adults who gain weight from the same medications, few, if any weight-loss interventions really grapple with the cause of the weight gain or come up with interventions that counteract the effect of the drugs on food intake.

Medications and other interventions like physical therapy have been developed to handle the side effects of chemotherapy and other medical treatments. Anti-nausea drugs, medications to control vertigo or mouth sores, and physical therapy to help overcome muscle and nerve weakness and pain are among only some of the ways drug side effects are being combated. But weight gain from drugs taken to help mental illness is the blind spot in the battle against drug side effects. The problem is ignored, rationalized as a small price to pay for the therapeutic benefits of the treatment. Or, the obese patient is handed off to a conventional weight-loss program with no experience in dealing with this specific cause of weight gain. If most of these programs have little or no permanent success treating obese individuals who gained weight the traditional way, how then can we expect any success among those whose meds are making them eat too much and too tired to exercise?

Prevention may be the only workable answer. When children are started on these medications, parents must be alerted to the increased appetite that will follow and advised to restrict or eliminate highly caloric foods in their homes, school lunches, and restaurants like fast-food chains. The child must also be encouraged to exercise constantly to prevent weight gain from becoming so excessive that it becomes difficult to do so.

And parents, teachers, school staff and relatives have to protect their child from becoming a target because of his or her weight gain. The child is already a victim of the side effects of the medications; more victimization is unthinkable.

I’ll Have a Glass of Grapefruit Juice With My Bacon Fat

How can it be? A dieting concept that is more than 80 years old and should have been laughed out of existence now suddenly may have some validity. The concept is grapefruit juice. My mother-in-law went on the grapefruit and lamp chop diet in the early 1930s (lamp chops were a lot cheaper then) to lose weight before her wedding. She told me about it years later, and wistfully recalled how quickly the weight came off.

Listening to her, my unspoken, but cynical take on this (she was my mother-in-law, so of course I did not say anything) was that restricting food intake to two or three items always causes weight loss. Boredom and even intestinal discomfort usually occur after a couple of weeks, if not sooner, and often the choice not to eat seems preferable to consuming, yet again, another grapefruit or well-done chop. Of course the weight came back, but that is true of most diets.

But the dieting world wasn’t done with grapefruit, even if my mother-in-law, after her wedding, was. It kept on popping up as a fat-burning food despite the lack of any credible research to support the claims. The Depression and WWII interfered with further promotion of grapefruit as a weight-loss stimulator. First, people didn’t have enough to eat and later, during the War years, rationing and limited food supplies must have made any dieting effort seem irrelevant and nonsensical.

But leaping ahead to the l970s, we find grapefruit emerging as the star food of the Hollywood Diet, or the Mayo diet, supposedly endorsed by the Mayo Clinic, which disdained to have anything to do with this fad. But here again, the diet was all smoke and mirrors. Of course the dieter would lose weight eating grapefruit at every meal. The dieter would have lost weight eating raw rhubarb at every meal. Only 800 calories a day were allowed on the diet, and like the Atkins program later on in the century, no carbohydrate was allowed. Only meat was okay to consume, although probably the cost of lamb chops was high enough so hamburger was substituted.

But the search went on for that elusive something in grapefruit that in some people seemed to promote more weight loss than expected from their daily calorie intake. It is known that grapefruit contains the chemicals naringin and hesperidin that have antioxidant activity. Could these be responsible for some unanticipated weight loss?

A study published in the journal Metabolism in 2012 by Dow, Going, Chow and others set out to answer conclusively whether grapefruit contained a potent weight reducer. The results were inconclusive. Overweight subjects who ate a half a grapefruit before each meal did not lose any more weight than control subjects who were not allowed to eat any grapefruit. Total cholesterol and the bad kind of cholesterol, LDL, decreased in the grapefruit group, as did their waist measurement but the differences were not statistically significant. However, the smaller waists of the subjects indicated that they might have lost belly fat, which is important in terms of cholesterol and blood pressure levels.

So is grapefruit moribund as a weight-loss activator? Apparently not. My mother-in-law may have lost weight not just because she became nauseated at the thought of eating another lamb chop and piece of citrus. Or to be precise, grapefruit juice now seems to be a potent inhibitor of weight gain if you are a mouse who loves to eat fat.

A few days ago, a group from University of California, Berkeley reported that mice that were fed a high-fat diet and drank pulp-free grapefruit juice gained 18 percent less fat than fat-eating mice that drank water. The grapefruit drinkers also had healthier glucose, insulin and triacylglycerol (a type of fat) levels in their blood. The study, conducted by Andreas Stahl and Joseph Napoli, was published in Plos One, a highly reputable online journal.

The mice were fed a diet that would have made Dr. Atkins weep with joy: it contained 60-percent fat and they ate it for 100 days. Mice in the fat-eating control groups were given water rather than grapefruit juice, and other groups were put on a healthier low-fat diet and given either the juice or water. And finally, the chemical naringin, which was assumed to be the reason people lost weight eating grapefruit, was given to two other mice groups also fed either high-fat or low-fat diets.

Against their expectations, the researchers found that the mice eating massive quantities of fat and drinking grapefruit juice gained substantially less weight than the water drinking, high-fat fed mice. Mice eating the more typical mouse-like, low-fat diet (mice normally do not feast on very fatty foods. They prefer grains, seeds and nuts) did not show much of a change in their weight regardless of what they were drinking. And naringin had no effect at all on decreasing weight gain.

These results perplexed the researchers, especially after they looked for typical explanations as decreased absorption of the food, increase in activity, and perhaps the fact that eating mostly high-fat food made the mice less hungry. None of these factors was responsible for the decrease in weight gain.

Obviously, human studies along with more animal studies must be done to find out how the juice from a particular citrus fruit could prevent weight gain on a diet that otherwise would provoke it. But this first report certainly raises intriguing possibilities.

Might a weekend of eating whipped cream-topped chocolate mousse and sausage, bacon and cheese omelets with butter drenched toast prevent the scale from imploding if you drink grapefruit juice along with your meals? Regardless of the answer, you can be sure that weeks from now there will be advertisements on the Internet promising magical grapefruit juice pills that will do just that.

Can You Get Scurvy If You Eat Out Too Much?

Soon after arriving home from a short trip to Manhattan, I took a vitamin pill.  No, there was nothing arduous about the return journey that required a dose of nutrients. But on the train back to Boston, I reviewed in my mind the various places where we breakfasted and dined (lunch was usually skipped) and realized, that except for a shared salad at one dinner and some fruit at a breakfast, I had failed miserably at consuming the recommended daily servings of fruit and vegetables.  For a 2000-calorie diet, the recommendation is to consume about 2 -2 ½ cups of fruit and 2 cups of vegetables daily.

This wasn’t because I had left vegetables and fruits untouched on my plate. There were never any on the plate. The restaurants (Greek, French, and mixed American), chosen by consensus, had large selections and theoretically should have been able to supply some vegetables. Indeed, the Greek fish restaurant did have appetizers, i.e., Meze, that incorporated some vegetables like eggplant and cucumbers into purées, dips and wraps (like grape leaves).  But the main courses in all three restaurants presented an entrée on an otherwise naked plate. To be sure, vegetable side dishes and salads were available but the size and, quite frankly, the cost of these extras made them less attractive. Somehow spending the money for three grilled asparagus that one would spend for a pound of the same vegetable at Whole Foods seemed like an unjustifiable extravagance.

Desserts were not considered but quick polite scans of the dessert menu (after all, if a server puts one in your hand, the least one can do is look at it) showed a uniform absence of anything resembling a fruit.

Obviously eating away from home because of business, travel or vacations is not going to cause acute malnutrition. And is certainly possible and not that all difficult to choose restaurants that offer enough vegetable and fruit selections to satisfy the USDA nutrient intake recommendations as well as one’s mother. Had we been eating on our own, we would have done so.

But we have come a long way from the time when all restaurants put vegetables on the plate, gave you a salad along with the breadbasket, and included fresh fruit on the dessert menu. There was a time when cafeterias were as common as fast-food restaurants are today, and the number of cafeteria trays holding vegetables was as numerous as those containing meat, chicken or fish. To be sure, the salad may have consisted of watery iceberg lettuce and tasteless tomatoes, and the vegetables came straight from an industrial size can, but no one expected a lunch or dinner meal to consist only of a solitary protein entrée. Fifty or sixty years ago, if you were served a plate with two lonely lamp chops or a chunk of fish and nothing else, you might have thought the server forgot to put the two veg and a potato on your plate.

Like other cultural changes that creep up on and take hold (who remembers records and landlines?), we don’t notice the chronic absence of vegetable options in the “nice”’ restaurants, or our habit of putting together our own meals without including them.  And a result, we fail to notice that we may have stopped eating vegetables altogether. They have become a forgotten food.

In contrast to the ongoing debate over high and low-carb or high & low-fat diets, the extraordinary powers of protein to turn us back into Paleolithic cave people, and the devastating effects of gluten on the brain, no one discusses vegetables.  Who debates the merit of spinach over kale or Brussel sprouts over broccoli? When was the last time the Science section of leading newspapers had research on the merits of vegetable consumption? 

Fortunately, there are some recent trends that may forestall an outbreak of scurvy or other nutrient deficient diseases. Leading chefs are inventing ways of turning the ordinary carrot, string bean or beet into creative, original dishes that rival the importance of the protein selections on the menu. Vegetable-laden smoothies and juices are becoming ubiquitous; the selection of bottled vegetable juices go far beyond V8, and juice bars allow customization of vegetable and fruit mixtures. Mixed drinks containing vegetables haven’t found their way into wine bars yet but someone will come up with an alcohol beverage that somehow incorporates kale. Supermarkets have, for many years now, made vegetables available for immediate consumption. No washing, peeling, slicing or dicing necessary; just chewing.  And to remedy the “How do I get my family or spouse to eat vegetables?” problem, many frozen varieties are sold with sauces or suggestions on how to transform the pea or carrot into a gourmet dish.

But….the vegetables have to be bought and eaten at home, not left to gradually decompose in the vegetable bin. If eating away from home is more frequent than dining in one’s kitchen, restaurants should be chosen that offer healthy salads and vegetable side dishes with affordable prices.  Most restaurants display their menus on the Internet so it should be possible to find some that do not regard vegetables as a colorful garnish.  The cost of those vegetable side dishes could be decreased if both the entrée and the vegetables and/or salad, are shared.  Lunch is an easy meal at which to eat vegetables as these days many feature salads or salad bars; even airport restaurants offer a variety of freshly made salads. (Our problem in New York was that we skipped lunch).

It takes some effort to develop scurvy; even the British sailors who did so were not vulnerable until many weeks of vitamin C deprivation. But it also takes a little effort to remember that vegetables are part of a healthy diet and should be hunted and gathered, even if the gathering is at a salad bar.