If Antidepressants Don’t Cause Weight Gain, What Does?

To Sally (not her real name), who wrote to me recently about her 100-pound weight gain after being given antidepressant medications for fibromyalgia, the recent study carried out by a group from the Massachusetts General Hospital will come as a surprise. Before starting treatment, her weight was normal, but after a year on a combination of Effexor and Celexa, she went from petite to extra large. Yet according to a study published a few days ago in the online issue of JAMA Psychiatry, this should not have happened. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. Most of the 11 antidepressants taken by the patients produced similar, small amounts of weight. Elavil and Wellbutrin were associated with the least weight gain and Celexa, the most. But even though Celexa caused significantly more weight to be gained, the actual amount was only a few pounds. Conclusion: The researchers said that patients should not be scared of taking antidepressants because they think they will gain weight. [1]

Although the electronic medical records refuted the connection between antidepressant use and substantive weight gain statistically, it left unanswered the question of how to explain more than a decade of reports of weight gain on these medications. A psychiatrist colleague told me that when he prescribes antidepressants, it is a race to get the patient feeling better before the weight gain is so great the patient decides to stop the medication. How does one reconcile the face-to-face experience of practitioners with the results of this medical record survey? What does one say to Sally and others like her? Your weight gain of 100 pounds on a combination of antidepressants is not related to your therapy? Even though your weight was normal before you started your therapy, you might have gained the weight anyway?

Maybe the explanation is to be found in the type of depression being treated. A Swiss researcher, Dr. Aurelie Lasserre, measured changes in weight over five years among more than 3,00 Swiss who live in the city of Lausanne, Switzerland. As reported in another issue of JAMA Psychiatry, about 7 percent of this population suffered from major depression. Weight was gained among those who had depression, but according to the author, only among those who had what she described as atypical depression, a depression characterized by increased appetite. [2] An example of atypical depression familiar to many of us is seasonal affective disorder (SAD). This winter-based mood disorder is associated with an increased appetite and people often gain 10 or more pounds during the weeks of limited sunlight.

Dr. Lasserre’s findings do not look at whether antidepressants are causing weight gain. However, they suggest that people who gain weight on antidepressants may be doing so not because of the medication, but because their depression has not gone away, and thus they continue to overeat.

This is a handy explanation but leaves several issues to be resolved:

1. Most people are of normal weight before starting on their medication despite weeks of the mood disorder. In my experience running a weight-management center at a psychiatric hospital, most of our patients never had trouble controlling their food intake until they started antidepressant therapy;

2. If the weight gain during antidepressant treatment is a function of an underlying tendency to gain weight while depressed, then how does one explain the tendency of a particular drug, Celexa, to cause more weight gain than other drugs? [3] Theoretically, no drug should be affecting weight;

3. If antidepressant drugs are not associated with weight gain, what is the explanation for the results of a year-long weight-loss trial with Prozac, many years ago, in which non-depressed, obese patients, gained weight? [4]

4. And what about Sally? She was being treated for fibromyalgia, not atypical depression.

Alas, statistics are not going to help Sally and the many others who have indisputably gained weight on their antidepressant treatment, regardless of why they were being treated. One hopes that patients who are gaining weight are not ignored their weight gain because a study says that they should not be doing so.

References:

1) http://www.nlm.nih.gov/medlineplus/news/fullstory_146648.html

2) http://archpsyc.jamanetwork.com/article.aspx?articleid=1878921#Abstract

3) http://consumer.healthday.com/mental-health-information-25/psychology-and-mental-health-news-566/weight-gain-from-antidepressants-is-minimal-study-suggests-688510.html pp 13

4) Michelson D., Amsterdam J., Quitkin F. et al . Changes in Weight During l Year Trial of Fluoxetine, Am J of Psychiatry l99, 156-1170-1176

Are Australians Becoming the New Fat Americans?

On our first recent trip to Australia, I could hardly wait sighting our first kangaroo, hopefully with a joey (baby) in its pouch. They did not disappoint, nor did the adorable but totally inert Koala bears, cockatoos with designer plumage (who talked back to me), wombats which looked like horizontal furry fireplugs and the platypus, first seen in a 2nd grade book on mammals that lay eggs.

But what I did not expect to see were obese Australians. My uninformed image of the sheep rancher in the outback, the crocodile wrestler, or surfer barely escaping shark attacks made me assume that all Australians were lean, muscular, vigorous, tall and wind-burned. And in the first city we visited, Sydney, this was largely true. No sheep ranchers were in sight but the crowds of men and women going off to work in their suits, briefcases, and sleek hairdos were by and large thin or of normal weight. They walked fast and looked like they spent some of their leisure time in gyms, or running or biking.

However, in conversations with some health writers, including physicians, at meetings my husband and I attended, I quickly learned that the low BMIs (body mass indexes) of Sydney residents were atypical. “Just wait until you get into the suburbs, small towns and other cities,” they told me. “Then you will see how fat we Australians are becoming.” And indeed, not only were their observations accurate, they were also reinforced by daily newspaper accounts about the obesity race Australians were about to win. Even though we Americans still rank number one in our prevalence of obes

One of the reasons given for the rapid rise in weight gain was to enable Australians to disguise themselves as Americans when they traveled abroad, but my nutritionist /health writer acquaintances described other causes as well:

• Too large portion sizes (although not as large as ours)

• Little awareness that excessive calorie intake will caused weight gain.” People seem not to understand that eating a fast-food lunch of 2500 calories will affect their weight,” one health journalist told me. “People just think they are getting more for their money.”

• Too much sugar in their beverages, both hot and cold. Australians love their coffee, which is understandable as it is superb, and are more likely to add sugar to their drink rather than a non-calorie sweetener. And they drink many fizzy, sugar and fruit-flavored drinks along with sugar- filled sodas.

• Butter is consumed like water. “Watch how we eat our bread and rolls,” another told me. “We slather it on, carefully covering the entire surface of a piece of toast or roll and would be horrified if bread were not served with butter. “ She was right. At the various dinner-lecture evenings we attended, I noticed that everyone split opened their roll and carefully used up the two pats of butter placed next to their plate. And at the ubiquitous breakfast buffets, the toast had a thick layer of butter before being layered with several slices of fatty bacon and/or sausage.

• Snack foods are very high in fat as well as sugar. Our low or fat-free starchy snacks like pretzels, rice crackers, and popcorn are not that common and people will, for example, eat scones, pastry tarts, doughnuts, and turnovers with an afternoon cup of coffee.

• As in the U.S., too little exercise is also linked to obesity among adults and children. Long commuting times and work hours, lack of physicaleducation in schools, and disinterest in playtime for children adds up to a sedentary life style.

Advice on stopping and reverse obesity was similar to those in the States: cut out sugar, increase physical activity, and eat less meat (they are great meat consumers). Also, consume more fruits and vegetables, whole-grain products and low- fat dairy foods. But none of these recommendations addressed what I was told was the major contributing factor to obesity: alcohol intake.

Everyone I asked told me that many Australians might drink a bottle of wine every night at dinner and then really drink over weekends. A physician friend said that binge drinking was common and not just among the young.

A young female wellness advocate said that she is pressured to drink excessively when out with friends. She went on to tell me that no one talks about the calories people consume from alcohol. It is rarely mentioned as a cause of obesity. And no attempt is made to decrease alcohol intake to promote weight loss. “The reason,” she went on before I could ask, “is that drinking is a cultural thing. It is who we are, what we do, and people are not willing to change. They focus on cutting out sugar even though that has 4 calories per gram and alcohol has 7. ”

She was right. Scanning articles suggesting ways of losing weight, I found all the familiar 21st century recommendations such as eating gluten-free foods, drinking smoothies made of lemon juice, kale, and kangaroo tail (no, not really), avoiding all sugar, fasting and feasting diets, and lap banding, an increasingly popular form of bariatric surgery to shrink the stomach.

After spending only two weeks in Australia, I hardly qualify as an expert on any aspect of their obesity problems. It took me almost this long to learn how to order coffee (black, white, long, flat white). But I suspect that just as with the U.S., the medical and financial costs of obesity will bring about changes, even in the current untouchable aspects of their butter, meat and alcohol intake. If not, most of the population will end up looking like wombats.

e adults and children, the reports stated that obesity was increasing at a much higher rate in Australia than in the States. And children, according to one long weekend newspaper article, were becoming so heavy, that it was hard for some of them to walk.

Unfit & Proud of It!

There is little dispute about the health benefits of physical activity. A comprehensive review of 152 articles studying the health benefits of exercise was published in the Canadian Medical Association Journal in 2006, providing evidence that physical fitness decreases vulnerability to a variety of medical problems and improves overall quality of life.

So why isn’t everyone exercising? Why aren’t we all fit? According to the Centers for Disease Control and Prevention, only 20.6 percent of us meet fitness guidelines for aerobic and muscle-strengthening physical activities. The number is rather shocking, and indeed probably would be even lower were it not for some occupations, such as construction or farm work, that involves sustained physical labor.

There are many in the 80 percent of the population who do not meet physical fitness standards, but would if they could. The reasons for this deficit include that time to exercise is incompatible with their over-loaded life; terrible weather conditions (too hot, too cold); too little money to join gyms; too much travel; too many home obligations; pain and disabilities; shift work; long commutes; caretaking for parents; and probably dozens of other reasons. Until exercise becomes compatible with the constraints of their lifestyle, they are simply unable to do it on a regular basis.

And yet, for many in the 80-percent unfit group, the response to such statistics is: So what? Who needs exercise? An older couple I recently met, let’s call them the Smiths, told me, quite proudly, that they never exercised in their lives. They obviously do walk since, unlike some ancient potentate, they are not carried from place to place on a litter. Presumably, they also climb stairs occasionally or bend down to pick up something they drop. But they valet park their car; use elevators rather than stairs; avoid recreational activities like hiking that require physical effort; and overall seek to avoid breaking into a sweat when moving. Assiduous dieting keeps them trim, for their age, and the wife said they try to eat relatively unprocessed, high-fiber foods. “We are healthy,” they said to me, “so why do we need to exercise? We have better ways of spending our leisure time.”

How does one reach out to and convince the Smiths, and others like them who have the time and economic means to exercise, to do so? Or to turn it around, how does one convince them that by not doing so, they may risk a silent deterioration of their overall health? The loss of bone and muscle, gradual worsening of memory, and the deterioration of balance are just some of the natural changes that come with aging. These changes come slowly, quietly, and often do not reveal themselves until they become symptomatic. Physical activity is known to slow down these processes and maybe even reverse them. Should it be necessary to wait until there is already evidence of bone or muscle loss, for example, or decreased balance, to convince the Smiths and people like them to start on an exercise regimen?

Clearly prevention makes more sense.

The reason the Smiths can believe their well-being is not dependent on exercise is that they have no evidence to the contrary. Changes in weight or blood pressure or blood glucose levels are routinely measured as part of a medical examination, and when the numbers veer into an abnormal range, therapeutic interventions begin. But early stages in muscle, bone and balance loss are not routinely measured. Women are not sent for bone density measurements until a certain number of years past menopause, and few physicians measure muscle strength or balance until their patients become elderly or show signs of weakness and/or dizziness. Even though exercise may improve memory and mood, how many physicians tell their patients to exercise when they complain about normal age-related memory loss, or feeling slightly depressed?

People need to be shown, not told, how their lifestyle is helping or hurting their health. Baseline measurements of physical fitness, including muscle strength and aerobic stamina, should be part of medical examinations every five or 10 years. Everyone accepts the necessity of medical testing to detect the early stages of disease. Shouldn’t the early stages of physical decline also be included so that positive interventions can be started before it becomes necessary to order the cane, walker or wheelchair?

When Stopping Meds Won’t Reverse Your Weight Gain

Weight gain is a common side effect of antidepressants, mood stabilizers, and antipsychotic drug treatment. It can be so significant that many patients discontinue their treatment prematurely so they stop gaining weight. As one physician told me, “It is a dilemma. We know the drugs will improve the quality of their lives, and yet we know the weight gain will decrease it.”

Patients assume that they will be able to return to their pre-treatment weight once the drugs are out of their system. They know they will have to diet and exercise to lose the weight gained, but many find this easy to do, because they will no longer feel the urge to overeat the way they did on their medication. But there are some who find that, much to their despair, months after they discontinue treatment, and after months of dieting and exercise, they are not able to lose any weight. An email from such a person described the futility of following a daily exercise routine and a 1200-calorie a day diet.

Why this should be the case is a puzzle. A search of the research literature revealed neither explanation nor remedy for this resistance to weight loss.

We have some understanding of why the weight is gained on these medications: patients experience persistent food cravings, especially for carbohydrates, and tend to snack more frequently. They may not feel full after a big meal and have been known to follow one meal with another an hour later, forgetting not caring that they ate already. The hunger has been described as ravenous.

As we discovered many years ago when running a weight-loss clinic at a psychiatric hospital, it is possible to bring back control over food intake even while patients are on their medication. When satiety; i.e., a sense of satisfaction after eating, is increased, patients are able to eat normal-size meals and control their snacking. The consumption of small amounts of carbohydrate before meals produced an increase in the serotonin activity responsible for promoting satiety. Our result? Patients no longer felt they had to stuff their stomachs with food to feel full, because their brains told them to stop eating.

This discouraging excess weight may also be gained from the fatigue associated with some medications, thereby causing a decrease in physical activity. But if the patients are helped to initiate an exercise routine, they often find themselves less tired than when they are sedentary and are willing to continue to exercise. Their expenditure of calories through physical activity decreases their weight gain and enhances weight loss.

But what about those individuals who, no longer on their medications, can’t seem to lose the weight they gained despite controlling calorie intake and strenuous exercise? What is the explanation? Unfortunately, there is none.

Among the possible reasons is a slow down in metabolism. Perhaps this is due to muscle loss, perhaps due to the inertia of depression. Has physical activity declined as sleep patterns change? Is the individual sleeping longer with less nighttime activity? Is there more napping? Research evidence point to that even small decrements in sleep activity would account for a small decrease in calorie utilization. Is there water retention so the effects of losing weight through dieting are masked by the inability to drop water? Is weight loss occurring, but so slowly patients abandon their diet after several weeks? Perhaps weight could be lost if the diet were followed for many months?

Given the variety of apps and devices now available that are able to monitor and record what we eat, how much energy we expend in exercise, and how inert or active we are when we sleep, might some of these be useful in explaining why a patient cannot lose weight? When the patient complains about the inability to lose weight, it is hard for the physician to know what to do. Often the response is either disbelief (the patient must be eating more than he says or exercising less), or the offer of some vague hope that after more time passes, weight loss will be attained.

The physician needs data, namely how many calories are being consumed from food and beverages over time. Written food records are notoriously inaccurate and usually underestimate what is being eaten. If apps can record calorie intake over the several weeks during which no weight is lost, then this can be the start of a conversation about what can be done.

Data on the patient’s day and nighttime activity are also needed. If the patient is following a vigorous exercise routine and not sleeping excessively, the physician cannot base lack of weight loss on inadequate physical activity. Many devices are available to record 24-hour patterns of physical activity, and should be used for this purpose.

If enough data are collected from people experiencing this weight-loss failure after the discontinuation of their medication, some explanations may be uncovered and solutions developed. Weight gain that won’t go away is not simply a cosmetic problem. The medical problems associated with obesity are real and range from increased risk to the fetus during pregnancy to the increased risk of heart disease and cancer.

How much longer will the weight gain caused by psychotropic drugs, and the difficulty people have in losing the weight, be ignored? Patients should not have to bear the health consequences of obesity because they took medication for mental health issues. Solutions must be found now.

He said that no matter what he did, the pounds stayed on.

 

Swimsuit May Day! Will Pantyhose Really Make Your Cellulite Go Away?

Cellulite is like mold. It appears out of nowhere and seems impervious to all but drastic measures of eradication. Not everyone has it, but those who do may wish that full-body bathing suits of the 1920s were still available, as they avoid wearing anything that reveals their thighs.  They may also refuse to look into full-length mirrors.

Women have been searching for a remedy that doesn’t involve a skin transplant ever since dimpled thighs were called cellulite. About once a year, a woman’s magazine will feature an article usually titled something to the tune of “10 Ways of Getting Rid of Cellulite,” and a search of the Internet brings up many times that number of “cellulite cures.” Most of the therapies involve topical applications of various creams or more invasive procedures like liposuction. But recently what seemed like a remedy out of science fiction caught the attention of women struggling to smooth out their skin.  Two different manufacturers of undergarments claimed that wearing their bras, panties and pantyhose/leggings would, in 30 days or less, cause cellulite to disappear along with unsightly bulges (called saddlebags) and even produce weight loss. The cellulite fix, as they advertised, was brought about by the action of a variety of nutrients that were incorporated into the fabric of the undergarments. Capsules of caffeine, Vitamin E, fatty acids, and other ingredients were microinjected into the cloth and supposedly penetrated the skin and wiped out the cellulite.

Alas, it may have been too good to be true. A suit has been filed in the U.S. District Court in Boston by two women against Maidenform Brands LLC and Wacoal America Inc. for failure to live up to the claims.  And it is not farfetched to believe that many other women whose thighs are still dimpled will file additional lawsuits.

All of us fall victim to advertisements that promise wrinkle-free skin, weight loss without dieting and exercise, and restoration of hair if we are bald (this applies mostly to men). So it is understandable that some would believe that food-infused panty hose would produce baby- smooth skin. But like these other claims, they promise more than they can deliver.

So what are the options for the 90 percent of women who have or may develop cellulite? Exercise seems to be the only effective way of diminishing this curse of the paparazzi, although losing weight also helps.  Increasing muscle mass by strength training and strenuous use of the thigh and leg muscles might (but in the interests of full disclosure, might not) help to reduce the puckering of the skin and give the lower limbs a toned and supple appearance.  Interestingly though, cellulite rarely appears on the upper body, so the type of exercises recommended increase mainly the thigh and hip muscles.

But telling people this has about much appeal as a language teacher telling students that it will be necessary to memorize verb groups, learn vocabulary and become comfortable with sentence structure before becoming fluent in the new language.   Improvement is slow and may not even be discernible for months. That is the bad news. The good news is that building muscle and stamina will benefit more than the appearance of the skin. Indeed, regular exercise seems to benefit everything from better sleep and cognition to diabetes, cardiovascular disease, and arthritis.

Maybe the appearance of cellulite is an early warning signal that women must maintain their muscle mass. Aging is associated with muscle loss, and this sarcopenia may be accelerated after menopause. [3] If it is not stopped and reversed, osteoporosis and frailty can result, leading to a significant deterioration in the quality of life and shortened lifespan. Dimpled skin is not the result of muscle loss, but its appearance should tell us that it might be risky to ignore the importance of exercise.

Approaching a health club for the first time can be a daunting experience, and it is hard to stop gawking at the muscled, toned, thin, YOUNG bodies working out. And yes, it is true that if you are over 25, you may never look like THEM. But exercising in a facility where others are serious about their workouts, where you see them sweating and maybe even grunting with the effort of pushing a heavy weight, can be motivating.  What is soon apparent is that the others are only concerned about their own improvement, and if they notice you, they will do so only with admiration that you are willing to be one of them in improving your own physical well-being.

So even if you start to exercise only because of cellulite, you will find benefits beyond smoother skin.

And it won’t take caffeine-infused panty hose to do this.

Beating Stress With Potatoes

As I was walking past the Vitamin section of CVS, I heard the word serotonin pass between a young man and a saleswoman. “I can’t find any 5HTP on the shelf,” he was telling her, “…You know, the stuff that makes serotonin? I need some for stress!” She peered at the supplement stocked shelves and nodded. “We must be all out,” she responded. “But there is a health food store a few blocks away. Maybe they have some.”

I casually wandered over and uninvited said, “You know, you would feel less stressed and more relaxed just by eating a potato. You don’t have to take supplements for your brain to make serotonin, so why go to a health for store for 5HTP? Your brain makes serotonin every time you eat pretzels or potato, or any other starchy carbohydrate. “

He listened to me patiently, although I suspect he was humoring some crazy lady wearing tennis shoes (actually I had just come from the gym and was wearing sneakers).

“But isn’t it better to take the supplement?” he asked.

“The problem with 5HTP is that taking it to make serotonin is unnatural. The brain normally makes serotonin from what you eat. Now if you were to buy that bag of pretzels (I pointed to snacks in the adjacent aisle) and eat them, you would have more serotonin in your brain within a half an hour.”

“You mean my brain makes serotonin after I eat a snack?” He looked at me as if I was really some weirdo roaming around CVS telling bizarre stories.

Obviously this was neither the time nor place to give him a lecture on the neurochemistry of serotonin synthesis. So I quickly mentioned how after carbohydrates are eaten, insulin allows tryptophan to get into the brain and this turns into 5HTP and then serotonin.

“There are no side effects from eating carbohydrates, but 5HTP certainly has a few, like drowsiness and nausea,” I added

He nodded and mentioned that 5HTP makes him so drowsy it is hard to work, and he worries about driving. He left the store carrying the pretzels, but I wonder if he also stopped by the health food store to get some 5HTP, just in case the lady with the sneakers was indeed crazy.

As I walked back home, I mused on how typical it is for people to bypass food in favor of herbs, supplements, teas, minerals, and special potions no doubt prepared in big cauldrons by witches. A friend told me that he has given up eating carbohydrates, but takes magnesium and alcohol when he needs to relax. Pointing out that magnesium is only a muscle relaxer as well as that alcohol has more calories per gram than carbohydrates, and its own share of side effects, was useless. He simply did not want to hear what he did not believe.

And of course there are so many others whose dietary advice is simplymake-believe. These are the proponents of diets that eliminate carbohydrates, or curtail their intake. These diet gurus make believe that serotonin can be made without eating carbohydrate, or refuse to acknowledge that the bad moods, aggression, anxiety, depression and insomnia following such diets is not due to vanishing brain serotonin.

Isn’t it time to go back to eating the way nature intended us to do? We evolved eating carbohydrates, and our brains responded by making serotonin. Even though 5HTP is found naturally in the seeds of the African plant, Griffonia simplicifolia, myths and folklore are not filled with tales of people roaming around the continent seeking out the seeds of this plant to attain tranquility and relief from stress. Yes, do Google this plant name to see it’s purported effects on libido. I have potatoes to write about.

Mystifyingly, we resist believing that the natural way to make more serotonin is to eat carbohydrates. And that is understandable because it doesn’t seem to make sense. Carbohydrates don’t contain tryptophan, or indeed any amino acids. Eating protein, which is made of amino acids, prevents tryptophan from entering the brain. Isn’t nature sometimes counterintuitive?

Apparently not. More than 30 years ago, two scientists at MIT discovered the connection between eating a potato, pretzels, or a tortilla and serotonin synthesis. There is a barrier between the bloodstream and the brain that monitors what does and does not enter the brain. When certain amino acids try to enter the brain, they must pass through specific gateways. Tryptophan shares an entrance area with five other amino acids that are more abundant in protein and the blood than tryptophan. After protein is eaten, digested amino acids “clog” the gateway to the brain, and the small number of tryptophan units are outnumbered by the larger number of the other amino acids. As a result, very little tryptophan gets into the brain.

When carbohydrates (i.e. a small bag of pretzels) are eaten, insulin is released and sends the amino acids that compete with tryptophan out of the blood and into the cells. At the same time, tryptophan is able to enter the brain easily because the competing amino acids are no longer crowding the gate. If my fellow shopper had eaten his pretzels on the way back to work, soon after they were digested tryptophan would be entering his brain and new serotonin taking away his stress.

But resistance toward eating carbohydrates to relieve stress, and experience the other benefits of sufficient serotonin such as satiety after eating and increased focus, is also based on the effect of excessive carbohydrate intake, especially sugar, on heart disease, obesity and maybe cancer. An excess of anything, even water, is bad. Fortunately, research has also found that only small amounts of carbohydrate have to be eaten to make serotonin. Twenty-five to 30 grams of carbohydrate—the amount in one cup of Cheeriosis sufficient. And if the carbohydrate is a starchy and very low-fat like breakfast cereal, or popcorn, pretzels or rice crackers, natural tranquility comes at a price no one should resist.

Pass the Chicken Fat! They Say it’s Good For You….

It turns out that eating butter, cream, egg yolks, fatty meats, and full fat cheese is no worse for our hearts than olive or canola oil, according to a recent study published by Dr. Rajiv Chowdhury and his colleagues in the Annals of Internal Medicine.  Maybe Paula Deen was right all along: We should be eating fried butter, cream, and cheese-laden casseroles, as well as egg yolk and whipped cream-stuffed desserts. This article appears to vindicate Ms. Deen because now (finally) we have scientific evidence that such foods will not immediately send us to the emergency room with chest pain.

As someone with a several generation-deep history of heart disease, I think I will pass on the lard, butter, and whipped cream, though. Even though the statistics of the study seem to show otherwise, I don’t want to be my own statistic in the cardiac intensive care unit.  But most people aware of the study are tossing their tofu and running, not walking, to eat marbled steaks and buttery croissants.  Indeed, one remarkable example of the current trend to embrace saturated fat comes from a recent issue of Bon Appetit magazine. A two-page spread prominently features an ingredient previously reviled for its artery-clogging (or so we thought) proclivity. The ingredient: chicken fat, or as it is known in certain circles, Schmaltz.

As someone whose grandmother taught her at an early age how to render chicken fat into a golden, chicken flavored spread for rye bread and potatoes, but who stopped eating it after a fair number of relatives died at an early age from heart attacks, I was astonished to see it making a comeback in, of all places, a magazine devoted to gourmet eating.

As a corollary to the safety of eating saturated fats, we are also told in this study that we must avoid starch since it, rather than lard and bacon, is contributing to heart disease, diabetes and other life shortening conditions. This poses a conundrum. Whereas it is possible to eat bacon with one’s fingers or along with eggs (a good source of saturated fat), how does one eat butter, or cream cheese, or whipped cream, or indeed, chicken fat, without something starchy or bready underneath? Dr. Atkins had many recipes that eliminated all starch but for many, no starch grew tiresome. How many butter-coated strips of bacon can you eat without feeling a wee bit nauseous? Whipped cream might taste good by itself, but it certainly tastes better when incorporated into a chocolate mousse.

Carbohydrate-free foods have been developed but rarely are they eaten more than once. Of course one could follow the suggestions of Bon Appetit and add duck or chicken fat, or failing that, more butter or lard to slow cooked vegetables.  It is curious however, that years ago, we were all told that the delicious but oh-so-unnutritious method of cooking greens for hours with salt pork should be stopped, immediately. We were all to steam our vegetables and not even allow a smidgen of butter to pass over them. But now? Pass the salt pork!

Sometimes it looks as we won’t live long enough to know what we really should be eating or not. Or if “they” are wrong, maybe we won’t live long at all. Moreover, what seems to be lost in the “I told you so,” or “How can they say that?” responses to every new conclusion about our diet and our health is that:

1. Unless we eat foods with the nutrients our bodies demand, we certainly are not going to be healthy as we should be;

2. Moderation in all food consumption has never been challenged; and

3. Excessive calorie intake, regardless of its source, it going to make us fat.

To be sure, collard greens cooked in salt pork, or turnips cooked in schmaltz for the better part of an hour, may taste better (to some) than the same vegetables prepared without gobs of saturated fat and cooked quickly.  But the nutrient poverty of such dishes after their vitamins have been cooked out of them should not be overlooked. Maybe they should be eaten with a vitamin pill chaser.

Eating moderate amounts of most foods (except those to which people are allergic) rarely causes any harm. But given the tendency of those in our country to do things in excess, how certain are we that giving a green light to eating butter and bacon will not result in the overconsumption of fatty foods? After all, none of the scientists in this study pointing out the non-relationship between saturated fat intake and heart disease has suggested making these foods staples in the diet.
What about calories? Will they go away just because no one is talking about them these days? What happened to the concept that if we eat more calories than our bodies need, the excess, regardless of where they came from, will end up in our fat cells? It is prudent to consider that all fat, whether it comes from olives or a chicken, contains 9 calories per gram. Protein and carbohydrate contain 4 calories per gram.  My grandmother expended more calories than I because she had no clothes dryer, no car, she lugged her groceries up many steps, chopped meat into hamburgers with a wooden bowl and chopping knife, rolled her dough for noodles with a heavy wooden rolling pin and beat rugs with a broom handle.  I beat the keys of a computer.

So let’s have a helping of common sense along with the pats of butter and dollops of whipped cream. It will go a longer way in keeping us healthy.

Are Baby Boomers Turning Into Dumplings?

“I just came back from my 45th college reunion,“ my neighbor told me, “and to my amazement, my Baby Boomer classmates have now turned into dumplings. They are overweight, walk slowly, don’t seem to have much muscle, and more than a few had difficulty negotiating the uneven brick walkways. What happened to them?!?”

We went on to reminisce about how Baby Boomers made health clubs, yoga, Pilates, kick boxing, high-protein diets, tofu, vitamin supplements, and yogurt part of American mainstream culture and thereby changed how the country ate, exercised, listened to music, and dressed.

“So how is it that they (our contemporaries) are now softer versions of Humpty Dumpty?“ she asked. Yesterday they were wearing long hair, fringes, and beads. Now they wear medical alert bracelets announcing that they have diabetes or pacemakers, and I read they have a higher prevalence of obesity than other generations.”

The Baby Boomer generation, which has been at the forefront of many changes in the lifestyle of our country, may now be leading the way into the unfortunate consequences of too much bad eating and too little time devoted to exercise. Are they giving up their emphasis on youth, as in the mantra of many decades ago of, “Don’t trust anyone over 30?” Are they whose early years were spent in marches and rallies now thinking walkers and canes? Are they capitulating to the inevitability of getting old? As someone I know who just turned 65 told me, “Finally I can eat what I want and not worry about how I look. Why should I care about being thin?”

The good news and the bad news is that given the increasing longevity of their generation, Baby Boomers ought to reconsider turning themselves into versions of their grandparents. It is premature for them to give up on exercise (presuming they had been doing it all along) and to be complacent about their bad food choices. Unless they run into bad medical luck, they may live to 100 and, as George Burns said when he reached that age, ”If I knew I was going to live so long, I would have taken better care of myself.”

In all fairness, changes in lifestyle that occur as the Baby Boomers retire, or at least work less, may make it harder to avoid gaining weight. Moving from a multistory house to a single-story dwelling, opting for the elevator instead of taking the stairs, doing fewer household and outdoor chores? This amounts to using up fewer calories in the course of the day. Dependence on a car may increase even above what it was during earlier years, if they are moving to communities without easy public transportation or access to nearby shopping areas. Social interactions revolve around dinners and often lunches as well; if one wants to see friends it is usually over a restaurant table rather than on a walk. A couple with whom we are going to a local museum insisted that we make reservations at the museum restaurant for lunch, even though the alleged purpose of the trip was to see the art.

Recreational sports such as skiing, tennis, and biking are often abandoned as coordination and balance deteriorate, thereby making a fear of broken bones seem too much of a risk. Health clubs are, in general, not particularly geared to those who are old enough to be parents of most of the members. Many classes are unsuitable for bodies that may have some orthopedic limitations, and standards by which to measure baseline stamina and muscle strength are rarely applicable to those over age 50.

Perhaps it is time for the Baby Boomers to lead the way into improving the lifestyle of those 60 and over. It is time for them to insist that restaurants serve portion sizes compatible to diners with a somewhat sedentary life rather than suitable for a construction worker. They should compel changes in menus so vegetables are included with a main course rather than being an item for which there is an extra charge. Might they able to compel food manufacturers to increase fiber content outside of a few breakfast cereals? No one expects bagels to be enriched with bran and chopped prunes, but the food wizards in the country could come up with more options than Bran flakes and Fiber One bars.

It seems that it is also time for this forward-looking generation to demand that health clubs start including classes with music that does not increase their already compromised hearing loss, and with movements which will not ultimately require knee replacements. They should consider turning, “Dine and Discuss” book clubs into walking discussion groups, or put pressure on golf courses to allow players to walk the course rather than ride in a cart. And why not ask towns to make indoor pools for water aerobics as common as wading pools for toddlers?

Baby Boomers must stop accepting their potential status as dumplings and do what they are best at: seizing hold of their life and making changes that will benefit their health and that of the generations to follow.

Depression After Gastric Bypass Surgery

For those whose weight has climbed steadily after years of failing on traditional diets, gastric surgery to reduce the size of the stomach seems almost inevitable. If the stomach pouch is made so small that it holds about the same amount of food that would feed a gnat, weight loss is inevitable. So little food can be eaten at a time that patients are told not to drink water at mealtime because doing so leaves no room for food. Pounds seem to melt off, leaving the post-operative patients optimistic about improved health, energy, and a lifestyle no longer limited by excessive weight.

But for some, as the pounds disappear, the problems begin. Nutritional deficiencies due to changes in absorption of food into the body are well characterized but handled by monitoring of food intake and vitamin-mineral supplements. Eating too much causes severe nausea and pain, another unpleasant but avoidable side effect if the temptation to take one too many bites is overcome.

However, some problems don’t disappear as quickly as the weight, and for some, may persist for years. Anxiety, depression and insomnia may be so severe and resistant to medication that some patients consider having the operation reversed. Anxiety about the operation is understandable. Who among us awaiting any operation has not awakened at 3AM with a pounding heart and in a cold sweat thinking about the procedure about to be done? And anxiety after the stomach reduction is also understandable. There is no rehearsal time to prepare for an entirely new way of eating and a newly emerging body. Clinical depression and insomnia are not so easily explained.

One could surmise that depression might follow the realization that certain foods are never again going to be eaten. Presumably waking up after surgery and knowing you would never eat chocolate again might put you into a permanent funk. But the depressions reported both in the scientific literature, and in the hundreds of personal anecdotes on gastric surgery blog sites, suggests otherwise. Some have associated depression with the very low-calorie diet followed for several months following the surgery. Studies carried out during and post-World War II on volunteers given a semi-starvation diet similar to those in prisoner of war camps showed significant depression that disappeared when the subjects were given enough food. For some, however, a clinical depression lasts well beyond the first months of very restricted feeding and is resistant toantidepressant therapy.

Could the cause be the lack of a specific nutrient in the diet, i.e. carbohydrates? The absence of carbohydrate in the diet invariably alters serotonin levels and that neurotransmitter activity. It is the insulin release after carbohydrates are eaten that indirectly allows more serotonin in thebrain to be made. Insulin changes the levels of amino acids in the blood and this enables one amino acid, tryptophan, to enter the brain. Serotonin is made from tryptophan, and thus is dependent on its brain availability.

Dietary regimens before and after bariatric surgery often create the perfect storm for serotonin depletion. High-protein/very low-carbohydrate diets are imposed on pre-surgical patients so they will lose some weight before surgery. Post-operatively, patients eat only protein and supplements to prevent muscle, vitamin and mineral loss. Even though tryptophan is one of the amino acids making up protein, studies done over several decades at MIT showed that when protein is eaten, little or no tryptophan enters the brain.

Low and/or inactive serotonin is associated with depressed mood and anxious mood, anger, irritability and fatigue. Women normally have less serotonin in their brains and are more likely to be depressed than men. Might their depression after bariatric surgery be related to their serotonin depleting diet?

How to increase serotonin production during the protein feeding phase is a difficult problem. The stomach is so small, there is not room for both carbohydrate and protein and the latter must be eaten. Would giving tryptophan as a supplement help? Should studies be done to see if increasing the synthesis of serotonin prevents or decreases depression?

Insomnia is also an unexpected side effect of the surgery. Other than patient reports, not much is known about the cause or how to handle it. “I was awake until 2AM, fell asleep, and then woke up at 4 AM. The only way I can sleep is by taking prescription sleep medication,” is not an uncommon description of persistent wakefulness of many post-surgical patients. According to some of their reports, the insomnia lasts for months and even years. Some people reported taking melatonin but in such large doses (the correct dose is 0.3 mg) that it shut off their body’s own production of this hormone and stopped working. Others would attempt to limit the use of prescription drugs for fear of addiction, but eventually give in after several sleepless nights.

Would eating more carbohydrates help? Might more serotonin help calm and soothe the mind so it stops racing around like a gerbil on a running wheel and allow sleep to come?

No one disputes the life-saving consequence of bariatric surgery as it removes or decreases the many health problems of excessive weight. But unless depressed, insomniac individuals find some way to feel and sleep better, they are a risk for regaining weight and losing their health. Call it an unexpected blindside of a surgery meant to make life easier to begin with.

A New Diet Each Day May Make The Pounds Go Away

There is something enticing and optimistic about a brand new diet. Like buying a cream to eliminate wrinkles or a set of language tapes to finally learn French, we hope that this time THIS diet will work. This new diet will detoxify the liver, decrease the acidity of our stomach, remove those inflammation-causing glutens from our blood stream, burn the fat, increase muscle mass, and eradicate any desire we have for food… permanently. Just the past month, magazines and newspapers have touted the advantages of a 10-day detox diet, an alkaline diet (no foods can be eaten that lower the pH in the stomach) and the life-affirming effects of avoiding any food that is white (cottage cheese, chicken, and yogurt excepted).

Novel ways of eating in the interests of losing weight have been put forth for decades. Liquid diets have come and gone and will come again. Eating certain foods on specific days (does anyone remember the Beverly Hills diet?), fasting, the Atkins fat and protein regimen, diets based on blood type, personality, and presumably on whether one uses a Mac or PC, keep popping up in both respectable and sketchy magazines. Indeed, I am seriously contemplating inventing the Patriotic Diet in time for the 4th of July. This novel diet insists that the dieter eat only red, white, or blue foods on specific days of the week during July. In addition to honoring our flag, the diet could promote weight loss or at least make the dieter dislike red, white and blue foods based upon an aversion through restriction model.

My diet is not real, but alas others with little more great authority and scientific basis are. They are marketed so the dieter believes that they will really work. And for a while, they do.

They work because they are examples of the effect of a placebo on changing behavior. A placebo is defined as an inert, inactive substance or intervention or device without any function. For decades clinicians have found that placebo treatments, e.g., the sugar pill or colored water or sham acupuncture needle, really do work to reduce pain, depression, and a large variety of other ills that seem impervious to medical treatment. [1] The explanation is that if one believes something is going to work, in many cases, it does. So if a new diet comes along that claims to detoxify my intestinal tract, rejuvenate my liver and make me energetic and happy, I may reap these benefits because I truly expect that these things will happen.

Another reason is a logistical one. Diet plans that target certain foods for consumption or avoidance must by necessity eliminate large numbers of foods that are fattening. Do away with bread, and presto! One therefore also eliminates butter, cream cheese, peanut butter, mayonnaise, cheese spread, and Nutella. Tell people that dairy products will do dreadful things to their gut and they right away stop eating not only fat-free yogurt and skim milk, but ice cream as well. Having a newly-discovered gluten sensitivity used to be a reliable way of losing weight because so few foods could be eaten. Now, alas, so many manufacturers are making gluten-free foods which resemble the old foods we used to eat problem-free, that it is hard to eliminate much from our diet.

Alas, there is no placebo for smaller portions, lower-calorie foods, substitution of vegetables and fruits for chips and cookies, and none for exercise. New diets become old very quickly as the weight returns and the diet plan is shoved under a stack of others that are no longer interesting.

The weight-loss plans that work are boring, predictable, slow acting, and do not make for interesting conversation. Very few people who exercise consistently rarely consider their workouts sufficiently unique to chat about them with others. (Golfers are an exception.) Who wants to know how many minutes your neighbor spent on an exercycle or doing a yoga pose? People who always eat salads, fish, low-fat dairy and steamed rice rarely mention these foods as the newest diet fad in the tabloids. Who wants to know how many servings of vegetables you ate this week or cups of cottage cheese you managed to swallow? Alas, a boring, slow weight loss, sensible diet will not make celebrity headlines or you, the follower, the center of attention at a party.

A new diet-a-day will not make the weight go away. What will make it go away is finding and following an eating and exercise plan that works for you, day after day, year after year. Eventually having a fit, thinner, healthy body will no longer be a novelty. It will simply be a way of life.

Reference:

1) http://www.scientificamerican.com/article/placebo-effect-a-cure-in-the-mind/