Are Diet Sodas Really a Diet Food?

“I’ll have a diet soda with my French fries and double bacon cheeseburger. Oh! And one of those apple things,” he added, pointing to a pastry. The guy giving the order then looked at me as I waited my turn to order coffee at the highway restaurant rest stop. “Might as well save some calories, ” he laughed as he patted his prominent abdomen. I nodded to him as I asked for my coffee to be sweetened with a packet of the blue non-calorie sweetener.

We all seem to do it: eat a high-calorie meal but drink a no-calorie beverage sweetened with something artificial, munch on a bag of potato chips along with a diet soda, dig into an obscenely rich dessert but add a non-calorie sweetener rather than sugar to our coffee or tea, and drink alcoholic beverages without concern for their calories but “freak out” if we discover we are drinking real soda, rather than the diet stuff.

But do we really think of our coffee sweetened with an artificial sweetener as diet coffee? If we add diet quinine water to a gin and tonic, is the drink now a diet drink? Is artificially-sweetened bottled cranberry juice or flavored iced tea a diet beverage? Do hard candies sweetened with a sugar substitute qualify as diet candies?

A petition just filed with the U.S. Food and Drug Administration by a California-based group, U.S. Right to Know, wants companies to stop using the word “diet” on products that use artificial sweeteners. The petition states that: “Consumers are using products — Diet Coke and Diet Pepsi — that are advertised to make us think they assist in weight loss, when in fact ample scientific evidence suggests that this is not true and (instead quite) the opposite may well be true.” [1]

Interesting. Do people really believe that they will lose weight by drinking these products? I doubt that the man standing in front of me contemplating his snack of a double cheeseburger, fries and dessert thought that he would be three pounds lighter because he drank a diet soda. And I suspect that my not ordering a doughnut (although I wanted to) along with my coffee had more of an impact on my weight than putting that stuff from that blue packet in my coffee.

The writers of the petition reviewed the research literature on diet beverages and weight gain that seemed to confirm the need to remove the word diet from sugar-free beverages. Some studies such one published in the Yale Journal of Biology and Medicine in 2010 suggested that artificial sweeteners may contribute to weight gain, [2] and another in 2012 found that an association between artificially sweetened beverages and weight gain might exist in children. [3] But just because an association exists between two events doesn’t mean there is a causative relationship between them. I have a relative who drinks copious quantities of a caffeinated diet beverage because she hates coffee and tea, but wants to consume caffeine throughout the day. She doesn’t like the taste of the fructose-sweetened version of the caffeinated sodas; they taste too sweet to her. If I asked her whether she thought drinking so much diet soda would help her lose weight, her answer would be, “In my dreams.”

However, might diet beverages indirectly cause weight gain? Might the man in front of me at the fast food restaurant justify ordering dessert because his beverage contained no calories? Do we have less guilt at gobbling up a rich dessert because there is no sugar in our tea? Do we reach for the sugarless chocolate ice cream in the freezer without a thought to its calories because it is artificially sweetened?

There is another, more biologically-subtle, reason why so-called sugar-free foods might cause weight gain. Many people have a natural and unavoidable craving for carbohydrates, especially in the afternoon and/or evenings. The craving arises from their brains and is related to the brain’s need to make the neurotransmitter serotonin. Often the craving is accompanied by a small, but very real, deterioration in mood. Eating a carbohydrate, sweet or starchy, will restore serotonin levels and improve mood soon after the carbohydrate is digested. [4 ]If the craver attempts to satisfy this need to eat something sweet with something artificially sweetened, there will be no restoration of serotonin levels in the brain and no improvement in mood. So what happens? The craver may eventually give in to his or her craving, which was, of course, not satisfied by the diet beverage. Consequently, this person may scarf down a snack food that is sugary but also high in fat like a chocolate chip cookie, an ice cream cone, a candy bar, or a cupcake with three inches of frosting.

Perhaps if the craver satisfied the craving immediately by eating a low-calorie, mildly-sweet snack like graham crackers or licorice sticks rather than attempting to quell it with the diet beverage, the impulse to eat a fattening carbohydrate snack could have been curtailed.

It will be interesting to see what becomes of the petition. Since so many of us order a diet (fill in the blank) drink without giving a nanosecond’s thought to the word diet on the label, it may be very difficult for us to get used to another name. We tend to use the work Xerox instead of copy as in, “I will Xerox this” or Kleenex rather than facial tissue as in, “I have a Kleenex.” So I suspect we will continue to call artificially sweetened beverages diet, even though we know they are not.


Will the Paleo Diet Turn You Into Attila the Hun?

For the followers of the Paleo diet, the one that allows you to eat mainly meat, with a few carefully chosen vegetables and fruits thrown in for garnish, it might be instructive to read about the exploits of a famous, infamous devourer of only flesh: Attila the Hun.

Attila is considered one of the most ferocious warriors in history. [1] Born in 406 A.D. in what is now Hungary, he and his brother (until Attila killed him) ruled over the tribes of the Hun kingdom. But soon his conquests went far beyond being the ruler of the neighborhood. Known as the Scourge of God, Attila attacked, devastated and conquered lands from the Black Sea to the Mediterranean with a ruthlessness that made his name synonymous with terror and savagery.

Could his Paleo-type diet have anything to do with his successful, murderous objectives? According to eyewitness accounts of those who dined with him, and as reported in Gibbons’ The Decline and Fall of the Roman Empire, Attila followed the Paleo diet:

“The royal table was served in wooden cups and platters, flesh was his only food, and the conqueror of the North never tasted the luxury of bread.” [2]

Many in the 21st century will applaud Attila’s diet, although not many might want him as a neighbor. “Down with bread!” these nouveau-Paleos will say. “Out with any carbohydrate! Dump the dairy, bump the beans, discard most fruit and vegetables and eat animal protein or perish!” Adherents of this diet, cleansed of the evil nutrient carbohydrate, claim unfettered amounts of energy, a lean strong body and an alert, mentally-active brain.

Attila died at 47, but the circumstances of his death are unclear. He either died from an unstoppable nose bleed or just as likely was poisoned or stabbed to death. But it is also possible that his “flesh” diet may have contributed to his early demise.

A highly-respected clinical researcher, Dean Ornish, in a recent article in the New York Times, elegantly described the health hazards of a predominantly animal protein diet. His research confirmed the dramatic improvement in cardiovascular health from eating high-fiber carbohydrates along with vegetables and fruits and eating only small amounts of animal protein. [3] Might Attila have died from an early heart attack?

Perhaps his cognitive abilities were impaired by his diet, so he did not take precautions to prevent himself from being murdered. A study published this March by the journal The Lancet [4] looked at changes in cognition, including executive function and mental alertness, among 2,654 Finnish subjects ages 60-77. Half were told to stay on their normal diet that was relatively high in animal protein, and the test group was given a diet in which over half the calories came from complex carbohydrates, fruits and vegetables, and minimal consumption of animal protein and fat. Those eating a diet somewhat similar to that proposed by Dean Ornish in this NYT op-ed did significantly better on tests of cognition such as executive function and mental alertness.

So did a diet only of animal meat leave Attila a little loopy?

Or maybe he was in such a bad mood all the time that he became impossible to live with. It is said that he died on his marital bed. (Lucky bride?) A zero carbohydrate diet all his life could have done a job on his serotonin levels. We know from decades of research on how eating carbohydrates indirectly causes serotonin to be made. [5] Without carbs in his diet, his brain may have had so little active serotonin that he was depressed, angry, or just apathetic about conquering more lands. Those familiar with two pesky mood problems, PMS and/or winter depression, know the feeling of fatigue, irritability, depression and anger associated with too little serotonin activity.

Of course, Paleo man and Attila would not have known that even though protein contains tryptophan, the amino acid out of which serotonin is made, very little tryptophan gets into the brain when protein is eaten. It took several more centuries for this to be discovered by some carbohydrate-eating scientists. [6]

But maybe we are judging Attila too harshly. Gibbons says that bread was a luxury. Could it be that Attila had tired of his Paleo diet and his conquests were driven by the need to find a good loaf?


2.) Gibbon Edward, The Decline and Fall of the Roman Empire, 1826 Vol 3. Chapter 28, p.210
6.) Ibid.

Why the Swiss Can Eat So Much Chocolate and Stay Thin (& We Can’t)

Living in Switzerland many years ago should have been prepared me for the onslaught of chocolate bars displayed in the Zurich supermarket during a recent visit. Perhaps the upcoming Easter holiday had amplified the shelf space devoted to this particular confection; chocolate bunnies and chicks in all sizes vied for space with seemingly miles of chocolate bars, boxes of expensive chocolate truffles, and elaborately wrapped balls of melted chocolate encased in slightly bitter chocolate shells. “This must be Swiss chocolate heaven,” I murmured to my husband as we gathered up armfuls of chocolate bars to take back to the States. “They eat all this chocolate, and yet they stay thin.”  Earlier that day, as I scanned the crowds of commuters exiting the central railroad station, as well as the pedestrians strolling near the lake in the unexpected spring-like weather, I saw only a handful that might be called obese. This contrasted dramatically with the travelers and airport personnel when we arrived back in the U.S. a few days later. There it was difficult to find anyone who was thin.

How to counter the so-called obesity epidemic in the States has occupied panels of obesity experts, researchers analyzing trends in nutrient intake, physicians prescribing the latest weight-loss regimens and/or medications, and enough Internet space on the best way to lose weight to fill a small planet.

The latest recommendation to cut back on sugar consumption (as that nutrient, not fat, seems to be what causes us to become obese) is yet one more attempt to solve what seems to be an insoluble problem. Although a casual reading of this recommendation might lead one to stop consuming anything that has sugar from milk (lactose) to apples (fructose and glucose) to ketchup (sucrose), the recommendation is an attempt to make people stop consuming soda and drinks that are high in fructose. A corollary interpretation from these recommendations could lead one to assume it is all right to eat butter, salt pork and pork rinds along with heaps of mayonnaise, heavy cream and bacon grease, because it is sugar, not fat, that is causing us to balloon into supersizes.

Which brings us back to the Swiss and their chocolate.

Chocolate contains a substantial amount of both fat (cocoa butter) and sugar. Eating small amounts of it may confer some health benefit because of some tiny amounts of antioxidants, but it hardly competes as a diet food compared to, for example, kale or broiled salmon. Indeed, reading the label of a bar of dark (72% cacao) chocolate bar purchased from the Swiss supermarket, I noticed that the 100 gram bar (3½ ounces) contains 591 calories. So how do the Swiss stay so thin, munching on their fat and sugar-filled snacks?

The answer, of course, has nothing to do with how much sugar or fat they eat. It has everything to do with portion size and exercise.

Like so much of the world outside the U.S., the Swiss do not eat the gigantic portions of food that we Americans typically consume. Dinner one evening at this conference we were attending was a buffet, but unlike those in American restaurants, diners did not serve themselves. Everything was served, even a sauce or salad dressing, and the portions were, to my American eye, exceedingly small: a few ounces of the entrees and tablespoon-size amounts of side dishes and desserts. Obesity specialists in the U.S. have pointed to our enormous portions as a major contributor to weight gain, but that has not yet translated into smaller burgers or bagels.

Exercise probably trumps portion size in preventing the Swiss from becoming fat from chocolate, because they never stop moving. Children are put on skis as soon as they can walk, and the elderly even hike in the summer and cross-country ski during the snow months. Sunday afternoons find entire families out walking, climbing, biking, sledding, sailing, or doing something other than watching sports on television or reading the newspaper in an armchair. They do not consider this exercise as in, “I have to workout or run in order to stay in shape and not gain weight.” Instead, all this national physical activity is their lifestyle, as basic to their routine as sleeping or brushing their teeth.

When we lived in Switzerland, and went for our own hikes, we noticed a fork and knife on signs along with the number of minutes it would take the hiker to reach the restaurant.  Of course.  After all, there had to be chocolate at the end of the road.

Isn’t it time to stop the battles over how much is too much, of what we are eating? Is it too much to ask that moderation in nutrient intake be promoted as a goal, rather than eliminating or excessively consuming one nutrient or another as a way to stay healthy? And isn’t it time to alter our work/leisure schedule to insert physical activity as a basic part of our lifestyle? If we stopped sitting in a chair, obsessively searching the Internet for a solution to obesity and started to move instead, we, like the Swiss, could enjoy our chocolate and stay thin.


Lydia Pinkham, Snake Oil and Herbal Supplements

,If you were an American woman living any time between the mid-19th and early 20th century, and if you suffered from women’s troubles, then you may have dosed yourself with Lydia Pinkham’s Vegetable Compound. Developed from a recipe sold, as the story goes, to her father for $25.00 as payment for a debt, the herbal-alcohol mixture was transformed through aggressive marketing into a wildly successful product. Lydia’s picture was on the label, as it should have been, since she concocted the potion in her kitchen. Eventually its manufacture moved into a commercial facility.

Pinkham’s Vegetable Compound promised to cure, or at least relieve, ailments that at the time had no treatment.1 Women with menstrual difficulties were treated with leeches, or even surgery, and premenstrual syndrome was often ascribed to either hysterical personalities or water on the brain. And of course, many women did not want to go to a male physician for their female problems. Treating themselves with the vegetable compound maintained their privacy and probably, through its placebo effect, took away some of their distress.

Today we chuckle at the naiveté of Lydia Pinkham’s’ customers and the many others who purchased products that in our modern eyes were clearly fake, and had nothing in them to relieve symptoms or cure disease. Patent medicines, aka Quack Medicines, claimed to cure or prevent ailments ranging from venereal disease to indigestion to cancer. Their promises were outrageous. One well-advertised product supposedly contained snake oil, an ingredient reportedly miraculous in its ability to cure. Subsequently if someone tried to sell an obviously fake medicine, he stood accused of selling snake oil. 2

Of course this could never happen today; we are much too sophisticated and medically knowledgeable to believe in such nonsense.

Or are we?

Lydia Pinkham’s Vegetable Compound contained many of the ingredients–like black cohosh root, fenugreek seed, dandelion root, motherwort, and gentian root–sold today to help women with menstrual and/or menopausal symptoms. However, unlike today’s elixirs for female problems, Pinkham’s beverage contained a substantial amount of alcohol, which may have relieved some of the stress the women were feeling from their cramps and bloating.

A recent issue of a popular tabloid magazine directed to women and sold at the supermarket checkout counter reported these medical claims:

A 500 mg dose of a flowering plant called Rhodiola (not sure if one is supposed to eat just the flowers or the stem and leaves as well)  will decrease stress and accelerate weight loss by making more serotonin (stress relief) and increasing energy output (weight loss). Fact:  Serotonin is made from the amino acid tryptophan. There is no evidence that this flower increases energy output.
Holy basil, which related to mint, will relieve stress by making a soothing hormone, dopamine. 

Dopamine is like amphetamine. It energizes and stimulates when it is released; it does not soothe. Also, it is not a hormone.

Siberian ginseng will reduce your tension, assuming that holy basil and the Rhodiola flower has not already done so. It soothes your adrenal gland, in case you were wondering. Really?

There are many more of these fascinating tidbits of ‘snake-oil’ recommendations, and this magazine is not alone in describing them. Just go to the Internet.

The Quack Medicines of the last two centuries were not only ineffective; many of them were dangerous and could even cause death. Morphine, opium, cocaine, and alcohol were added, sometimes in substantial quantities and given not only to adults, but also to babies and children who might have colic or were fussy because of teething. Not surprisingly, physicians and medical societies were skeptical and critical of this ‘alternative’ medicine and those who did not want alcohol and drugs like opium to be included in these potions reinforced their criticism. But also, not surprisingly, there was pushback from manufacturers of the quack goods, as well as from the newspaper owners who benefited from the advertisements. Finally, in l908, Congress passed the Pure Food and Drug Act under President Theodore Roosevelt’s administration and prohibited the sale of products with misleading advertising and unlabeled or mislabeled ingredients. 3 So the era of Lydia Pinkham and similar patent medicines came to an end.

Or did it?

More than 100 years later, the New York Attorney General investigated the contents of what we now call herbal supplements. And like the Emperor’s new clothes, whatever was supposed to be there wasn’t. Herbs like St John’s Wort and ginseng listed on the label were not in the bottles; only the fillers like starch were to be found.4 Was the testing accurate? The manufacturers fighting the inevitably swift to arrive class action suits claim that the testing may have been flawed.5 However others stated that this was not the first time the content of an herbal supplement was missing or the dose incorrectly stated.

What is the consumer of such products to believe? At least Lydia Pinkham’s beverage contained enough alcohol to give the user a slight buzz, even if she did not get relief from menstrual cramps. But what if you were taking Echinacea to prevent getting a cold, or St John’s Wort to help your depression? And now you find out that the Echinacea was missing from the bottle and it was filled with ground houseplants instead, or that your St John’s Wort bottle contained only rice, garlic or beans?

There are two conclusions: The first is that a placebo is mighty powerful and rarely causes side effects, so be happy you stayed healthy, didn’t get the cold and your depression got better, even if you were ingesting ground rice. The second is that it is time to hold the manufacturers of herbs, twigs, grasses, and root supplements to the same standards to which pharmaceutical manufacturers must adhere. And maybe we should bring Lydia Pinkham’s beverage back on the market. At least she labeled her potions correctly.


Can We Have a Food-Free Zone?

The meeting was scheduled to begin at 9:30am, but traffic woes for many caused a half hour delay. The 50 or so women already present thus had extra time to eat the breakfast items laid out on the long table: bagels and cream cheese, croissants, muffins and coffee cake. And most of us did.

The woman sitting next to me complained that she had just started a diet and it was hard for her to resist eating one of everything on the table. “Of course I ate breakfast before leaving home,” she told me.  “I am not hungry. But it’s hard to resist a croissant or muffin. Why must there always be food wherever I go?”

Why indeed. I suspect every woman at the meeting had either eaten before leaving home or, if not, avoided eating because she was not hungry early in the morning. Was it really necessary to put out food, and so much of it that everyone there could have eaten a bagel, a croissant and a muffin without leaving the table empty? Why must refreshments accompany so many meetings, workshops as well as morning or afternoon programs? People attending these events must have food at home; they are not depending on the ‘refreshments’ to compensate for an empty refrigerator.

Food has become inextricably linked with activities outside the home. Performance venues always sell food although some, thankfully, like the theater or concert hall, do not do so during the actual performance but limit sales to before programming and during intermission. This is not the case at sporting events, where someone can spend as much time buying food and eating as they do watching the game. In fact, you can watch the game while you buy food and eat, courtesy of big screen TVs inside stadiums. Religious services are followed by an ‘eat and greet’ hour, parent-teacher evenings have snacks set out in the gym or lunchroom, and late afternoon lectures at universities provide snacks and drinks before the speaker begins. It begs the question, is the food provided to get people to leave their labs and libraries to come to a talk? I have a young relative, a law school student, who managed to avoid cooking dinner for an entire semester because so many of the afternoon and evening lectures were accompanied by substantial appetizers.

It is hard to resist eating when faced with an array of cookies, coffee cake, or chips and dip, even when we are not hungry. A cube of cheese, a cracker, a potato chip scooping up dip, perhaps a tiny sandwich: How much caloric harm can these do? They are so small! And then of course, if we are chitchatting while standing next to the table with the food, our hand may manage to snag some nuts or a cookie and pop it into our mouths without us really noticing.

So we nibble and snack at these situations unaware of how much we are eating.  We behave as if we are on, as that old joke goes, the Seafood diet: “Whatever we see, we eat.”

Are we, by being so generous with our culinary offerings at every gathering of more than two humans and a dog, contributing to weight gain? Might we be obesity enablers? Probably.

So one must then ask, is it time to change, unless we wish to continue, as a nation, to gain weight?  We should do two things: cut down, or cut out the food at all events not actually linked to a meal. (Obviously if there is to be an after-dinner speaker, one has to serve dinner first.)  It will take time to change people’s expectations that whenever someone is speaking, someone else is eating. And it is possible that some lectures might have fewer attendees because the lure of food is not longer present. One way of defusing the disappointment is to announce that the money that had been used to buy snacks is now being given to shelters or other charities.  

Resistance to making certain places and events into food-free zones will come from those who believe that many professional and/or social encounters work better when food (and drink) is available. How can people gather at an art exhibition or after a church service if only coffee, tea and soda water are served? What will people do with themselves if no cookies are offered at a parent-teacher night? No one will hang around for the last three talks of an all-day conference if they don’t get fed at the 3:30pm coffee break. Who will sit through a movie without buying something from the concession stand? (We all know that this is how theaters make their money…) Yet we manage to sit through a play, a concert, and a funeral without eating.

It is time to undo the almost unconscious expectation that someone will feed us whenever we go to an event. This was appropriate when we were toddlers and fed Cheerios to stop our whining. But we are grownups now, and if we don’t stop our almost constant eating, we will certainly start our own whining at our growing girth.

What Does the Paleo Diet Man Give His Sweetheart for Valentine’s Day?

The original cave dwellers, back in the pre-agricultural, pre-civilization neighborhood, didn’t have to worry about Valentine’s Day. Its invention was thousands of years in the future, and so Paleo man could live and die (his life span was exceedingly short) without guilt at not giving Paleo woman chocolate for that special day in February.

Not so today. The high protein and fat diet, mimicking the food supply of our distinct ancestors, may help some shed weight and keep it off, but it does cause some pesky problems. The most immediate: what would be an appropriate gift on this holiday that links romance with sweet goodies? How does someone who will defend to his last breath (bad breath, by the way, is a side effect of the diet) the dietary perfection of not eating carbohydrates, yet give his sweetheart a big box of chocolates? A friend suggested substituting cheesecake, but this baked good contains sugar and, alas, dairy, another food group avoided by modern Paleo dieting man.  Perhaps a bouquet of bones, the kind that are attached to rib steaks, would do. If the sweetie doesn’t want them, her dog will.

Valentine’s Day is a lovely example of sharing with others the pleasurable self-indulgence of eating chocolate, heart-shaped cookies iced with silly romantic messages, tiny sugar candies in yellow, pink, and green, or maybe those wildly expensive, melt-in-the-mouth pastel French macaroons.   But these delectable icons of Valentine’s Day are forbidden to those who lump sugar sweetened treats with poison, addictive drugs, and brain-altering medications. And just as one would not give one’s sweetheart a piece of chocolate laced with arsenic (well most people wouldn’t unless, they had another sweetheart in the wings), the true-blooded Paleo Diet man cannot give his beloved any yummy, mouth-watering, mood-elevating confection even on the day of days when this is done.

The grumpy, aggressive, distractible moods of the Paleo dieter are well known. One has only to go to blog sites and read about the aforementioned bad breath and PMS-like symptoms of those, mostly men, who believe that their weight, health and longevity are dependent on avoiding carbohydrates. The complaints from those who live, work, or socialize with a Paleo dieter give some idea of how mood, concentration, and even sleep can be deranged by lack of carbohydrates. The reason is simple: the absence of carbohydrates in the diet prevents the mood-soothing, sleep-producing, concentration-enhancing effects of serotonin from improving one’s life.

No serotonin is made when no carbohydrate is consumed.

This equates to that eventually the serotonin levels in the brain drop, leaving behind people with the empathy of a mosquito and the calm of a hummingbird.

Sacrificing one’s good nature and restful sleep for the supposed health benefits of eating only protein and fat on occasion, is a personal decision.  But when one’s eating ideology may affect others, as in “Can I give my honey chocolate for Valentine’s Day when I think it will cause her mental and physical distress?” the decision must be based on science, not myth.

Some myths take a while to be replaced by fact. The harm caused by smoking was not only disbelieved for decades, but people thought the reverse was true. The belief that smoking was good for you was changed only when it was indisputably shown that smoking was associated with respiratory distress, cardiovascular disease and cancer.

Fortunately, the role of carbohydrates as the basic energy source for the body including how their role in setting in motion a physiological process that results in serotonin synthesis, has been well established.  Moreover, humans have been eating carbohydrates as their staple food ever since the first human figured out how to plant, harvest and process grains. It is no accident that in ancient Hebrew the word for bread is also used for food. Bread is mentioned in the first line of the Lord’s Prayer, and breaking bread together describes positive social and indeed, political interactions. Somehow, despite Paleo Diet man’s assertions to the contrary, we have survived all these centuries of eating carbohydrates–and even sweets on Valentine’s Day. (Of course, there are medical conditions like diabetes that limit–but do not eliminate—carbohydrate consumption.)

So Paleo Diet man, why not replace that bouquet of steak bones with a small, sweet something that has a red bow on top? And maybe you have a nibble, too.


The New Generation of Weight-Loss Drugs: Which Is Best?

Suddenly, for the people struggling to lose weight but are failing to do so with diets and exercise alone? They now have help.  The FDA has approved four drugs for the treatment of obesity over the last two years.  While they will not have the potency of tapeworm eggs, a sure way of losing weight promoted about a hundred years ago, the drugs may prevent many from developing Type 2 diabetes and/or the health risks of high blood pressure or elevated cholesterol levels.

Unlike wrinkle cream or Botox, available even to those who do not need it, physicians are not supposed to prescribe them for skinny people who want to get skinnier. If your mother-of-the-bride dress may be snug for that May wedding, don’t expect a reputable physician to give you a weight-loss medication so you can go from a size 10 to a size 8. That is, unless you stand under four feet and wear a size 10 dress; this would mean that you really are obese.

Other limitations to the use of these drugs have been recommended as well by Dr. Caroline Apovian, a physician from Boston University School of Medicine. She chaired a group from the Endocrine Society; a group tasked with the job of providing guidelines for physicians prescribing these drugs. Endocrinologists tend to specialize in the treatment of diabetes, and thus would be likely to prescribe these drugs to help obese patients with Type 2 diabetes lose weight.  Although most of the advice centered on preventing drug-drug interactions, (avoiding weight-loss drugs that contain phentermine or buproprion if the patient has high blood pressure) Dr. Apovian stressed the importance of diet, exercise and counseling. Obviously one of these weight-loss drugs is the magic potion that will banish excess fat forever.

What are these drugs and how effective are they? The drugs are: BELVIQ (generic name: lorcaserin); QSYMIA (a combination of two drugs:the generic names are phentermine and topiramate); CONTRAVE (a combination of two drugs: the generic names are buproprion and naltrexone); and SAXENDA (generic name: liraglutide).

The drugs differ in how they bring about weight loss. They all affect the brain, but in different ways. BELVIQ works with serotonin to increase a sense of fullness before much food has been eaten.  OSYMIA relies on a combination of phentermine, a type of amphetamine that works on the brain chemical dopamine to decrease hunger, and topiramate, a drug originally prescribed as an anti-epileptic drug that also increases satiety or early fullness after eating.  However, regarding topiramate, according to an article on the web site, “the precise mechanism of action of topiramate on chronic weight management is not known.” The naltrexone in  CONTRAVE has been used to treat alcohol and opioid dependency and bupropion  (trade name Wellbutrin) treats depression and smoking cessation. It affects dopamine and thus may decrease hunger.  Some believe that naltrexone decreases the pleasure experienced in eating, so theoretically, the dieter will lose the urge to eat a piece of molten chocolate cake or a bacon cheeseburger with onion rings. Or if this Contrave user does give into temptation and eat these foods, they won’t get any pleasure from doing so.

Saxenda was just approved at the conclusion of 2014. Saxenda has the same composition as Victoza, a drug used to treat type 2 diabetes, but Saxenda has not beenapproved to treat diabetes, only obesity. This drug does not affect the brain directly, as do the other drugs. Saxenda’s composition is similar to a naturally found compound in the intestines called glucagon-like peptide-1 receptor agonist (this will not be on a test) or GLP-1. This GLP-1 and the drug combine to help cells in the pancreas make and release insulin so that blood sugar levels stay normal. This compound can get into the brain and may affect regions of the brain involved with appetite, but not too much more is known about how this drug makes people eat less.

The first three drugs are taken in pill form. Saxenda must be injected daily.

In order to be approved as a weight loss drug by the FDA, 5% of pre-treatment body weight had to be lost by 12 weeks in clinical trials.  Based on these results, physicians prescribing these drugs are told that if this doesn’t occur with their patients, then the drug may not be suitable for them and should not be taken any longer and/or the dose should be increased.

So who can get the medication? If a person is healthy except for obesity, which translates into that he or she must have a BMI (body mass index) of 30 or more. BMI can be calculated by dividing one’s weight in kilograms by height in meters squared. For the arithmetic challenged, charts that convert your weight in pounds and height in inches to these metric measurements are available on the Internet, along with highlighted areas indicating obesity. For example, a 5’5” woman who weighs 180 pounds has a BMI of 30. A 5’10” man who weighs 210 pounds also has a BMI of 30.  However, if another medical condition like high blood pressure is present, a weight-loss drug can be given if the person has a BMI of 27.

Alas, the side effects of weight loss drugs must be considered as well.  One consideration is whether other drugs are being taken that might interact with the weight-loss drug and lead to serious medical complications. Like the monotonous voice reciting the side effects of medications being advertised on television, the potential side effects list is long and for some of the weight-loss drugs, perhaps intolerable or dangerous. For example, someone with a family history of thyroid tumors cannot take Saxenda, and some may not tolerate the nausea it causes. Contrave must not be used in people with seizure disorders and contains a warning about an increased risk of suicidal thoughts and behavior. Qsymia can cause mood disorders as well as depression, and should be avoided by people with a history of depression. It also is associated with cognitive problems such as decrease in attention, memory and word retrieval.

Belviq comes with the warning that it must not be taken if the patient is on one of a long list of drugs or herbal supplements, including St John’s Wort and tryptophan, for mood disorders.

And yes, every one of the drugs will be effective only if…you know what is coming…the patient follows a diet and exercises regularly!

So which is the best for you?  The choice depends on your personal overeating profile: Is your hunger uncontrollable, or do you have difficulty stopping when you are full? Do you have addictive-like cravings? The choice also depends on your medical profile, which includes your current medications, and underlying health problems such as diabetes or depression. Your physician will be the best and only judge of this. But knowing something about these drugs before consulting your healthcare giver will make you a full participant in the decision.

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.