Binge Eating Disorder: Hunger for Food or Something Else?

The advertisement for a drug to treat B.E.D. kept appearing in commercials during our favorite TV series.

“What is B.E.D.? “ I asked but my spouse had no idea. “Bad Energy Day?” he responded. “No,” I answered, “it must have something to do with hunger because the drug is similar to amphetamine.“

Then it hit me. Binge Eating Disorder, that’s what it is. Interesting that a drug to take away hunger has been approved by the FDA. People who binge never eat only from physical hunger. Otherwise they would stop eating when the hunger is gone.“

I treated patients with binge eating disorder but insisted that I would do so only if they were also being seen by a psychotherapist. Even though the major symptom of binge eating disorder is the ingestion of enormous quantities of food in relatively few hours, the disorder is a psychiatric problem. Interventions focus on psychotherapy, along with nutritional advice to undo the weight gained from constant bingeing.

Binge eating disorder may affect as many as 1-5% of Americans, according to the National Eating Disorder Association. In fact it has its own association, BEDA, which offers Internet support and information as well as Internet contact with others who are living with this problem.  It is only relatively recently that the binges have been viewed as more than a derangement of appetite, or an inability to adhere to a rational eating plan. People with this disorder feel helpless to prevent themselves from gorging.  And because they do not compensate for their high calorie intake by starvation, laxative abuse, vomiting or excessive exercise, they may be morbidly obese.  Women are more prone to having this disorder than men and the bingeing is often accompanied with anxiety, depression, guilt and self-loathing.  Bingeing can occur several times a week, and sometimes a few times each day.

But bingeing is not the same as being very hungry and unable to stop eating until feeling stuffed. Teenage boys who can clean off a buffet table faster than a swarm of locusts are not bingeing; they just eat an enormous amount of food.  Diners on a cruise ship may feel an obligation to eat gigantic quantities of food to compensate for the price of their trip, but they are not bingeing either.

Bingers eat in secret and often they consume only tiny amounts of food when they are eating with others. Moreover, binges are often planned for the time when the eater is alone. The binger goes food shopping so there will be food in the house that the binger enjoys eating. Or she might go to several restaurants in a crowded food court. Ordering take-out food from several restaurants is also done because it is embarrassing to order a large amount of food from the same restaurant all the time. I had a patient who shopped on Thursdays for weekend binges. She turned off her phone, pulled down her shades, and spent from Friday evening to Sunday afternoon eating until her stomach could no longer hold food. Then she would sleep and upon awakening, start bingeing again. She was never hungry. How could she be?

Bariatric surgery might seem to be an obvious solution to halting bingeing and restore normal weight. But according to experts, reducing the size of the stomach, or bypassing it altogether, might cause extreme side effects. Physically limiting the amount of food consumed doesn’t reduce the emotional pain causing the overeating.  Without the psychiatric counseling before and following surgery to detect and help the underlying cause of binge eating, the bariatric patient is at risk for consuming much more food than the surgery allows and becoming extremely ill in the process.

In the winter of 2015, the FDA approved Vyvanse for the treatment of B.E.D. The drug is classified as a central nervous system stimulant like amphetamine, and had been already approved in 2007 to treat ADHD.  Vyvanse decreases hunger when used for ADHD, and this may have been the reason it was tested on binge eating disorder patients. Two studies were carried out, each for 12 weeks, among 700 people with binge eating disorder.  Compared with placebo treated subjects, the drug decreased the number of days each week people binged and also decreased the number of binges each day.

According to eating disorder experts, it is unclear how the drug works to reduce bingeing.(It is important to note that bingeing did not stop entirely in the studies.) Moreover, long-term results have not been reported. Questions to consider are… does the effect of the drug wear off or become even more effective over time? It is possible that the amphetamine-like drug removes the compulsion to eat, thus giving binge eaters a respite from their pathological focus on food. Instead of dealing with the constant bingeing with the guilt and shame of the aftermath, they  now have  emotional  time to deal with the reasons for their overeating. In a sense they are like binge drinkers who go into recovery and while they are abstinent, attempt to deal with the causes for their excessive alcohol intake. It is obvious that helping such people would be useless while they are drinking. And so too, it may be that helping the binge eaters, while they are still bingeing constantly, would also be futile.

Vyvanse is not a magic pill, and its ability to decrease binges does not mean it can decrease the emotional antecedents to the binges.  Replacing food as a coping mechanism will require more than a pill that takes away hunger. Eliminating binges is a long, complicated process requiring emotional healing and learning non-eating strategies to deal with future emotional upheavals. Removing hunger is necessary but not sufficient. But at least it is a beginning.

If There Were Doggy Bags at Catered Events, Would People Eat Less?

Have you ever gone to a pre-celebratory social event, tasting of foods e.g., a wedding or a fund-raising dinner?  A friend in charge of a fund-raising dinner for a local musical organization invited to me to join a group of six other ‘tasters’ to sample menu choices for such a meal. I was the token non-meat eater, and I think she wanted me there to make sure the vegetarian option was passably edible.

I wasn’t sure what the protocol was in this process. Does one eat and swallow, or eat and spit, or take tiny bites or eat everything (even if it doesn’t taste good)? There was no spitting, even of the various wines we were asked to sip. However, whether or not the taster ate every sample in its entirely or just nibbled was a matter of individual style.

The appetizer samples kept coming and coming, although I avoided eating many tidbits such as Brussels sprouts wrapped in bacon, lamb chunks on round squares of toasted rice, and spicy chicken wrapped in puff pastry. In view of the main courses and desserts we were about to sample, I kept to nibbling except when a couple of appetizers were too good not to gobble up.

Nevertheless, I was already stuffed, when the main courses were brought out. Though thankful they were served in small dishes, I was feeling like a judge on a food network competitive cooking show. I tried to taste all the components of each entrée, and eventually the desserts. Fortunately, these also came in tiny serving sizes.

But then, to my surprise, we were shown what our choices would look like plated for a meal, rather than a tasting. The serving sizes were gigantic. Not sure whether my full tummy magnified the size of the fish and the meat entrée, I asked the caterer about the weight of the entrees.  

“The fish is almost 8 ounces,” he told me, “and the meat, lamb loin, is about 7 ½ ounces.“ The first course, a cold soup, was about 8 ounces and accompanied by a large piece of crunchy cracker covered with a thick layer of whipped ricotta cheese. The serving of soup was sufficient to be a meal in itself, if eaten with some crusty bread and a salad.

“Why are you serving so much food?” I asked the caterer, but another taster chimed in to answer.

“Because when people come to a fund-raising event, they expect to get a lot of food,” the person told me. “If they think the portions are too small, they feel they are not getting their money’s worth.” The friend who invited me added, “And the guests will blame the caterer for not giving them enough to eat, not the committee who decided on the menu.”

“It’s too bad doggy bags aren’t given out at these affairs,” I mused. “That way, people could eat a reasonable amount of food, especially if their party clothes are a bit tight anyway, and then take home the rest. I was thinking of how much more I would have enjoyed the desserts had I been able to taste them when I still felt like eating.”

“It might be a bit awkward for women in long gowns and men in tuxedos to leave a fancy event carrying aluminum containers filled with filet of sea bass or chocolate mousse,” she replied, and added that she always feel stuffed after these events because she hated to leave food on her plate.

Most of us are not obligated to eat catered food frequently unless we are politicians, make a living as after-dinner speakers, work in the fund-raising development area, or have lots of friends and relatives who are getting married or celebrating major birthdays.  But when we do go to the lavish wedding or significant birthday or anniversary party, where the food is overly generous in quantity and variety, it is tempting to consume much more than we would eat at our kitchen table. Often the food selections include items that we would not ordinarily eat because of their expense or non-availability. We are tempted to fill our plates at the pre-dinner cocktail hour buffet, and go back for seconds at a sweet table served at the end of the meal. Who can resist a mountain of shrimp and lobster tails, or a chocolate fountain spilling its mouth-watering liquid over strawberries and chunks of cake?

Such offerings are irresistible; so we eat and eat and eat, and of course, drink too much as well.

There are many reasons to lament the excess of food at these events, not the least of which is the disparity between what is overeaten and/or thrown away, and the need for food among so many in our population.  (Some caterers are able to give away food that is not served to food pantries and shelters.) But consider as well the disparity between the need to eat less and more healthfully, a mantra repeated endlessly in the media and doctors’ offices; and the willingness of the guests to eat more and less healthfully. Obesity experts have gotten some to eat less in restaurants by promoting the doggy bag idea so half of the usual oversized portion is taken home for a meal the following day. Servers are always willing to take the uneaten portion from the diner and bring it back in a (usually too large) bag. But I suspect that servers will not do this at a wedding or bar or Bat Mitzvah, even if some guests would be delighted to go home with some of the delicacies they were too full to really enjoy at the event.

Maybe this should be the newest trend in catered dining.  Years ago, the idea of asking to take home one’s uneaten portion of food from a restaurant would have been considered dreadful manners. It just wasn’t done unless you were over 90, and put the rolls from the breadbasket in your voluminous purse because they would taste so good with coffee the next morning. But all it takes is a celebrity or two, squeezed into an outfit appropriate for a red carpet event and yet taking home a doggy bag of caviar, to start this trend.

Diets Don’t Work When You Are Stressed

“Why do you think you gained back the weight after your last diet?” I asked the new client sitting in my office.

“I like food, I guess, “she replied.

“Well, most of us like food,” I nodded, “but liking food and overeating food are not the same thing.”

She sighed and looked quizzically at me. Obviously my job was to tell her why she gained her weight.

“Do you remember what was going on in your life when you noticed yourself gaining weight?” I prodded.

And then the story came out: a new boss who imposed impossible deadlines, a nine year old son diagnosed with ADHD, as well as a mother who might need to enter an assisted living facility.

“Any one of these stresses would have been enough to cause weight gain,” I told her, “so I can understand why it was hard not to overeat when you experienced all three.”

My client, let’s call her Gail, was a repetitive dieter whose weight bounced up and down in response to whether her life was in control, or in chaos. She figuratively threw up her hands when facing problems without quick and effective solutions and decided, often unconsciously, to ignore her weight, her fitness, and her health. Gail’s situation was more difficult than many because she was a single mom, and although she had siblings, most of the responsibility for caring for her own mother fell upon her. As she described her situation it sounded as if she never got enough sleep, had to make up work time over the weekend because she took time off during the week for doctor’s appointments for her son and her mother, and ate too many take-out meals because she had too little time to shop for and then prepare food. As she told me, she spent her evenings worrying and eating. Sometimes she would binge on a large pizza or a quart of ice cream, or a frozen cheese cake. She did not seem to be able to stop.  But she added that she hoped going on a diet would give her back control over her life and perhaps (it must have been magical thinking) make her problems more manageable.

This is why she is a constant dieter.

Diets don’t take away stress. Indeed the necessity of following a meal plan with its attendant demands of food shopping, cooking, exercise, and a support group or private sessions may simply add to the burden of daily life. Some welcome a new diet because the need to count points, count calories, to eat only certain foods, or to cleanse or fast temporarily distracts the dieter from her problems. As long as her mind is focused on whether kale has fewer calories than spinach, or deciding to take a yoga class or a long walk; it is not focused on her mother, her mortgage, or her marriage. And as the pounds come off there is a feeling that at least something in my life is working.

But if the dieter, like Gail, handles stress by overeating, how lasting can her weight loss be? What good will it do to know that carrots are a better choice than carrot cake, when it is the carrot cake, not the carrots, that will be overeaten when the next stress enters her life?

I told Gail that she should not start yet another diet until she acknowledges her habit of solving unsolvable problems by bingeing, rather than looking for workable solutions. She had to accept that bingeing wasn’t going to ease her workload, but perhaps talking to her supervisor or someone from the HR department of her company might.  Bingeing would not help her son’s ADHD, but a qualified therapist could. Bingeing would not resolve her mother’s living arrangements, but a social worker might be able to help.

In a perfect weight loss world, dieters would have life coaches, therapists, career counselors, social workers, psychologists, and even matchmakers or divorce lawyers at their disposal to help them get through the stresses that might derail their diets. Since this world does not exist, the dieter, with the help of a weight loss advisor, must identify situations that trigger overeating: problems with work, family, friends, or changes in hormone levels (menopause),   seasons (winter depression), or medication. Unless effective strategies are found that replace eating as an automatic way of dealing with these stresses, the dieter will return to eating once the diet is over or abandoned.

Weight loss programs that advertise, ‘Permanent Weight Loss!’ or ’This Diet Will Succeed Even if Others Have Failed!’ or ‘You Will Change Your Lifestyle Forever!’ may work in the short run, but unless the dieter understands why he or she overeats, the weight will return. No change in the ratio of protein to carbohydrate to fat in a meal plan will change how the dieter responds to stress. No celebrity eating plan is going to impact the dieter’s personal response to unbearable and/or irresolvable problems. Eliminating gluten or adding anti-oxidants is not going to address the chronic issues that weaken willpower and make weight gain ultimately unavoidable.

January is the traditional time to start a weight loss program. And if the dieter knows how to avoid the overeating that so often accompanies stress, this January may be the last time a new diet has to commence.

Procrastination: The Grown-Up Way of Saying ‘I Won’t!’

For months, maybe even a year, a weight-loss client has resisted my exhortation to exercise. The excuses ranged from plausible to doubtful, but the result is always the same.

“Maybe next week.”

She had participated in a walking program in the past, a few diets ago (before we met), and because of back pain, had been given exercises to strengthen her core muscles. But this time, despite knowing intellectually that her weight, her diabetes, and her bad back would all benefit, she refused to literally take, the all-important first step. But she also refused to join social groups, volunteer, look for a job, or get out of the house; in short my client refused to do anything that would stop her from sitting home at night and eating. “I will, I will,” she would tell me. But she never did.

When we discussed this, she excused her failure to take on those activities beneficial to her attempts to lose weight by saying she was a procrastinator. Obviously she would get around to following my suggestions, but not just yet.

There have been many studies on the phenomenon of procrastination, and it is a rare person who has not put off doing something he or she has to do. The reasons range from fear of failing a task (such as locating cancelled checks for income tax preparation) to avoiding emotionally painful situations like breaking up with a boy/girl friend.  Dieters or wannabe dieters may procrastinate starting a weight-loss regimen because of past failures, and memories of deprivation and hunger. More than several weight-loss clients have told me that they waited for years for a perfect weight-loss pill to be discovered before attempting to diet, and the effect of this procrastination on their health did not bother them. (Some are still waiting.)

Procrastination may also lead not just to putting off strategies to lose weight; it can easily contribute to weight gain. Eating is an effective way of delaying doing what one does not want to do. The procrastinator tells himself, “I will eat dinner and then maybe a small snack after dinner, and then maybe make myself a cup of tea and a couple of cookies. Oh, then I think I will pop some popcorn and fish out the ice cream from the freezer to take away the salty taste of the popcorn and then…” Eventually time passes and suddenly there is no time to pay the bills, or phone the parent, or clean up the garage.

Procrastination is a huge stumbling block to effective dieting. How many very low-calorie ice cream bars or bowls of air-popped popcorn can the dieter justifiably eat while procrastinating without eventually undoing the diet? And how long can the dieter avoid, as my client is managing to do, engaging in some exercise and non-eating activities, without this influencing the rate of her weight loss?

Any parent who has lived through the toddler and adolescent stages of child rearing knows that it is often impossible to get the two-year-old or the 16-year-old to do something they do not want to do.

“No, I won’t” is a favorite reply, be it a toddler told to pick up toys or a teenager asked to at least take the dirty clothes on the floor and put them in the laundry basket. The teen, considerably more sophisticated than the toddler, may temper the reply with, “I will do it later” and thinks, “I can procrastinate until I move out of the house.”

But what about the grownup who says, “I will do it later” to excuse failing to take on the responsibilities associated with weight loss, i.e., choosing low-calorie healthy foods, drinking sufficient liquids, getting enough sleep and exercise, and dealing with the stresses causing overeating—rather than eating his way through them?  Isn’t, “I will do it later…” a way of saying, “NO, I don’t want to do it at all”?

Weight-loss counseling really does not have any answer for this problem. If it did, fewer people would fail to lose weight and even fewer would fail at maintaining their weight loss. So far, we don’t know how to strengthen motivation and commitment to permanent lifestyle changes so someone can banish being overweight for good.

Maybe one reason why so many wannabe dieters fail to commit to permanent change is that it is overwhelming. There are complicated diets with points, counting calories, and determining good and bad carbs, saturated/unsaturated fats, and whether a food is high or low protein. Exercise is boring,  repetitive and even unpleasant and painful if muscles are worked too hard. It is easier to put it off, to procrastinate.

But I think of advice given often to new runners by those experienced in the activity. The new runner is told to run for a minute or two and walk for the same period of time. Run and walk, run and walk. Eventually as muscles and stamina grow stronger, the runner is able to shorten and then cancel the walking bit. By that time, she is committed to the sport.  Perhaps dieters should be given similar advice: eat sensibly but do not follow a harsh and unforgiving diet. Exercise, but start slowly. Five minutes is better than zero minutes, one pushup up better than none. Try one activity, class, or social interaction on a lonely winter weekend rather than keeping company with the refrigerator and cookie shelf.  No excuses.

Eventually these small changes will increase into large ones resembling a healthy lifestyle that feels natural and comfortable.  Reserve procrastination, saying, “I won’t!” for balancing your checkbook.

Winter & PMS Woes

“I hate winter. It’s not just the ice, the shoveling, too many snow days, and long traffic-congested commutes. What I really hate is that my PMS becomes unbearable. From November to April, I dread those days before my period comes because I turn into Attila the Hun!“ So stated a weight-loss client of mine. She is not alone.

Most women are not transformed into the 21st century version of a marauding barbarian when they have PMS—premenstrual syndrome—but they may feel that their lives are disrupted and moods out of control. PMS is linked to hormonal changes at the end of the menstrual cycle. The symptoms are numerous but most women do not, thankfully, experience more than a few. The most common are feeling depressed, angry, irritable, longing for sweet or salty fatty foods like ice cream, chocolate or chips. Often a foggy mental state that makes speaking coherently, or concentrating a difficult task, occurs. PMS affects women of childbearing age, from teenagers to women about to enter menopause (whose symptoms are very similar but last for months rather than days).

PMS arrives, often without warning, during the fourth week of the menstrual cycle and may last hours or days, retreating only when menstruation begins.  Changes in mood for no apparent reason, disturbed sleep and increased irritability are often the first signs that PMS is present, but also some women experience a dramatic increase in their carbohydrate craving.  A friend of mine who does the family grocery shopping once weekly, told me of coming home with bags of pasta, bread, cookies, crackers, ice cream, doughnuts and boxes of instant mashed potatoes and nothing else. When her husband helped her put away the food, he asked why she did not buy any milk, vegetables, chicken and fruit. “Because I bought what l wanted to eat,” she told him.  “I have PMS.”

Many of the PMS symptoms are similar to those of Seasonal Affective Disorder (SAD) or winter depression. People suffering from mood and appetite changes associated with diminished hours of daylight experience similar irritability, fatigue, depression, and carbohydrate cravings although they tend to sleep, if they can, many more hours. PMS, in contrast, often causes broken and unrestful sleep. Of course men also suffer from Seasonal Affective Disorder, and there is no age limit as to who may experience it.

Winter can worsen PMS; symptoms can last longer and be more severe. One explanation might be that many of the stresses associated with winter add to the stress of PMS:  prolonged commuting time; roofs sinking under the weight of snow; inability to exercise because sidewalks are too icy or weather too cold; and cabin fever that comes from not being able to escape the house over weekends. But there is probably a biological explanation as well as environmental discontent. Our research at MIT and that of a group from UCLA found insufficiently active serotonin underlying PMS symptoms. Decreased serotonin activity has also been linked to SAD. The diminished hours of winter sunlight further decreases serotonin activity, according to the research of Barbara Parry, thus exacerbating the moodiness, depression, anger distractibility and poor sleep of premenstrual syndrome.

Ironically, Parry and others who have discovered this relationship live in southern California, where the fluctuation in hours of daylight is much smaller than in the northern tier of states where differences in sunrise and sunset between July and January are dramatic.

Other than moving south, getting pregnant or becoming menopausal, there are not many options to ease the monthly mood swings. Parry’s research suggests phototherapy, which involves sitting in front of a so-called lightbox that emits the light spectrum of sunlight without the damaging ultraviolet rays. It is still unclear how exposure to sunlight interacts with serotonin to increase its activity, but positive changes in premenstrual mood are evidence that it is having an ameliorative effect.

The carbohydrate cravings experienced by women with PMS is a clue to another therapy. This one involves consuming a specific dose of carbohydrate once or twice a day to increase serotonin synthesis. The carbohydrate craving is real and measurable. Women with PMS eat about 1100 extra calories daily when they have PMS. The foods contributing these extra calories are sweet and starchy carbohydrates such as breads, pasta, cookies, chips, crackers, and candy.  We have studied the changes in mood, concentration, and cravings before and after premenstrual women consume a beverage containing either carbohydrate or a placebo. Statistically significant improvements were found after the carbohydrate drink, but not after beverages containing nutrients like protein that do not increase serotonin synthesis.

The carbohydrate acts like an edible mood elevator. Eating about 25 to 30 grams of any carbohydrate (except fructose) increases serotonin levels and activity, and subsequently takes the edge off many PMS symptoms.  Eating protein prevents this effect, as protein prevents serotonin from being made. It is best to eat a carbohydrate food like popcorn or oatmeal before eating protein, or two or three hours after a protein-containing meal.

If winter woes include a worsening of PMS, it may be necessary to eat a carbohydrate snack two or even three times a day. (Avoiding fat-containing snacks and limit the calories to about 120 per snack).  Relief comes soon after the carbohydrate is digested. This is another reason why eating low or fat-free carbohydrates are best. They are digested faster if they contain no fat.  From our research we know that the symptoms ease for about three hours.

So far the combination of phototherapy and carbohydrate consumption has not been tested against each of these therapies alone. But presumably eating a bowl of oatmeal while sitting in front of a light box should make even a gloomy winter PMS or SAD day brighter.

Will You Gain Less Weight If You Shop on Thanksgiving? (Or any family get together event…

Business reports indicate that the sharp rise in large retailers open on Thanksgiving Day has leveled off. Perhaps, as has been suggested, this is due to consumer dismay at seeing the holiday hijacked by the temptation to buy deeply discounted electronics and toys, rather than eating another piece of pumpkin pie. However, a few national retailers are opening their doors at the time most people are attempting to carve (not hack) their turkey into attractive servings. It is possible that if this trend increases, Thanksgiving dinner will become a brunch so people can shop in the afternoon.

In the past, a traditionally spent Thanksgiving Day started with morning high school football games, road races usually with the title Gobble or Turkey as in Turkey Trot, much cooking, much traveling, and then much eating. Then, by late afternoon, the inevitable nap followed while attempting to watch more football, and finally a second meal of turkey sandwiches and leftover stuffing and pie was served. And no one needs to be told that the combination of eating and sitting in the car, in the bleachers, at the dining room table and on the sofa, adds up to consuming many more calories than the body needs for energy.

Consider then the benefits of ditching the 2- or 3-hour meal and nap for standing in line outside a big box store, perhaps even shivering, running through the store to find the bargains, pushing heavily laden shopping carts to the checkout area, lifting boxes into the trunk of the car, and then carrying the heavy boxes out of the car and into the house. All that standing, shivering, running, pushing, and lifting takes energy and uses up calories. Couple this bout of physical activity with the “no time to eat seconds,” the lack of opportunity to lie on the couch and nibble the nuts, cookies and chocolates on the coffee table, and a missed chance to pick at the pies and sweet potato casseroles before they are wrapped up in aluminum foil and stored in the refrigerator. It is possible (although unlikely) that dedicated shoppers could even lose a few ounces because consuming is directed toward buying, and not eating.

Overeating may also be diminished for another reason: less stress at the dinner table. In contrast to the imagined scenes of happy families sitting around the table oohing and aahing over a perfectly roasted turkey brought into the dining room (why don’t my turkeys look like that?), the family members may be already in verbal combat mode. Ancient quarrels, nasty remarks, boredom, too many invasive questions about someone’s weight, or grilling about a boy or girl friend, or failure to find a job and other unfortunate conversations can cause stress. And that is often the trigger to overeating.

Every year as Thanksgiving approached, many of my weight loss clients would beg me to think up some reason they could use as an absentee excuse, because they couldn’t bear to be with their families for the holiday. Their weight was always the issue. If they had gained, then every morsel of food put into their mouths would be scrutinized and “tsk tsk” would be heard from someone who saw any food my clients ate, as being too much food. On the other hand, if they had lost weight, there was the pesky relative telling them they looked wan, gaunt, and even sick so why didn’t they have some gravy on the turkey or a larger piece of pie? Now, of course, these beleaguered individuals can escape. Who can fault them for skipping dessert entirely or packing a piece of pie in their tote bag as they race out the door to stand in line to buy a tablet or a computer-driven stuffed animal?

However, there are flaws in substituting shopping for a Thanksgiving celebration. Those who must work are not able to celebrate this national holiday, this day of thankfulness. And unless and until retail stores can be staffed by computers, this is not going to change.

And then there are the dishes. Does everyone go to the store or do some stay behind to clean up the mess?

Finally, if the meal is concluded prematurely, no doubt there will be much food left over. At least until the shoppers come home, take off their coats and sit down again to eat.

At What Age Is It Alright To Act Old?

At a museum where I volunteer, a group of women and a handful of men came for a talk and a tour. They live in a retirement community, and ranged in age from their early seventies to mid-eighties. Most had difficulty walking, and gratefully sat down, even though they had been on a bus for two hours (traffic was bad). After hearing a talk and watching a video, many continued to sit even though visiting the exhibits required walking. The few who did stroll around the museum were conspicuous in their relative vigor despite, judging from their appearance, they did not look any younger than the rest of the group. Ninety minutes later, they climbed back on the bus, happy to be going off to lunch.

The reluctance of most of the group to walk around the museum they had come to visit may be typical of this age group. A review article by Drewnowski and Evans in the Journal of Gerontology pointed out that people 65 years of age and older significantly reduce the time they spend in voluntary physical activity. Some in this age group are unable to do any activity that requires muscular strength, such as getting up from a chair, carrying small items like dishes, or dressing themselves. Clearly the museum visitors have not fallen into dependency on others to assist them in what is called the activities of daily living, but if they had been forced to leave the museum quickly, say because of a fire alarm, I doubt most would have been able to walk, even in that circumstance, sufficiently fast enough to be safe.

Many of us take for granted that if we reach our ninth decade or even our eighth, we will be in a sense physically shackled by the decline of our bodies. And it is true that people who engaged in recreational sports such as skiing, tennis, running or biking when younger decide that they are too physically slow, their bones too fragile, their balance too uncertain to continue as they age. Indeed, I once had a weight-loss client who told me with great seriousness that, as she was soon to be forty, she was too old to exercise.

But does old age mean resigning oneself to a life of increasing frailty and limited mobility? Certainly joint and muscle pain or neurological degenerative diseases like Parkinson’s disease make movement difficult and often painful. But, as Drewnowski and Evans point out, the answer is no for the healthy elderly. If they engage in physical activities that improve muscular strength, endurance, and flexibility, they would find themselves walking more easily with improved balance and endurance. They would also decrease their risk of falling and fracturing their bones.

I wonder if people in this age group, like the museum visitors, consider themselves too old to be more physically fit? Perhaps they believe this, in part, because others reinforce that attitude by making it too easy for them to avoid walking or standing. When I asked one of the museum staff people why the visitors should be sitting for an hour of lecture and video after being on the bus for two hours, her reply was, “They are old. Let them sit.” Would she have said that if Jane Fonda,who is about to be 78, were in the group?

Do we make people behave old just because their age puts them in that category? Are we telling people that once they receive Social Security and Medicare, they can accept the inevitable deterioration of their bodies and should stop trying to slow it down by physical activity? Do we tell them, ‘You are old, so act your age!’?

And if they believe that they have the right to sit their way through their eighties, how are they going to fare as if they get into their nineties? If they enjoy reasonably good health now, they can expect to become part of the fastest growing group in the country–the ‘oldest old.’ The cohort of people 85 years of age and older is expected to triple between now and 2030. But if people 5-10 years younger than the oldest old are experiencing limited mobility and endurance, how will they manage as they age without needing to be dependent on others for their needs?

One problem is the absence of role models for this age group. There are too few like Jane Fonda, Lily Tomlin (76) and Morgan Freeman (78). Also, one can’t go to a newsstand or bookstore and find glossy magazines featuring exercise and healthy lifestyles for the over 70 crowd. Fitness facilities ignore this age group, who may feel uncomfortable with the density of twenty-something bodies in various states of uncover working out to blaring music. Even workout clothes are designed for the cellulite-free limbs of the younger cohorts. And exercise classes are rarely designed to protect aging knees or backs. If they are, they may be almost too protective and not push the participants hard enough.

The result is acceptance and complacency. I’ve heard the following: “If everyone around me is complaining of aches and pains and can’t walk far, or climb stairs, or lift packages, or do yoga stretches, why should I? If I go on a trip and the bus driver makes sure I don’t have to walk more than a few yards to a restaurant and I can sit down at the museum, why should I exert myself? I am too old.”

What is too old? Perhaps it time to tell the 75 year-old that if she wants to live a strong and healthy life into her 90′s, she better stop acting her age now.

Cruising Into Obesity

It’s true what is said about gaining weight on a cruise. Well, at least for some people. Having recently ended a seven-day trip on a riverboat, I have direct evidence that if an enormous supply of food is available, some will certainly eat enormous amounts. When I remarked on the seemingly endless opportunities to overeat I was assured, by those who had been on ocean cruises, that the food supply on this riverboat was paltry in comparison. But buffet style breakfasts and lunches, with the option of ordering extra dishes from the kitchen, offered more food than one plate or most stomachs could hold. And the four courses at dinner with the possibility of more than one dessert ensured that no one went to bed hungry. Supposedly there was a midnight snack of pastries and sandwiches, but I had to rely on second-hand information to verify this.  Cookies and chocolates were put in the rooms to stave off any hunger during the night.

And people ate, and ate, and ate.  At lunch, for example, after a morning of sitting on a bus or strolling through a cathedral, people returned to the boat to pile their plates high with cold meats, sausage, cheese, mayonnaise-coated cold vegetables and then order a hot entrée, vegetables and potatoes to eat along with it.  One reason so much food could be consumed was that the plates were quite large.

Long lines formed in front of the person scooping out several scoops of homemade ice cream and topping them with fudge sauce. A variety of pastries could be selected to eat along with the ice cream.   People often went back for a second serving.

The large calorie consumption might have been justified if the diners had spent the day engaged in vigorous hikes, long bike rides, or many hours of walking.  Instead, the distance from dockside to the center of the towns being visited required long bus rides that often continued to sites that were  too far from each other to be easily visited in a morning or afternoon.  Once the group was able to walk around a historic site or visit a museum, the pace was sufficiently slow to allow for mini-lectures and cell phone pictures.  A small gym was available on the boat, but since many excursions started right after breakfast, working out required waking up too early for anyone still on U.S time to exercise and eat breakfast.  It was not a popular destination. And for those who did not want to walk the half flights up or down from one deck to another (there were only three), an elevator was available.

By the end of the week, mutterings about going on a diet after the return home were heard as people waited to enter the dining room, and indeed some seemed to be wearing looser fitting clothes.

Much research effort, money and scientific forums have been devoted to understanding why so many in our country are obese. The reasons given include genetics, alien microbes in the intestinal tract, the carbohydrate content of breast milk (really?), side effects of certain medications, insane diets, fructose-filled soft drinks, fast foods; the list goes on. Some of these factors are probably operative for some individuals.  But the real reason for many was amply demonstrated on the cruise:  eating too much and moving too little.

We are not going to be able to reverse the high rate of obesity until we understand why people ignore recommendations about making healthy, non-weight gaining food choices. An editorial in the Boston Globe lamented the refusal of people to listen to WHO and 2015 Dietary Guidelines Advisory Committee advisories to decrease consumption of processed meats such as sausage, luncheon meat, and bacon and instead eat more vegetables and whole grains.   Calorie labeling allows informed food choices in many restaurants known for high calorie items, but its effect on decreasing calorie intake has been barely noticeable. Pleas to do more physical activity because of its positive effect on health and indeed weight are largely ignored except by those already doing it.

Might the cruise boat be a good research environment to study the eating behavior of people who presumably know how to eat healthfully but won’t? Might we be able to understand why an abundance of food makes people eat abundantly? Certainly it is not because they have just come from a war-torn or famine beset country. A passenger in such an environment does not have to be a rocket scientist to know that a week or so of eating three large meals (and in most cases alcohol) combined with a paucity of exercise is going to increase his or her weight. So why does it occur? No one goes on a cruise to gain weight, and the necessity of going on a diet upon returning home is as annoying as jet lag but lasts longer. It has been said that people eat and drink more than they normally do because the food and drink are included in the price of the trip. Perhaps this accounts for some of the excessive food consumption, but would this also mean that at home all leftovers are eaten, and food is never thrown out just because it is already paid for? Maybe people overeat because they feel themselves in an alternate reality as they float on a river or ocean, detached from the real world.

Not all passengers deviate from a sensible diet even when surrounded by non-sensible but tempting foods. Others allow themselves to eat foods they might not at eat at home, but calculate the benefit /risk of eating extra calories in the form of a regional specialty they can obtain only on the trip.  How are these folks different? Why don’t they throw caloric caution to the winds and eat whatever they want in whatever quantities they can swallow?

Such people are not dieting. Rather they are maintaining their weight. Since it is widely accepted that  95% or more of people who are on a diet gain back their lost weight within five years, even without going on a cruise, perhaps the focus of obesity research should be on weight maintenance.  Thus, a cruise should be the perfect natural laboratory to study eating behavior of those who will be gaining weight and those who will not. But somehow I doubt if there will be people in white lab coats peering at the food on the plates of those going through a buffet and asking, ‘Why are you eating this?’  

 

Will a Low Carb Diet Deepen Your Winter Blues?

Pity the poor (and misinformed) dieter who has been led to believe that losing weight depends on NOT eating carbohydrates. And pity everyone who knows him or her during the next several months. The said dieter’s moods will fall as naturally and inevitably as the leaves falling from the trees. Contentment will be replaced by agitation, altruism by anger, and emotional energy by a ‘down in the dumps’ mood. Indeed, by the end of the winter, the personality of a low-carbohydrate dieter will be as engaging as a hungry bear emerging from hibernation (and both the bear and the low-carb dieter will have bad breath).

The switch to standard time is this weekend, and the seasonal shortening of daylight hours that coincide, will once again bring to the forefront of how the longer hours of darkness each day dampen our mood. This phenomenon, known clinically as Seasonal Affective Disorder (“SAD”), and colloquially as the Winter Blues, affects almost all of us. Those who are spared usually live in the southern tier of states where the days are not quite as short and where the sun usually shines, even in the winter. But those who live in the other half of the country begin to feel the mood misery of day after day of brief sunshine often hidden by clouds, rain, fog, or snow. Even when the sun is bright, it appears long after many of us are at work, and disappears before we get home again.

Strange as it seems, this environmental event brings about changes inside our brain. Despite the fact that our brain is hidden inside our skulls, it is not impervious to changes in the relative hours of daylight and darkness. When the behavioral changes of SAD were first described, in l984 by researchers at the NIH, it was thought that the hormone melatonin was responsible for the depression, tiredness, increased appetite for sweets, and sleepiness that characterize this syndrome. And this initial theory generated the use of a sunbox or light box therapy, i.e. sitting in front of a light source that emits the spectrum of natural sunlight. Light is responsible for metabolically removing melatonin from the bloodstream and since melatonin seemed to be the culprit behind SAD, this therapy made sense.

Now, many years later, the picture is more complicated.  The activity of the neurotransmitter serotonin seems to be slowed by the decrease in daylight hours. Also the symptoms—craving for carbohydrates, rapidly changing emotions, tiredness, irritability, anger and depression—resemble some of the behavioral changes seen in other disorders linked to too little serotonin activity, such as premenstrual syndrome (PMS). Consequently, people suffering from SAD have been treated with antidepressants that enhance serotonin activity.

And this is where our carbohydrate avoidant dieters take an emotional hit. Eating carbohydrates – any carbohydrate except fructose – is the first step involved in the brain making more serotonin. Serotonin isn’t made from carbohydrates; rather, eating a potato or a bowl of popcorn will allow an amino acid, tryptophan, to get into the brain. As soon as that happens it is changed into serotonin. Eating protein prevents this from happening, so the carbs either have to eaten before protein is consumed (a snack before dinner) or in a meal containing very little protein (for instance, pasta with tomato sauce or a rice bowl with stir-fried vegetables).

Carbohydrate craving is one of the main symptoms of SAD; it may be the way the brain gets you, the eater, to realize that you need to make more serotonin. Certainly it is a lot nicer reminder than a spouse or friend telling you that you better eat some carbs because you are grumpy and impossible to live with.

But what if, by following a misguided and unnatural diet, very few carbohydrates are eaten? Or maybe none at all? Well, the dieter might consider seeing if Airbnb rents cave so he or she can crawl into one and wait until spring. The alternative is a four-month siege of bad mood brought on by darkness and diet-induced scarcity of serotonin. Maybe Paleolithic people experienced the latter since they could not board a jet to Florida or Arizona for the winter. But the modern-day Paleolithic dieter does not have either the cave option nor employment that allows for four months on a beach in the Caribbean.

The choice is simple: eat small amounts of carbohydrate, about 30 grams, twice a day as snacks, and if possible, eat a largely starchy carbohydrate dinner to boost serotonin and mood.  Or, go into social hibernation until spring arrives and the increasing hours of daylight vanquish the winter blues.

Why Are Health Care Workers Unhealthy?

A friend of mine moved to a new city and obtained a new primary care doctor, along with a new hairdresser and gym. She writes, “I was somewhat appalled at the size of the receptionist and nurse in the doctor’s office. The doctor was a little pudgy, but the two others verged on morbidly obese. It was like going into a hair salon and seeing all the hairdressers with split ends and gray roots, or going to the gym to see the personal trainers sitting in the gym smoking and watching television.”

Her observations were not unique. I have been making weekly visits to a local VA hospital because of a research collaboration and noticed that many of the employees, both administrative and clinical, are also overweight or obese. The unhealthy weight of health care workers is now well documented in a research study published in 2014 in the American Journal of Preventive Medicine (vol 46: 237-248). The lead author, Sara Luckhaupt, analyzed data from the 2010 National Health Interview Survey and found that 35 percent of health care workers, both in medical offices as well as clinics and hospitals, are obese. The study was very careful to eliminate factors such as gender, race, smoking, and age as contributing to their excess weight.

Long hours, stress, limited access to healthy food, excessive commuting time, and sedentary jobs push us toward eating the wrong foods and/or eating too much and avoiding exercise. But all these factors operate across most work situations. And in some respects, health care workers who can stop working when their shifts are over are better off than the corporate worker, who is expected to be on call and meet work obligations 24/7.

Yet my friend wondered why the people working in her new doctor’s office were so overweight. Was it because there was a large container of Hersey’s Kisses on the counter where the patients check in and, in the small room where coffee was available for the staff and patients, a basket of highly caloric cookies stood next to the coffee machine?

“I feel as if I am receiving a dual message,” she told me. “I don’t need a medical degree to know that excess weight may affect my blood pressure and make me vulnerable to diabetes since I have a family history of that disease. So why the candy and the cookies? You wouldn’t expect a dentist to offer sticky sweet snacks to the patients unless business was poor. It was hard for me to resist eating the chocolate. It must be much harder for the office staff who stare at the container all day.”

Obviously my friend wasn’t going to cancel her appointment with her new physician because the person checking her in was overweight. As she told me, “I take full responsibility for my weight and I don’t need to be in a medical office with a skinny staff to motivate me to eat healthy foods.” But then she went on to wonder if someone who is struggling with her weight would decide that it is all right to be obese if surrounded by hospital and medical office employees who are also obese.

Seeing hospitals and medical offices filled with very overweight employees gives the impression that this profession is not taking care of its own. It is hard to understand how health care workers can see evidence of the medical consequences of obesity, and yet fail to maintain a healthy weight themselves.

Imagine going into the orthodontist’s office and seeing the dentists and office staff with pathologically bad teeth alignment. Or being examined by an optometrist who can’t read the figures on the machine because she needs glasses. What if the hospital staff never got flu shots and consequently they all come to work with fevers, bone aches and coughs?

No one in the health care profession has the right to impose weight standards on anyone else in the profession anymore than a dentist has the right to insist that the staff use dental floss. But given the multitude of health problems associated with obesity, it should not be necessary for the health care worker to become a patient, before his or her obesity is addressed.

It begs the question, this contradiction of obesity in the health care industry… Could changing the work environment help reduce the high incidence of obesity among health care workers? Do current work schedules contribute to overeating, stress, and too few healthy food choices, especially for evening and overnight shift workers? Should exercise facilities be made available on the premises, or at least a room for yoga, Pilates and relaxation techniques? Should employees who are morbidly obese be offered weight-loss strategies, including bariatric surgery?

Ironically, the health care profession is in the best position to implement a healthier work environment among its employees, because it is the health professionals who are telling the rest of us how to eat, exercise, decrease stress, and live more balanced lives. If they take care of their own by making it easier for them to maintain a healthy lifestyle, the health profession will be an example for the rest of us. But if they are not interested or fail, then the take-away message for the patient is, “Do what I say, not what I do.”