The Unfortunate Association Between Pain and Obesity

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

Thus more pain is experienced.

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

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

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

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

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

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

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

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

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

Accidental Weight Loss: A Gift for the Dieter

Three of my friends are suddenly thinner, and they are delighted because none of them was dieting.  One lost weight because work required her to travel across several time zones, and she found that she was sleepy, but not hungry, at mealtimes in the new time zone. Another had unexplained abdominal pain, was put in the hospital for tests, and did not eat for several days because of the tests and the pain.  When she returned home, she found that she had lost several pounds. The pain went away unexplained, but the weight loss remained. A third moved and was so busy unpacking, she ate when she remembered to eat, and that consumed were protein bars unearthed in one of the boxes. Because she couldn’t remember where anything she had unpacked was, she walked miles in her home trying to locate the stuff she needed, such as her cell phone.

None of these women was obese, but each wanted to lose between 15 and twenty pounds, but had not gotten around to doing so (one for several years). However now, after noticing their unexpected weight loss, they put themselves on a diet because as one of them told me, “My weight loss was a gift and I didn’t want to throw it away.”

Who knows what motivates someone to go on a diet at a particular moment? Sometimes it is done during a traditional dieting time, such as the first week in January. Diets are started because a special occasion is occurring several weeks or months hence and right now the article of clothing to be worn is tight. Or the occasion itself calls for appearing slimmer; weddings and reunions are noteworthy for being diet motivators. Medical reasons are often motivators for weight loss, too, but sadly are usually accompanied by the development of a medical problem like diabetes or painful orthopedic issues. Occasionally a picture of oneself from an unflattering angle strips away the ability to deny the excess pounds, or the inability to fit into the new season’s clothes that fit a year ago demand that either weight be lost, or a new wardrobe be purchased. But these reasons for starting a diet involve a conscious ‘before’ when the individual was not on a diet, and a conscious ‘now’, when the diet has been started. Accidental weight loss is just that; no conscious decision is involved, it just happens.

Perhaps the most positive aspect of accidental weight loss (in addition to the lost weight itself) is realizing that it is possible to drop pounds without even trying. Many who struggle to lose weight believe that they won’t be able to. The pounds appear to be stuck with permanent glue to various parts of the body. Diets are started and weight may be lost, but to do so requires a great deal of effort: meal planning, and preparation, and time for exercise. Of course this healthy way of life should be followed regardless of weight change, but we are human and unless weight loss is substantial, we may feel that losing weight is not worth the effort we are putting into doing so.

Accidental weight loss seems to produce a looser skirt or pants, a zipper that goes up easily, a shirt whose buttons close without any obvious effort.  “My unplanned weight loss proved to me that when I eat less and move more, the pounds came off, “said my friend, “and I didn’t have to follow any peculiar diet, or any specific kind of exercise.“

Accidental weight loss challenges the claims that the dieter must eat, or avoid eating, foods from specific food groups, must overcook the food, or eat it raw, must allow it to ferment to produce specific bacteria, must subject the body to fasting, cleanses, supplements made from herbs and twigs, injections of fat burning hormones, hypnosis, packaged foods made in an industrial plant, or the latest tabloid ‘miracle’ diet, in order to lose weight. When weight is lost accidentally, it seems that the body wasn’t paying attention to all these diet remedies. It just responded to less food coming in, and in some cases more energy was being used up by your body, and that simply equates to that your physiology used up some of its fat stores, for energy.

The realization that the body is capable of losing weight without formal dieting should be transformed into a strategy for continuing to lose weight. The first step should be reviewing in a non-judgmental way, the eating and physical activity habits that caused the weight gain, and next figuring out what acceptable changes can be made to sustain the weight that has already been lost. With a suddenly slightly lighter body, eating smaller portions, or going for walk rather than sitting on the sofa, may become easier. Throwing away high fat, high sugar, and high sodium snacks that have been an obstacle to weight loss, might seem sensible rather than a culinary sacrifice and exploring alternate methods of decreasing stress other than eating.

After accidental weight loss, you are unlikely to continue to lose weight without consciously making an attempt to do so, but you will be able to. Your body has shown you that it is able to remove a few of those pounds you once felt would never be lost. Now your body is just waiting for you to continue to lose more.

Do Those With Psychiatric Diagnoses Get Enough Medical Care?

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

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

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

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

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

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

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

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

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

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

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

Funeral Potatoes Comfort, But At A Caloric Cost

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

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

Why?

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

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

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

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

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

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

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

Fortunately no.

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

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

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

Why Weight Loss Is Rarely Permanent

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

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

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

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

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

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

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

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

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

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

Peak Physical Fitness as Protection Against Dementia

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Low Carb v Low Fat: What if Neither Diet Works For You?

Are you on a Paleo diet, a South Beach diet, a feast and famine diet, or an all-the-chocolate you can eat diet (I made this one up)? There are so many diets from which to choose where all give evidence of success, with the participants claiming increased energy, decreased blood pressure, and no hunger. Sometimes specific foods, rather than the diet, are given credit for the weight loss: the dieter stops eating all white foods, gives up eating fruits with pits in them, drinks only milk that comes from nuts, stops eating all fried food, or eats only fried foods. Arguments about the virtue or uselessness of various diets cause unwinnable arguments, because one person’s weight loss is someone else’s failure.

Now the arguments can stop. Recently, newspaper and publications on health matters reported the results of a 12-month weight-loss trial that seemed to halt discussions of “my diet is better than yours.” Published in JAMA, the study presented the results of a year-long weight-loss study in which the 609 participating adults were assigned to a either a low-fat or a low- carbohydrate diet. (“Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion,” The DIETFITS Randomized Clinical Trial, Gardner, C. , Trepanowski, J., Del Gobbo, L., JAMA, 2018;319(7):667-679.) At the end of the study period,their weight loss was similar.

The foods on the low-fat and the low-carbohydrate diets were carefully regulated; only healthy fats like avocado and nuts, and healthy carbs such as whole grains, lentils and beans, were allowed. The operative word influencing food choice was healthy. Both groups were encouraged to eat large quantities of fresh vegetables and instructed as to how to prepare foods that were relatively unprocessed.

The amount of weight loss was moderate; both groups lost about 6 kg, or about 13 pounds, in 12 months. This amount of weight loss cannot compete with claims made in television advertisements or tabloid magazine articles for commercial diets. However, unlike the “quick weight-loss” promises of such programs, the diets in the research study produced the type of weight loss that can be sustained over long periods of time and maintained after weight-loss goals are attained. Indeed, the food choices in both diets were similar to those recommended for everyone in order to avoid heart disease and diabetes.

But will this news make an impact on diet programs? Will it stop self-appointed nutrition experts from claiming that their method of weight loss is optimal? Will it decrease the claims that a particular herb, hormone, mineral, spice or berry has the power to alter metabolism so that weight will be lost easily? Might it stop celebrities from self-righteous statements about their total avoidance of a particular food group, usually carbohydrates but sometimes most food , in order to attain a perfect body? Probably not, because the diet plans tested were sensible, not sensational, and unlikely to sell tabloid magazines, books or magazines promoting the latest way to lose weight.
But there are reasons why the results from this study should not close the discussion on the best way to lose weight. People who suffer from morbid obesity often need an intervention that produces more than a 13 pound weight loss per year. Surgery that reduces the size of the stomach may be the only effective solution with the type of diet subsequently followed designed to ensure that patients eat enough protein. Besides, the JAMA study diets that include bulky vegetables, whole grains and other high-fiber foods may not be suitable for stomachs that can hold only tablespoon quantities of food after surgery. Of course eventually, when the stomach can receive larger quantities of food, patients might be able to follow the JAMA diets.

Obesity associated with emotional overeating, especially binge eating that is often linked to anxiety, will not respond to any dietary intervention without sufficient psychological counseling. When and if the emotional component no longer causes excessive food intake, then either low-fat or low-carbohydrate food plans may work.

Weight gained as a side effect of psychotropic drug treatment may be hard to reverse with either of the diets described in the JAMA article. Anti-depressants and related drugs cause a persistent craving for carbohydrates along with the absence of satiety. Patients who rarely had weight issues prior to treatment struggle to overcome their medication-induced need to eat. So far the only dietary intervention that increases satiety and decrease carbohydrate cravings is one which allows a small snack of carbohydrate to be consumed prior to meals and sometimes between meals. The carbohydrate increases brain serotonin which in turn increases satiety and turns off craving. Since the subjects in the JAMA study were not on such medications, there is no way of knowing if either or both diets might have been effective.

The weight-loss program in the study educated the participants in healthy meal preparation. In an ideal world, dieters have time to do just this: shop for the right foods, prepare them and clean up after the meal. One hopes that the advice and training given the participants also included what to eat when staying late at work, dealing with sick children, car pools, long commutes, bad weather, travel, holidays and other often unavoidable situations that make it difficult to make the right food choices.

However, the study presents the hopeful possibility of stopping the arguments over which type of diet is best. Now future studies can focus on the best weight-loss intervention for those whose weight loss may not respond to conventional diets and on how best to help the dieter adhere to whatever program is recommended.

If I Don’t Pay Attention to What I am Eating, Will the Food Contain Calories?

“What do you usually eat on a typical day when you are not dieting?”

I often ask this question when meeting a weight-loss client for the first time. Although I write down the information, I know that it is rarely complete. It is very hard for any of us to recall everything we have eaten yesterday or a few days ago, especially food that is not consumed as part of a meal. Did we munch on the potato chips that came with the lunchtime sandwich? Did we pop a few nuts in our mouths when we saw the bowl on the coffee table? Did we taste the food we are making for dinner and perhaps do more than just taste? Did we or didn’t we have a glass of wine with dinner, or was it two?

As hard as it is to remember what we ate it is even harder to remember how much. Few of us visually measure the size of the entrée put in front of us in a restaurant, or notice the quantity of food we eat at home. Was the chicken 4 ounces or 6? Was the rice a half a cup or two cups? How big was that piece of blueberry pie? And sometimes our best intentions to eat only a small part of what is put in front of us get lost when our attention is directed elsewhere while we are eating. I remember seeing a couple aghast at the size of their meals when it was put down in front of them in a restaurant known for their supersized portions. But they consumed everything on their plates because their attention was diverted to an intense discussion they began as they started to eat. The faster they talked, the faster they ate, and I suspect they never noticed how much they were eating until their plates were empty.

Reading emails on one’s smartphone, watching a video on a laptop device, or texting with the non-fork containing hand also interferes knowing how much is being eaten. When attention is elsewhere, the act of eating becomes automatic. The fork moves from plate to mouth to plate again, and the eater may not notice how much is being eaten until the plate is empty. If an hour later the eater was asked what and how much was eaten, he or she might be able to give only vague details. Indeed, sometimes the eater denies that much was eaten at all. “I just tasted the food and left most of it,” he will claim when the reality is that there was nothing left on the plate when he finished the meal.
Unless we must keep track of our food intake for health and weight-loss reasons (for example, a diabetic keeping track of grams of carbohydrate), we usually give only perfunctory attention to what we are eating. But even if we forgot what we put in our mouths, our metabolism does not. A calorie we do not notice eating still counts as a calorie we have eaten.

This absent-minded eating can make it very hard to lose weight. The heavily advertised weight-loss programs that restrict all food intakes to packaged drinks, snacks, and meals delivered to your door make paying attention unnecessary because the meal choices are programmed to enable weight loss. But if you are on a weight-loss program that gives you choice of what, and to some extent, how much you are eating, then often the only way to keep track of what you are eating is “to keep track.” There are apps for this, along with the traditional paper and pen food diary. Some people are able to keep track of everything they eat (they also balance their checkbooks), sometimes for months, and they are usually successful in losing weight and keeping it off. But for the rest of humanity for whom even keeping track of today’s date is difficult, recording everything that is eaten becomes very tedious very fast.

People who have maintained an appropriate weight for many years often follow an unchanging menu for breakfast and lunch. They don’t have to pay attention to what they are eating because their meal choices never vary. They often have rules about what they will eat for dinner as well: limited alcohol intake, salads with dressing on the side, eating only half the restaurant portion or sharing an entrée, avoiding fried foods and dishes with thick sauces or melted cheese, or avoiding all carbohydrates or all fats.

Weight-loss programs that do not make it necessary to pay attention to what and how much is eaten because all the foods are pre-measured rarely offer effective advice on how to pay attention to what is being eaten after the diet is over. The concept doesn’t sell very well in television advertisements for people who just want to lose the weight, but it is critically important to do so.

Making rules that limit food choices may be the most effective method, but may turn eating into more of a chore than delight. One thing that helps is spending 20 seconds to look at what is on the plate before eating. In those 20 seconds you can decide what you will eat in its entirety, what you will avoid and what you will eat sparingly. Taking a picture with a cell phone so the calories can be figured out later is also useful. It also may give you an idea of whether you have eaten anything healthy that day. Mindless snacking is a caloric hazard. Dipping one’s hand into a bowl or bag of snacks like nuts, cookies, or chocolate almost always causes excess calories to be eaten without any memory of doing so.

Not paying attention to what you are eating has a price: you may not know but, alas, your clothes and scale will eventually know only too well.

Should Cauliflower Be the Main Course at a Vegetarian Wedding?

I could have chosen the fish entrée at the wedding we went to a few weeks ago. But since we eat fish several times a week, and since the caterer was known for creative healthy main courses, I opted for the vegetarian choice. Maybe I would discover a novel way of preparing non-animal protein to add to my cooking repertoire.

But alas it was not to be. The mix of vegetables, grains, and lentils that were described in the printed menu was like a bait and switch. The plate arrived containing a mound of steamed cauliflower surrounded by two tiny pieces of sautéed mushrooms. I looked wistfully at the perfectly grilled fish my spouse was eating. Next time I will know better.

But why? Why shouldn’t a caterer prepare a vegetarian entrée with the same balance of protein, vegetables and starch that would appear on a traditional meat or fish dish? Why do caterers or chefs in general assume that vegetarians eat only vegetables? People who identify themselves as meat and potato eaters surely must eat other foods for breakfast or lunch. And why do caterers and chefs conflate vegetarian and vegan? They are not the same.

Indeed, the menu said “ vegetarian” entrée, not vegan. This meant that protein from dairy products and eggs could have been incorporated into a main course, thus allowing for a large variety of possible dishes. Moreover, if the entrée had been listed as vegan—meaning no dairy or eggs—then other protein sources such as beans, lentils, soy, and quinoa could have been used.
It is not necessary for the chef preparing a vegetarian meal to reinvent the wheel. Because animal protein has always been expensive and out of reach for much of the population, each culture has developed signature non-animal protein dishes from cheese blintzes to bok choy stir-fry with crispy tofu. Moreover, the Lenten season restricts the consumption of animal protein, and over the centuries many vegetarian dishes have also been developed to feed families unable to eat meat or chicken.

But none of this seems to be considered when the catering kitchen or many restaurants plans the components of a vegetarian meal. Unfortunately, despite the protein sources that could be incorporated into a vegetarian dish, the protein is usually omitted. Sometimes this is because the caterer simply takes the vegetables from other entrées and dumps them on the plate for the token vegetarian. But protein is often left off of the plate because the chef doesn’t take the time to learn how to include it.

Ironically, eating a vegetarian entrée at a catered affair that serves the main course often hours after one normally eats is a wise choice. Ingesting a slab of filet mignon or heavily sauced chicken at 9 or even 10 pm does not make for a sound sleep a few hours later. Digesting the fat in these animal protein dishes sometimes causes sleep disturbances or a lighter sleep than normal as well as a feeling of heaviness upon awakening the next morning. Vegetarian options tend to contain less fat (unless substantial amounts of cheese are used) and are less likely to demand heroic digestive function late at night.

Until the education of chefs at well-known culinary institutes includes an intensive education in preparing protein-rich vegetarian dishes, there is little hope that vegetarian entrée options at catered affairs will improve. And until cooking shows feature vegetarian dishes that provide at least 25-30 grams of protein and which seem “yummy” enough to be reproduced in the viewer’s kitchen, there is little hope that home cooks will find making a well-balanced vegetarian meal as desirable as grilling chicken or a hamburger. Fortunately, there are many excellent cookbooks and some gourmet cooking magazines that provide ample recipes for the vegetarian home chef. And in fairness to the caterers and restaurant chefs who have developed nourishing vegetarian main courses that look and taste good, it is hoped that they will be able to stimulate others to provide nourishing meals for those who abstain from animal protein.

However, until this occurs, it may be necessary to plan on eating before going to a catered event or bringing protein bars to nibble, discreetly, along with that cauliflower. And if there is any benefit to being denied a substantial vegetarian meal at a catered affair… it is that you will be one of the few who don’t feel your wedding finery is getting snug.