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.”

If You Eat Carbs When You Are in a Bad Mood?

Eating a dish of chocolate-sauced ice cream or a large bag of potato chips when feeling sad, angry, tense or worried is pretty standard behavior for people who turn to food rather than alcohol, nicotine or recreational drugs when their moods go south. Women with PMS know all too well the impulse to chow down a bag of chocolate chip cookies or half a sheet cake when the hormones are ‘raging,’ i.e. the end of the menstrual cycle.

But few of these eaters would put the blame for their bad moods on the carbohydrates they are inhaling. Rather, they know that a social disaster, financial problem, cranky mother-in-law, their teenager, or even the early sunsets of winter is driving them to food.  Chocolate cravings appear with great regularity among some premenstrual women, along with the feeling that all is wrong with the world. But few who may brave a blizzard to get a chocolate bar would blame their moods on the chocolate. (Of course, if the chocolate were unobtainable, their bad mood might worsen.) But now some scientists, and the carbohydrate overeaters themselves, are suggesting that the trigger to the bad moods is the carbohydrates themselves.

Isn’t it true? After all, what do depressed people eat and overeat? Not celery, kale, cottage cheese and boiled chicken. Not gobs of mayonnaise, lumps of butter or hunks of lard. Carbohydrates, either sweet/gooey or crunchy/salty, are the feel-good foods of choice. And of course, we all know where this type of eating leads: weight gain, obesity, a multitude of medical problems and depression because of the obesity. Certainly someone who looks at the empty quart-sized ice cream container, crumpled bag of potato chips or the crumbs of a depleted box of cookies feels remorse, depression, anger and even helplessness at the eating that just occurred: “Now I am really depressed,” thinks the overeater. “I probably just gained 10 pounds on top of the twenty I already need to lose.  It is all the fault of the carbohydrates. “

But is it? Does eating carbohydrates in association with negative mood mean that eating carbohydrates causes the negative mood states?  When we drink water in association with thirst, do we assume the water causes the thirst?  When we put food in our bodies in association with feeling hungry, do we assume that food causes hunger?  When we take a pain-relieving medication in association with back pain or a headache, do we assume that the medication is causing the pain?

Fortunately, we don’t have to rely on word play to answer this charge.

It is possible to test the carbohydrate-mood link in the laboratory.  The format for such research is to measure the moods of volunteers when they are not in particularly good moods, for example people who get grumpy every afternoon around 4pm or women with PMS. Volunteers fill out self-reports on their mood and then are asked to consume a beverage containing carbohydrate or protein. They don’t know what the beverages contain because the taste and textures are identical. An hour or so later, after the carbohydrate or protein has been digested, the volunteers fill out the same mood reports. We did such an experiments at MIT with people who always ate a carbohydrate snack late in the afternoon when they started to feel irritable, restless, impatient, distractible, tense, and even a little depressed. After they consumed the carbohydrate-containing beverage, their moods improved significantly. But their moods did not get any better after drinking the beverage containing protein.

Several years later we did a similar test with women whose carbohydrate intake (we measured this directly) increased enormously when they were in the throes of their mood-altering PMS symptoms. These women also consumed a carbohydrate or protein-containing beverage and, as in the earlier study, did not know what each beverage contained.  The carbohydrate beverage significantly decreased their anger, depression, tension, confusion, and even fatigue. None of these moods was altered after they drank the beverage containing protein.

There goes the ‘carbohydrates cause depression’ theory.

Was it the taste of the carbohydrates that put them in a better mood? Unlikely. Their moods were measured an hour and more after they finished the drink. Moreover, the drink had a mild fruity taste but would not be a contender for best tasting drink.  The reason for the improvement in mood was due to the increase in the ‘feel-good’ brain chemical, serotonin. The carbohydrates did not produce the serotonin, but their consumption triggered a series of biological events in the blood and brain that caused more serotonin to be made. And that produced a better mood.

What is wonderfully curious is how we know to eat carbohydrates when we are feeling blue, despondent, upset, stressed or anxious. It is not something we are taught and indeed, given the current anti-carbohydrate attitude of self-proclaimed nutrition experts, we have been told to avoid eating those dreadful foods. But (Thank you, Mother Nature!), there must be some sort of signal from the brain, to our emotional self, to our mouth and eyes that says: Now it is time to have some crackers, or an English muffin or a small bowl of oatmeal. I call it a ‘carbohydrate-thirst.’ Indeed, one of our early volunteers said, “My mouth is calling out for carbs.”

Whatever the signal, the outcome is the same. A small amount of carbohydrate, no more than 25 or 30 grams, is enough to perk up our serotonin and take the edge off whatever bad mood we are experiencing. Like thirst, or hunger, or the need for sleep, eventually the carbohydrate hunger will come back when, for a variety of reasons, mood begins to deteriorate.  But for several hours after eating the carbohydrate, we will feel a little less stressed, a little calmer, and even a little happy.  And that, fortunately, is not going to change.

Surgery Can Remove Hunger, But Can It Also Remove the Emotional Need to Eat?

Dieting may be the traditional method for losing weight. Yet more and more obese individuals are giving up counting calories and measuring their food and instead are turning to surgery. Advances in bariatric surgery over the past 10 or so years has made possible a relatively short, simple operation to turn the pouch-like stomach into a skinny sleeve that holds no more than 2 to 7 ounces of food. The operation, called the gastric sleeve, is done laparoscopically, which means recovery is quicker than conventional surgery.  According to the American Society for Metabolic and Bariatric Surgery, almost 42 percent of all bariatric surgeriesperformed in the United States in 2013 were sleeve gastrectomies,i.e., it’s currently the most popular weight loss surgery.

The operation is non-reversible; the major part of the stomach, which looks like a mildly curved banana pouched at one end (as if the banana swallowed a golf ball), is cut away. The original stomach cannot be reconstructed any more than a pair of jeans can be reconstructed after the legs have been cut off to make short shorts.  The stomach still functions, but eating has to be miniaturized. Eventually, the stomach may stretch somewhat so food does not have to be measured with an eyedropper. Still, people who have had this operation will be unlikely to be able to eat a large pizza or a 12-ounce steak unless they spread the eating over several days.

Fortunately, one of the biggest advantages to this type of weight loss surgery is that when the fundus, that bulge at the bottom of the stomach, is removed, so too is ghrelin (rhythms with melon). Ghrelin is an appetite-stimulating hormone produced in the fundus. Normally, when the stomach is empty or (and this is bad news for a traditional dieter) when low calorie diets and/or chronic exercise regimens are followed, more ghrelin is produced. Hunger does not make dieting easy. Ghrelin goes up before meals and, not surprisingly, decreases after food is eaten. But the gastric sleeve surgery significantly decreases this hunger hormone.

The resulting lack of hunger is so striking that for months after the surgery, patients must remind themselves to eat. Consequently, during the post-operative year, weight is lost easily and many of the medical complications of obesity-like diabetes are lost as well. But as with other types of bariatric surgery, getting to a goal weight is not always attainable. It is possible to gradually restretch the stomach enough to hold more food and more calorically dense food.

But for most, the hunger may be gone, but the need to eat remains.  As a woman wrote on an Internet site devoted to bariatric surgery, the operation does not ‘mend the mind.’ She was describing her need to eat sweets when she was tired or stressed. Others chimed in with their stories of being unable to control their eating when they experienced the mood and appetite changes of PMS. A man wrote in about drinking alcohol again as a substitute for eating candy to which, he said, he was addicted.

Will power, the surgically imposed inability of a now skinny stomach to hold much food at a time, and motivation to reach a healthy weight, keeps many from giving in to these cravings. But for some, not capitulating is like not taking a pain reliever during a bad headache or backache. These individuals use food as a sort of self-medication; they eat when they are depressed or anxious, or in an irritable mood and by doing so, feel better. The improvement in mood is not wishful thinking or a placebo effect.   

Nature gave us a way of eating our way out of stress. We can do so by consuming carbohydrates that, in turn, results in the production of the brain neurotransmitter, serotonin.  Serotonin is made when the amino acid tryptophan enters the brain. It does so only after starchy or sweet carbohydrates are eaten. (Eating fruit does not have this effect.) Eating small amounts of carbohydrate increases serotonin levels within about a half an hour.

Serotonin levels may fluctuate during the day, leading some people to feel a serotonin low in the afternoon. Serotonin is also lower during PMS and the dark days of winter.

However, nature never intended for the carbohydrates to be consumed in the form of cookies, chocolate, ice cream, pie, doughnuts, muffins, cinnamon rolls or strudel. The effect on producing serotonin is just the same if steamed rice, plain pasta, unadorned bread, unsweetened cereal, and boiled potatoes are eaten, rather than the fat and sugar-filled pastries or salt and fat-filled crunchy snacks. Again, it is unnecessary to eat large amounts of carbohydrate; about 25-30 grams, the amount in a small bag of fat-free pretzels, is sufficient. Presumably someone could consume this amount with a sleeve-like stomach once enough months passed since the operation, and real food is once again being eaten.

Of course it would be better not to eat out of emotional need. It would be wonderful if those of us who think ‘I have to eat something’ when confronted with a distressing situation or experiencing PMS, stopped feeling this way and managed to get through the stress or PMS without giving in to ourselves.  But our brains are not all alike in this regard, and there will always be some of us who really need to eat some carbohydrate when we are upset. Only a brain transplant will stop us from doing so!

Post-operative gastric sleeve patients are given detailed instructions on how to eat to recover, regain their strength and not alter the size of their tiny stomachs. Would it not be helpful for these instructions to include how to eat to minimize stress without risking weight gain? Shouldn’t women be helped to get through their premenstrual days without imploding by showing them that tiny amounts of carbohydrate can have a enormously positive impact on their mood? The same remedy applies to people suffering from the winter blues, as well. Information about post-op refeeding should include the fact that the absence of carbohydrate will decrease serotonin, and perhaps lead to depressed or anxious moods.

Patients who eat out of emotional need can be taught to consume controlled, small portions of non-fat, non-sugary carbohydrates. By doing so, they will find that their emotional well-being will match their improved physical well-being.

How Do You Milk An Almond?

“My trainer told me that I should drink a shake each morning made with almond milk, protein powder, and fruit.” The young woman was discussing her new fitness routine with a group of us drying our hair in the health club’s locker room.

“Why almond milk?” I asked, wondering how to get milk from an almond.

The answer, agreed to by everyone listening to the conversation, was that almond milk was much healthier than milk from that definitely milk-able animal, a cow.

“But almond milk doesn’t have any protein, well, at least not much,” I responded, trying to remember when I had last read a food label on the side of an almond milk container.

“That’s all right,” she replied. “I just add some protein powder to the shake.”

At this point, my wet hair demanded more attention than her nutritional needs, so the conversation stopped. But later on that day, while in the supermarket, I stopped by the milk case to read food labels. I was right. Almond milk contained only 1 gram of protein per serving. Cow’s milk contained 8 grams. But to my surprise, almond milk contained a lot of calcium, actually about 45 percent of the daily requirement for this mineral. But where was the calcium coming from? Almonds don’t naturally have much, if any, calcium. There it was on the label: calcium carbonate, an additive. So why not instead, eat some almonds and swallow a calcium supplement?

Almonds are natural, but almond milk? Well, it’s not quite as natural as cow’s milk. It contains sea salt, carob or vanilla bean extract, cane or brown rice sweetener, emulsifiers and preservatives, added Vitamin D and, of course, the added calcium carbonate.

At least my locker room acquaintance was getting protein from the protein powder she added to her blender. But is protein powder as good a source of protein as that derived from real food, e.g., milk or eggs? Trying to ignore my mild obsession with her breakfast, I looked up the nutritional adequacy of protein supplements. It was not a topic for the faint-hearted. Claims for bodybuilding power were as thick as mosquitoes on a humid summer evening. And reading on, I came across blogs with horror stories of protein powders containing rat droppings, heavy metals, and genetically modified plant extracts. Who writes these stories? Were they true?

It is necessary to get beneath all the hype promoting the potency of one protein powder over another to find out about the amino acid contents of these various powders. In order to make new protein, for muscle, skin, or any other organ that needs new or replacement protein, our bodies must have amino acids. Protein is made from amino acids and although we, as humans, can make some amino acids, there are eight, the essential amino acids, which we cannot. We get them from the proteins we eat. Not all proteins contain adequate amounts of these essential amino acids, and are ranked according to their amino acid contents.

Two of the most widely used proteins in muscle building supplements come from milk: casein, which gives milk its milky look, and whey, the watery residue formed when cheese is made as in “Little Miss Muffet, sat on a tuffet, eating her curds and whey.” (Curds are goes into the making of cheese.) Miss Muffet’s muscles must have been outstanding, since whey protein is especially good for building muscle. Perhaps this is why she was able to run so fast when the spider frightened her away! The other widely used protein in protein powder supplements is soy isolate, which is produced in a concentrated form, from soybeans.

The Chinese have known about the importance of eating soybeans since approximately 2838 B.C., but they probably did not consume it as a muscle-building protein powder until late last century. And because the amount of essential amino acids is smaller in soybeans than in animal protein, it was assumed that soy was not a particularly good source of protein for athletes, or anyone attempting to develop a large muscle mass. However, in a review of which proteins athletes should consume, Drs. Hoffman & Falvo, in the Journal of Sports Science and Medicine, pointed out that the concentrated form of soy protein has an amino acid content equal to that of whey and casein.

So for people who would rather drink their meals rather than eat them (no, not a regimen of beer for breakfast and liquor for lunch), soy protein powders are an option, along with powders containing either of the two milk proteins.

But other than eliminating the pesky need to chew, is it better to drink a shake for breakfast containing purified and/or synthetic ingredients than to eat foods in their natural state? On one hand, the answer is yes. Blending rather inedible foods with other foods that taste good (for instance, raw kale and blueberries), makes their consumption less of a challenge and permits the consumption of foods that otherwise might be overlooked. Moreover, shakes can be consumed more easily than a bowl of cereal and milk in the car, or on commuter train, or while hanging onto a trolley car strap.

But we seem to be straying away from eating foods in their natural state and perhaps, ironically, eating more foods that are highly processed. Dumping synthetic foods like almond milk and highly refined foods like protein powder in a blender is not eating naturally. Maybe the time has come to go back to eating real food: milk from cows, eggs from chickens, bread made from wheat flour, and turkey made from turkeys (instead of tofu). If we do so, we can stop trying so hard to get milk from almonds.

Are We Working Ourselves To Death?

If you are an executive, manager, emergency medicine physician (EMP), Silicon Valley employee or struggling law associate, you and many like you are probably working more than 60 hours a week. According to a survey published in the Harvard Business Review a few years ago, you may be working an average of 72 hours a week.

Contrast this with the government’s desire to limit excessive working hours about 80 years ago when, on June 25, 1938, Franklin D. Roosevelt signed into law the Fair Labor Standards Act (FLS). This law banned oppressive child labor, set the minimum hourly wage at 25 cents, and the maximum workweek at 44 hours.

Moreover, more than a hundred years ago, workers were given an entire weekend off from work. (How many EMPs can expect this?) The five-day workweek was started in 1908 by a New England cotton mill owner to allow Jewish workers to observe their sabbath on Saturday. They were expected to make up the work on Sunday but complaints about having the mill operate on a Sunday resulted in closing the factory for the entire weekend. Later, in l926, Henry Ford shut down his automotive factories for the entire weekend. He wanted his employees to have leisure time to buy automobiles. The Amalgamated Clothing Workers of America Union demanded a five-day workweek in 1929, and received it; but it wasn’t until 1940 that the two-day weekend was adopted countrywide.

But now, many people work at least 10 hours daily or longer; some companies even provide dinner to make sure their employees stay late. Salaried employees often are tethered to their smartphones during the weekend and expected to be available. Their jobs often require working throughout the weekend. If their company, sensitive to criticism that their employees have no time off at all, tells them not to work one day during the weekend, the employees find themselves working twice as hard on the other day to catch up with the work handed to them on Friday afternoon. To be sure, their work load is not as relentless as that of a galley slave who was chained to his bench for the length of his servitude, rowed for up to 20 hours a day, was whipped incessantly and fed vanishingly small rations. They, by and large, did not live long. But now we are learning that the modern day equivalent of the galley slave may not live out his or her natural life expectancy either.

The medical journal, The Lancet Online First, published an article recently comparing health risks of people who worked 55 or more hours weekly compared with those who worked 35-40 hours. Working many more hours was associated with a 13% increase in the risk of cardiovascular disease and a 33% increase in the risk of a stroke compared to working 35-40 hours (the so-called normal work week). The report is sobering. The many researchers who contributed to the study pooled information from 25 different studies that tracked the health of adults for 7-8 years. When the study began, the more than 600,000 participants had no evidence of coronary heart disease and nearly 530,000 of them had no evidence of stroke. Seven or eight years later, the formerly healthy workers who had the greater work burden were now facing medical risks that might shorten their longevity. The scientists searched for reasons. Was it economic status, smoking, age, gender and/or weight? What might be contributing to these dire findings? The answer was none of the above. Only working 55 or more hours per week was associated with these risk factors. 4
Interestingly, the authors did not conclude their article by suggesting a decrease in working hours. Rather, they said that employers should pay attention to identifying and managing heart attacks, stroke, high blood pressure and other symptoms of cardiovascular risk among their employees. Maybe they meant that employers should be trained in CPR in case a worker keels over in his cubicle.

The reasons for a deterioration in health associated with galley slave-like hours are not hard to find: stress, depression, lack of sleep, lack of exercise, lack of fresh air and sunlight, too much sitting: the list goes on and on. The overworked worker is told to make better food choices, get more sleep, exercise and relax. These are all good suggestions, but if deadlines and excessive work assignments reduce free time to hours spent traveling back and forth to work, it is almost impossible to make use of this advice.
Yet one suggestion might be some help to those struggling under an impossible work burden: eat to perform better and to relax.

Lean protein helps maintain two brain chemicals that are involved in mental alertness and rapid mental processing. Caffeine also increases mental alacrity and focus. Water prevents silent dehydration associated by many hours in a dry environment. People don’t realize that their bodies are losing water because they are not sweating. However, consuming too little liquid often causes fatigue and headaches. And fat should be avoided: it makes the brain sluggish and the body slothful.

Starchy carbohydrates, in contrast, help the brain and body relax when, finally, work is over. Serotonin, the mood chemical produced when all carbohydrates, except fruit, are eaten, decreases stress and anxiety and soothes the mood and the brain into a calmer, less agitated state.

It doesn’t take much, perhaps a small baked potato, or a bowl of oatmeal, pasta or rice, to do this. But protein and relaxation do not mix. Protein prevents serotonin from being made. Eat it when you want to be alert, not tranquil.

Exercise, sleep, and recreational activities all help combat the health risks of extended working hours. Sleep is the most important; even the galley slaves were allowed to sleep, (maybe they did not row in the dark) but exercise and taking some personal time are also important.

Let us hope that we do not have to wait for a new version of the Fair Labor Standards Act to be enacted before the 21st century worker is given some relief from an impossible work schedule so that death does not precede retirement.

Will The Crusade Against Sugar Be The Next Prohibition?

There seems to be an eerie similarity between the current rages against the consumption of sugar, in any form, and of any amount, that parallels the rampages against alcohol in the early part of the 20th century. To be sure we don’t yet have axe wielding anti-sugar fanatics crashing down the supermarket aisles throwing boxes of brown sugar on the floor and setting cookies ablaze.  And so far, sugar is not contraband property, available only after whispering a password and exchanging money with some scary figure guarding the door to the pastry shop. But given the books, documentaries and internet sites devoted to demonizing this sweet carbohydrate, such events may not long in coming. Mary Poppins, who sang that a ‘spoonful of sugar makes the medicine go down,’ might be burned as a witch were she to sing that ditty today. Or to put a contemporary spin on the response of the anti-sugar crusade to her advice, she might be fined several thousand dollars and forced to drink a glass of unsweetened lemonade.

No one disputes the unhealthy consequences of consuming too much sugar.  We must stop teenagers from  drinking  20oz of a sugar containing soda or fruit drink as their  breakfast, or elderly people eating only cookies for dinner. They will suffer not only the consequences of eating too much of this simple carbohydrate, but also the consequences of disastrously poor nutrient intake. And we should be aware that large amounts of sugar lurk not only in soda, but in the very popular energy drinks. One might think that the entire country is overcome with fatigue when considering that not only adults, but also teenagers and children drink these beverages. The energy in energy drinks comes not only from the caffeine but also from sugar; per ounce the drinks may have the same or even more sugar than Coca-Cola.  

No one needs that much sugar for energy unless running 100 miles, biking across the continent, or shoveling out from a three day blizzard. In England, there is presently a campaign to ban the sale of such drinks to children. Given that caffeine and sugar are hardly optimal food groups for kids in any country, these drinks ought to be limited to adults as well in the U.S.

Very few of us consume sugar by itself.  Perhaps Pooh Bear could polish off a jar of honey, but few humans, fictional or otherwise, sit down and consume the sugar in the sugar bowl, or eat maple sugar candy. Anyone who has attempted to eat the latter knows how difficult it is to consume more than a few bites because of its granular consistency and intense sweetness. We consume sugar as an ingredient in prepared foods, and oftentimes foods that contain large amounts of sugar (other than beverages) contain large amounts of fat as well: doughnuts, cake, cookies, candy bars, pies, frosting, fried dough, etc.  Thus, when we decrease our sugar intake we concurrently decrease our consumption of saturated fat. This is a win-win all around, unless one believes that eating large amounts of fat is healthy.

But why insist that those of us who eat moderate amounts of sugar in an occasional cookie, cupcake, piece of wedding cake or chocolate bar, stop eating sugar entirely?  If I want to add a few teaspoons of sugar to tomato sauce, sweet and sour red cabbage, or a marinade to offset the white vinegar or lemon juice or to help caramelize the meat, is this sugar going to shorten my life?  Will eating a piece of birthday cake cause my brain cells to implode and hasten the coming of dementia?

The ‘Sugar is Death’ people seem to overlook the fact that honey, a sugar containing food, has been consumed for thousands of years and in every major religious group; this sweet, sugary food symbolizes health, a sweet future, longevity, and spiritual strength.

I believe it is important to compare the anti-sugar campaign with the concerted efforts of well-meaning people to ban alcohol. To be sure, those folk were not worried about people drinking sacramental wine during religious ceremonies, or the small glass of sherry drank by a 90 year old woman to honor her birthday. Nevertheless, the ban on alcohol was all encompassing, unless of course one had connections. The anti-sugar crusaders seem to be taking the same Prohibitionist approach, and even though they are not banning sugar (yet), they certainly are making many of us feel guilty and embarrassed if we eat a chocolate truffle, or ice cream. And many people who proclaim themselves non-sugar eaters look askance at their friends and family members who are still putting that supposedly toxic ingredient in their bodies.

Could we call for a bit of moderation here? No one condones binge drinking or alcoholism, and no one condones excessive consumption of sugar from energy drinks, sodas and a diet of pastries and ice cream.  We attempt to make people recognize the dangers of drinking too much, to one’s own health and that of others (drunk drivers). In this vein, the intake of sugar ought to be limited and people made aware of its negative effects on health if consumed in large quantities and/or too often.

Truly, a world without any sweetness? Without any sugar, honey, or maple syrup? It would be a grim world indeed.

The Vanishing Bread Basket

My breadbasket disappeared.  It was a small container, big enough to hold a couple of rolls or freshly toasted garlic bread, but its size and shape announced that it was meant to hold something small and solid, not gravy, roasted Brussels sprouts or pickles.  My problem is that I cannot find a replacement. Stores selling housewares, from the lowly discount store to high-end retailers, don’t seem to carry this item.  However, I have not tried the summer antique fairs because I don’t want to find something tarnished and in need of buckets of silver polish.

But not only has the breadbasket disappeared from my kitchen; it seems to be disappearing from restaurants as well. Over the past several weeks I noticed that during the time between giving an order and receiving the first course, a time when a basket of freshly baked bread, rolls, or even bread sticks used to appear, nothing is put on the table.  In the past, the starchy delights would soothe the (presumably) hungry diners into not growling at the server, “Why aren’t you here with my appetizer?”  Now there is nothing to prevent the growl.

Recently, looking at the empty spot on the tablecloth where the breadbasket should have sat, my spouse asked for some bread. The server looked taken aback as if the request had been for a roasted pig’s head or bucket of live eels.

“Bread?” he asked. “You want bread?”  

And then several minutes later, a very small roll was served—one roll served to one person. “Uh, could I have a roll also? “ I asked. The server’s glance seemed to say, “You shouldn’t be eating this.”

What has happened to us as a formerly bread eating country?  Haven’t most of us grown up eating sandwiches all through elementary school, making sandwiches for picnics and car trips, discovering ethnic bakery shops that made us want to eat a freshly baked baguette, a raisin, nut and cranberry whole grain roll, a puffy hot pita or a savory corn bread on the spot? Haven’t we mopped up a delectable wine sauce or rich gravy with sourdough bread and thought we were in heaven?  Most cultures reserve special breads for special holidays, and its true that the scent of freshly baked bread, wafting over a sidewalk, has the power to make most of us salivate.

But something strange has happened.  It’s as if an evil queen from a non-bread eating fairytale kingdom has cursed us. Self-appointed gurus have convinced us that eating bread will produce the direst consequences for our brains, our bellies, maybe even our investments in the stock market.  To be sure, there are a very small number of people who suffer from celiac disease associated with the consumption of gluten, and others who may have some type of allergic response to the gluten protein, or perhaps some other protein in wheat flour. But copious information is available pointing to the rarity of these conditions, not that most self-diagnosed gluten-avoiding folk want to know this.

And bread—plain, ordinary, unadorned bread, made from yeast, flour and water—has been reviled as a major contributor to obesity. That the calorie count for a gram of bread is the same as a gram of an egg white is ignored.

What is also surprisingly ignored is the role bread plays in controlling our appetite. Bread, like any other starchy carbohydrate that contains very little protein, has a prominent role in increasing our brain’s supply of serotonin. The amount of carbohydrate in a medium size roll (not the golf ball size roll my spouse was served) when digested increases the amount of serotonin in the brain.  And this serotonin, in addition to soothing our moods, decreases our appetite. Around forty years ago, serotonin was identified as the brain chemical that turned off our desire to continue eating. It functions to increase satiety, that is, the feeling that we just don’t want to put more food in our mouths, even if we haven’t eaten that much.

Indeed, we developed a successful weight-loss strategy by advising dieters to eat a small amount of carbohydrate, such as a roll, about an hour before mealtime. Doing so ‘spoils the appetite,‘ as your mother undoubtedly told you when you asked for a cookie an hour before dinner. The carbohydrate initiates serotonin production, which serves to calm and subdue a ravenous appetite.

Is it possible that restaurants don’t want we diners to eat bread before the main course because we will be too full for dessert? Could be. Because as our dieters found out, the increased serotonin in the brain really did diminish their desire to keep eating after they finished their main (calorie controlled) course. We never did a study to see whether eating bread at a meal improved relationships between the diners because their mood was improved, but it is possible.

So I say bring back the breadbasket before it is such a rare item, it is displayed on “Antiques Road Show.”