Excessive Exercising: Is it About Fitness or a Compulsion?

Whenever I am in my gym, I see a skinny but well-muscled woman working out. She is there, already dripping with sweat, when I arrive, and she is there when I leave. My workout schedule is somewhat erratic, but regardless of when I arrive, she is there.

I suspect she is suffering from exercise bulimia, a disorder characterized by compulsive exercising to burn calories. Unlike bulimia, an eating disorder in which large quantities of food are consumed and then quickly removed from the body by vomiting or excessive laxative use, someone with exercise bulimia may be consuming only normal amounts of food. Normal, that is, to most of us. In a desire to attain a very low weight and keep it off, the exercise bulimic tracks every calorie consumed and makes sure that the exercise burns off enough calories so no (gasp!) weight is gained. If in a moment of weakness, a small bag of potato chips or a kiddie size ice cream cone is consumed, exercise to get rid of those calories begins as soon as possible.  And if for some reason it is impossible to exercise—for example, a cyclone has just destroyed the individual’s house—an overwhelming feeling of despair, agitation, and helplessness is experienced. These feelings may be similar to those experienced by someone who has consumed an enormous amount of food, and then is unable to get rid of it by vomiting.

It is difficult to distinguish a compulsive need to exercise, a need that may take priority over other activities, from the desire to excel in a competitive sports event. Someone who trains for a triathlon by swimming, biking and running long distances, can look as if he has exercise bulimia because the pressure to do well in these three activities requires hours and hours of physical activity. But there are two critical differences: the intense workouts required for a competitive event come to an end when the event is over, and the exercise is not coupled with the goal to work off calories. Indeed, the individual in training often increases significantly his or her calorie intake in order to replace the calories used in exercise and also to prevent muscle wasting.

Although weight loss, stamina, muscle strength, and overall fitness may increase because of the incessant exercising, the health risks of compulsively exercising eventually outweigh the benefits. When women lose too much body fat, they stop menstruating and become vulnerable to significant bone loss. Continuous fatigue, and injury to tendons, ligaments, muscles and bones (e.g. tendinitis and stress fractures) may result at any age; these injuries and fatigue rarely stop the exercise until the injury becomes too severe to continue.

Like the purging that occurs after the excessive eating of bulimia, excessive exercise is used to prevent calories from turning into fat and weight gain. To the person with this eating/exercise disorder, it is as if every item of food comes with a label that reads, ”Must exercise strenuously to use up calories in this food!” and then the food label lists the number of minutes or hours of exercise that have to be performed.

”You just ate a doughnut? Run on the treadmill at a high pace for 45 minutes!”

What makes this type of exercise “purging so destructive to health is that every morsel of food is regarded as an enemy of low weight.  It doesn’t matter if the food is healthy and required for nourishment or eaten for pleasure; its calories must not remain stored in the body.

Ironically and sadly, excessive exercise can increase the appetite and cause an inevitable need to eat more. Athletes in training consume much more food than when they are not preparing for a competitive event. So the exercise bulimic who has spent three hours in the gym may go home and eat a big meal because he is really hungry. And then he feels compelled to go back to the gym to work off the calories.

Breaking the cycle of exercising compulsively to get rid of the calories just consumed is difficult. There is the problem of the compulsion itself, a behavioral state of mind that is not easy to change. There is the guilt and anxiety that must be dealt with if exercise is prevented, and also the anxiety and depression that might drive overeating itself. And underlying all this is the uncertainty and bewilderment over what constitutes appropriate food intake. How does one convince an exercise bulimic that the body needs a certain amount of calories to function; that the body demands a variety of nutrients for basic physiological functions; and that the brain needs glucose for energy and other nutrients like amino acids in order to produce the cellular connections that allow it to communicate?

Might the exercise bulimic be helped if he or she stopped eating real food? If every morsel of food announces to the exercise bulimic how much exercise has to be done to remove unwanted calories from the body, why not switch to a food stuff that supposedly has the perfect number of calories for the exerciser’s body?  One possibility is a synthetic food called Soylent that was engineered to meet the needs of people such as programmers who don’t want to waste time eating real food. Rob Rhinehart developed Soylent, a liquid meal replacement, and it provides all the nutrients needed to meet daily caloric and nutritional needs.  Soylent is supposedly palatable, but not so wonderful in its taste and texture, so that anyone would be tempted to binge on it.

If the exercise bulimic is convinced that the food being consumed is in balance with the body’s caloric needs, the compulsion to exercise may diminish. If not, this will be indicating that the exercise is not really based on caloric intake, but instead a compulsive disorder played out in the gym.

Distracting Yourself Into a Better Mood

“My head is full of stuff I am worried about today,” a fellow gym member told me as we were about to start a yoga class. “So if I am standing up when everyone else is sitting down, it is probably because I am not paying attention to the instructor. “

She was right: She was so self-absorbed in her worries that she was always about two yoga positions behind everyone else. About halfway through the class, I noticed her keeping up with the instructor’s moves, and no longer looking so worried.

When the class was over, she said, “I feel so much better! Once I started to focus entirely on whether I was in the correct yoga position, I was distracted from the laundry list of problems that had been bothering me.“

Yoga is one of many distractions that work to relieve, or at least subdue, a variety of emotions from boredom (e.g. “HOW long do I have to wait on the telephone to speak to a representative?!?”) to depression, anxiety, anger, and worry. Think of the scene in a movie or television where people are waiting to hear news about an operation. Someone always says, “Let’s go to the cafeteria and get some coffee.” The coffee is not what is desired; it is the distraction of moving to another place and engaging in another activity (buying and drinking coffee) that may somewhat help relieve the tension.

Sometimes the lack of distraction makes a situation unbearable. Imagine sitting in a waiting area awaiting your own operation. You are awake and alone and there is nothing to distract you from your anxiety and worry. A friend of mine who recently had his cataracts removed told me that, while he was waiting to be operated on, all he could think was “What if something goes wrong and I became blind?” He said. But, “if someone had been there to talk to me, or even if I could have watched television, I might not have worked myself into a panic.”

So-called Retail Therapy has long been recognized as an effective, albeit short-lived, therapy for anxiety and depression. It works, but has its limitations and unfortunate financial consequences if shopping leads to buying items neither needed nor affordable. The distraction of finding something desired and buying it lasts very briefly, and it is a costly way of keeping away unwanted thoughts. But certain shopping venues like gigantic flea markets, or bargain warehouses that require lots of walking and poking through piles of stuff that ultimately are rejected for purchase? They effectively focus the mind and move it away from unpleasant emotions.

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Distracting Yourself Into a Better Mood

Redirecting your focus is a very healthy coping strategy.
Posted Sep 14, 2017
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“My head is full of stuff I am worried about today,” a fellow gym member told me as we were about to start a yoga class. “So if I am standing up when everyone else is sitting down, it is probably because I am not paying attention to the instructor. “

She was right: She was so self-absorbed in her worries that she was always about two yoga positions behind everyone else. About halfway through the class, I noticed her keeping up with the instructor’s moves, and no longer looking so worried.

When the class was over, she said, “I feel so much better! Once I started to focus entirely on whether I was in the correct yoga position, I was distracted from the laundry list of problems that had been bothering me.“

Yoga is one of many distractions that work to relieve, or at least subdue, a variety of emotions from boredom (e.g. “HOW long do I have to wait on the telephone to speak to a representative?!?”) to depression, anxiety, anger, and worry. Think of the scene in a movie or television where people are waiting to hear news about an operation. Someone always says, “Let’s go to the cafeteria and get some coffee.” The coffee is not what is desired; it is the distraction of moving to another place and engaging in another activity (buying and drinking coffee) that may somewhat help relieve the tension.

Sometimes the lack of distraction makes a situation unbearable. Imagine sitting in a waiting area awaiting your own operation. You are awake and alone and there is nothing to distract you from your anxiety and worry. A friend of mine who recently had his cataracts removed told me that, while he was waiting to be operated on, all he could think was “What if something goes wrong and I became blind?” He said. But, “if someone had been there to talk to me, or even if I could have watched television, I might not have worked myself into a panic.”

So-called Retail Therapy has long been recognized as an effective, albeit short-lived, therapy for anxiety and depression. It works, but has its limitations and unfortunate financial consequences if shopping leads to buying items neither needed nor affordable. The distraction of finding something desired and buying it lasts very briefly, and it is a costly way of keeping away unwanted thoughts. But certain shopping venues like gigantic flea markets, or bargain warehouses that require lots of walking and poking through piles of stuff that ultimately are rejected for purchase? They effectively focus the mind and move it away from unpleasant emotions.

Years ago, Boston had a two-story bargain store, Filene’s Basement, where the merchandise was marked down according to how long it had been on the racks. Shoppers hunted for a drastically marked-down piece of clothing or shoes; they rarely found one but considered the hunt itself to be a lot of fun. In order to deal with the death of both parents within a short period of time, one of my mother’s friends told me that she would go to the Basement every weekday during her lunch hour.

“I never bought anything, but searching for the ultimate bargain distracted me temporarily from my grief.”

In order for distraction to work; in other words, doing X to take your mind off of thinking about issue Y, it should absorb all of one’s attention. Moreover, the distraction must be easy to initiate, not necessarily require the participation of someone else, and be convenient. Skill-driven physical activities such as indoor rock climbing or paddle boarding, where loss of concentration means falling off the rock wall or the paddleboard, are effective distractions. Still, simpler and more accessible activities like going to a driving range or playing Ping-Pong also work. Games such as bridge or chess or even group activities such as singing in a choir, or joining a conversation group in a language you are learning? They require total concentration and thus, for a while, are a total distraction. Crossword and other word puzzles work, unless they add a level of frustration to an already difficult situation, like waiting for a long-delayed plane. And sometimes a conversation that forces you to concentrate on what the other person is saying is a distraction from an inner voice that talks too much about your concerns.

Overeating is unfortunately often used as a distraction but, like retail therapy, the distraction is short and the cost, in calories, considerable. Indeed, overeaters are advised to redirect to new distraction activities such as: take a bath, take a walk, make a phone call, see a friend, or read a magazine to decrease the eating. These activities, however, are weak distractions and often are accompanied by the eating they are supposed to halt.

Sometimes thinking outside the box is the only way to identify a distraction that will work. Years ago, a weight-loss client complained that he was eating at night to deal with problems from work he was bringing home with him. “You should find something to distract you,” I told him, listing the obvious contenders.

Nothing seemed to appeal to him. Throwing up my hands in frustration I said, “Well, what about learning to play the bagpipes? That will keep you from eating.”

“What a good idea,” he said. “I have bagpipes in my closet. I haven’t played them in years. I am going to l start playing them tonight.”

I really hope he had soundproof walls.

Moods for Overeating: Good, Bad and Bored

“I am in the mood for  . . .(fill in the blank.)“

How many times have we said this to ourselves or others as we plan lunch or dinner? (Very few people are in the mood for anything except more sleep in the morning.) Sometimes the “mood” for a particular type of ethnic cooking or a prime piece of beef is heightened because the meal is celebratory, or a respite between bouts of unrelenting work or home meal preparation.  But this type of mood-influenced eating rarely lasts beyond a meal or two, and rarely leads to sustained overeating and weight gain. Too many calories may be consumed at a dinner celebrating the completion of a difficult project or an anniversary, but this type of eating rarely results in continued excessive calorie intake.

Not so the type of eating generated by moods we would rather not have. Boredom, and its frequent companion loneliness, may lead to an overly important focus on what to eat as a distraction from a long weekend or evenings alone with little to do. Rainy vacation days with few places to go inside to escape the dreary weather often brings tourists into restaurants for meals for which they may not even be hungry. It is something to do.  Long distance flights generate an appetite for foods that if served on the ground would be rejected immediately. Yet flyers that are not hungry will eat them because, again, it is something to do.

Bad moods are different. Anxiety, depression, premenstrual syndrome, and posttraumatic stress disorder are among negative or dysphoric moods that can provoke overeating, sometimes for days every month (PMS) or years (like PTSD when undiagnosed or untreated). Anxiety seems to trigger the excessive eating of binge eating disorder.  (“Emotional eating, alexithymia and binge-eating disorder in obese women,” Pinaquy, S., Chabrol, H., Louvet, J., Barbe, P., Obes, Re., 2003 11:195-201.)  But anxiety may also cause chronic overeating without the dramatic bouts of excessive food intake seen in binge disorder. In that case, the overeating may be enough to hinder successful weight loss and /or cause small but continuous weight gain. (“The association between obesity and anxiety disorders in the population: a systematic review and meta-analysis,” Gariepy, G., Nitka, D., and Schmitz, N., International J of Obesity 21;2010 34: 407-419).

Sometimes the obesity, which results from “bad mood” overeating, does not appear until years after the mood disorder appears. Researchers who examine the results of longitudinal health surveys have identified participants who have mood disorders at a young age and then become obese many years later. Data from the Nurses’ Health Study that began in l989 was used to see whether women who were diagnosed with posttraumatic stress disorder during the early years of the survey were more likely to be obese in later years than women without this disorder.  They found that having PTSD was a risk factor for obesity; women with this disorder gained more weight than women who experienced trauma but not PTSD and much more than women with neither.  (“The weight of traumatic stress: a prospective study of posttraumatic stress disorder symptoms and weight status in women,” Kubzansky, L., Bordelois, P., Jun, H., Roberrts, A., et al, AMA Psychiatry 2014; 71: 44-51.)

Depression is also a predictor of obesity and, like PTSD, the obesity may not appear for years after the depressive episodes.  Several research groups have used health surveys following male and female participants over many years to look at the weight status of people who were clinically depressed when they entered the study as older adolescents or young adults.  A significant number of them became obese a few or several years after they no longer were depressed. (“Trajectories of Change in Obesity and Symptoms of Depression: The CARDIA study,” Needham, B., Epel, E., Adler, N., Kiefe, C., Am J Public Health 2010; 100: 1040-106. “Overweight, Obesity, and Depression,” Luppino, F., deWit, L., Bouvy, P., et al, Arch Gen Psychiatry 2010; 67: 220-229.) Because the obesity appeared much later than the depression, the weight gain is probably not due to treatment with antidepressants although the studies did not look at this specifically.

 

We know that obesity and emotional overeating are strongly linked; certainly eating in response to anxiety and stress is evidence of this. Sometimes an immediate response to a stress is to grab something to eat. A friend who was renovating an old house told me that the first thing she did after she found that the closets were too narrow to accept a normal-size hanger (after the renovation) was to go to a convenience store and buy candy.  But what explains the development of obesity years after women develop PTSD or among depressed individuals years after the depression is gone?

The problem with looking at survey data as opposed to being able to talk to the people who provided the data is that these questions can’t be answered.  Were levels of physical activity low because of stress-associated fatigue? Did the people who were depressed and then years later became obese suffer in the years in between from chronic “blue mood”? Might they too have been too tired to exercise?  Was food a solution for their moods?  Did they eat to feel better, heedless of the calories they were consuming? Did they eat what they wanted because they had had enough deprivation in their lives and did not want to add the deprivation of a diet to everything else?

More research is needed to know the answers. But what we do know is that when people overeat, the reasons are as likely to be due to their mood as to what is tempting them.

 

Travel Can Leave You Well Fed, But Not Well Nourished

The group of women with whom I was traveling stared at the menu in some dismay. For those who shunned gluten, meat, dairy, and a category of vegetables known to cause intestinal discomfort to some, there was almost nothing to eat.

“Maybe we can find a supermarket somewhere,” one suggested, but then realized that to do so required driving to a shopping mall a few miles away from the gift shop-congested town center. Fortunately, a few protein bars were discovered at the bottom of someone’s tote bag, and hunger was relieved momentarily. We were in a geographical part of the country noted for heat-infused food from chili peppers, the liberal use of melted cheese with pork products, beans refried in lard, gluten-containing flour tortillas, and a notable absence of soy or almond milk for those lactose intolerant.  Although the women were athletically fit and had traveled to spend a few days hiking in remarkable landscapes, their digestive systems did not have the same robustness as their muscles. Eventually, our finding a ride to a large supermarket provided enough food for dinner, as well as snacks for the hikes; an Internet search of restaurants revealed a few that met most of their dietary needs.

But their experience demonstrated how difficult it can be to obtain foods from restaurants in places not accustomed to altering menu options for those whose stomachs need special foods. These days, we assume when we travel, we will be able to get our personalized food needs met.  After all, it is no longer the early part of the 20th century when people traveling on the new highways had to content themselves with eating in small Mom and Pop restaurants their typically questionable cleanliness and food preparation skills.  Standardization of food for highway travelers came only when restaurants like the Howard Johnson franchises opened around the country. Today the ubiquitous fast-food restaurants and the next generation sandwich shops that make salads and sandwiches to order make it relatively easy to find safe and reasonably tasting food.

But even now, eating as a traveler may mean giving up trying to eat a well-balanced diet. The recommended five servings of vegetables and fruit to be consumed each day may not even be consumed in five days. Vegetables rarely appear on the plate with the main entrée, or are reduced in size to microscopic versions of the natural object. Salads and side orders of vegetables are costly, and the vegetables may come coated in cheese, drenched in butter, or breaded and fried.  It is possible, sometimes, to get fruit as a dessert but often the fruit is a few raspberries garnishing chocolate cake or in syrup topping a dish of ice cream. Foods we can obtain at home, such as low or fat-free dairy products (and milk substitutes), may also be hard to find. Many restaurants serving breakfast do not provide low or fat-free yogurt, cottage cheese and milk for cereal and coffee. And finding high fiber foods to maintain healthy and predictable digestion is harder than finding kale in a MacDonald’s.

When traveling is relatively brief—less than a couple of weeks—the scarcity of nutrients or fiber or food items suitable for a limited diet is not going to plunge the traveler into a state of malnutrition. We start our trip well-nourished and certainly are not going to develop scurvy or osteoporosis in a couple of weeks. But many people travel constantly for work and some have the time and financial freedom to travel for long periods for pleasure.  This type of travel can result in more than just piles of dirty laundry to take home; it can affect the nutritional status of the traveler. And curiously, we tend to ignore this problem when packing for a trip.

Packing requires anticipating weather conditions, activities ranging from work to sightseeing and entertainment and even sleeping comfort. But how many of us pack to ensure that we are not surprised by eating environments as unpredictable as the weather? Are we making sure that the eating culture at our destinations will provide food meeting our personal dietary needs? And if not, do we have in our carry-on luggage food items that will prevent us from returning several weeks later in a state of sub-optimal nutrition?

Some simple steps to take before a long trip:

Check out the types of foods typically eaten at the destinations. The Internet will provide this information both from a description of the food highlights of the destination, and also from a brief scan of moderately priced restaurants (these are the ones most likely to be visited, not the very pricey ones).

If breakfast is included in the lodging, try to learn what is served. Sometimes a breakfast buffet will provide foods from all the food groups. (Israeli hotel breakfasts have done this for decades.)

Pack multi vitamin-mineral supplements as insurance against many days of vegetable, fruit and dairy deficient menu options. Lactase pills to digest the milk sugar lactose are tiny, fit into a toiletries bag and allow you to add milk to your coffee or cereal if you have lactose intolerance.

Pack gluten-free baked goods if you must avoid gluten, because eventually a need for some digestible carbohydrate will arise.  Baby carrots, vacuum-packed apple slices, and a sandwich bag filled with high fiber breakfast cereal will provide some fiber. Oat bran cereal can be put in a sandwich bag as wel,l and if the hotel has a coffee maker, the hot water will reconstitute it as hot cereal.

Pack protein bars that contain 15 to 20 grams of protein. These will be useful when the protein on the menu is incompatible with a vegetarian, pescetarian (fish only), kosher, or low-fat diet.

Although these extra items take up space on the outbound trip, their consumption frees up space for the return home to be filled with whatever your heart, not stomach, desires.

Can You Lose Weight If You Don’t Know How to Diet?

Our formerly thin, physically active friend had gained close to 80 pounds following two years of debilitating orthopedic problems that left him with chronic back pain. His previous constant exercise, which included tennis, skiing, long bike rides, hiking, and running had kept his weight normal, but became no longer possible. Now he was able to move only with the help of a back brace and two hiking sticks that he used as canes.

“I am trying to lose weight,” he told us, “but it is slow going.”

When we were guests at his home, it was obvious how physically impaired he was as well as how hard it was going to be for him to attain a weight that would help relieve his back pain. The one day he walked on his long hilly driveway to point out a particularly beautiful landscape, he paid for it in increased pain the next morning. Simply moving from living room to dining room was difficult for him. He talked about how he never needed to diet before he developed a back problem because his level of physical activity kept his appetite down and burned off excess calories. A review of the relationship between physical activity and weight change confirms his experience. (“The Role of Exercise and Physical Activity in Weight Loss and Maintenance,” Swift, D., Johannsen, N., Lavie, C., Earnest, C., Church, T Prog Cardiovasc Dis 2014, Jan-Feb; 56 (4): 441-447.)

Routine physical activity like the type my friend used to do slows, or even prevents weight gain, without any change in calorie intake. And the long duration of many of his physical activities may even have dampened his appetite according to a very recent study published in the Journal of Endocrinology. (“Acute effect of exercise intensity and duration on acylated ghrelin and hunger in men,” Broom, D., Miyashita, M., Wasse, L., Pulsford, R., King, J., Thackray, A., Stensel, D., J Endocrinol. 2017; 232 (3): 411-422.)  Now, however, the beneficial effect of exercise, when added to a reduced calorie diet on hastening weight loss is out of reach for him.

Told by his physician that a substantial weight loss might lessen his back pain has motivated him to decrease his calorie consumption. His strategy, as he told us, is to consume less than he had been eating.  But he has lost very little weight over the past few months of attempting to do just this.  His lack of success may be due to his inexperience in dieting. He doesn’t know how much he is eating, nor does he know whether what he is eating is particularly high or low in calories (he does know the difference, however, between salads and cake.)  Another family member, who has never had a weight problem and likes to cook dishes containing high calorie ingredients, prepares his food. Butter, heavy cream, and cheese are routinely added and her sweet tooth motivates her to bake or buy cakes, cookies, pies and other desserts that are offered to our friend.  Eating in restaurants for dinner (and occasionally both lunch and dinner) occurs frequently, and this adds to the uncertainty of how many calories are being consumed. Overly large restaurant portion sizes, and the habit of chefs to add butter or oil to food to keep them moist, also inadvertently boosts his calorie intake. And, unlike experienced dieters, he has not developed an eye for judging portion sizes and not eating the entire amount if it is too big.

None of this would matter if losing weight were for cosmetic rather than medical reasons. However, when weight loss is crucial to improving health, and, in his case, restoring lost freedom of movement and removing his pain? Dieting must be done with the same care and knowledge as any other intervention to improve health. The approach cannot be casual or haphazard, and would probably benefit from the professional services of a dietician or nutritionist. The type of diet must also be sustainable and balanced nutritionally for the many weeks it takes to lose the necessary weight. Many alleged quick weight-loss diets, so tempting because results after only a few weeks are supposedly so dramatic, often lead to weight gain as soon as the diet is over. (Remember the Oprah Winfrey’s famous fast weight-loss from a low calorie liquid diet, and the subsequent rapid regain several years ago?) Regaining weight is not an option when it may bring about a return of the medical problem like intolerable back pain. Thus the diet plan has to be malleable enough to change into a long-time maintenance program to keep the now lower weight stable.

Being honest with family and friends about how hard it is to lose weight and consequently asking for help will improve the chance of success. Imagine how much more weight our friend would have lost if his meals had been significantly lower in calories and size. Preparing meals at home that that could be made without the addition of fat-dense ingredients such as cheese would help reduce the calories he was eating. If others wanted to add more cheese to their dishes, for example, they could do so after the food was prepared.  His problem in reducing calorie intake in restaurants could be solved by either eating in establishments that served normal-size portions, or ordering appetizers for a main dish or splitting an entrée. The temptation to eat dessert would disappear if it were not on the table in front him.

Dieting is like any new activity. As it is with playing the piano, speaking a foreign language, or planting a successful garden, it has to be learned. Instruction is needed, along with patience, the willingness to practice and make mistakes, and encouragement from others. And like taking on any new activity, even small successes are worthy and worth striving for.

Would Walkable Sidewalks Keep Us Thinner?

A few weeks ago on a trip to a picture perfect Vermont town, we asked the proprietor of our B&B if we could walk to the concert that night.

“You can, sure… it is less than a mile, but it will be dangerous walking home in the dark. There are no sidewalks and no street lights,” she told us.  So we drove, despite feeling silly at using the car for such a short distance, but happy we had done so when we left the concert. Ground fog was adding to the darkness in concealing the road, and we were sure we would not have felt safe walking back up the hilly, winding route.

The next day, we chatted about the lack of sidewalks and street lights with our hostess. She told us that daytime walking on the roads was manageable in the non-snow months, but not in the winter; the snow banks reduced the width of the roads and eliminated any possibility of stepping off the pavement.  “See, there’s is no side of the road to stand on when a pick-up truck comes speeding down the mountain….no one walks; it’s just too easy to be hit.”

There is no lack of activities in Vermont to provide opportunities to exercise, even if taking long walks in the winter is not one of them (Unless it is on a packed snow trail.) But unlike the quick convenience of going out the door to take a walk when sidewalks (plowed, of course) do exist, the lack of sidewalks in suburban or rural areas makes this simple activity difficult to carry out.

For the exercise committed, there are, of course, numerous opportunities to engage in physical exercise regardless of weather or environment. Not so for those who prefer being sedentary and are unlikely to seek out opportunities to move. In an episode of a television program focused on finding a house to buy, the client announced that she was too old (she was in her fifties) to buy a house with stairs. “Too much walking, “she told her realtor. Not surprisingly, the community in which she was house hunting had no sidewalks. If this woman had been advised to walk for her health and weight, she would have had a ready excuse. “Where? There is no place to walk where I live!”

No one has to be told about the rising incidence of obesity. Simply looking around confirms its prevalence, although the effects such as diabetes, back & leg pain, as well as the increased risk of certain types of cancer are silent.  One obvious culprit is that we eat too much, in part because portion sizes of just about everything have increased. Another fault lay in that we no longer live a lifestyle readily allowing us to burn off those excess calories. When physical activity was unavoidable in order to earn a living and maintain a household, a large caloric intake provided the fuel for the constant physical activity.  Now caloric intake has remained the same, or most likely increased, while physical activity has become optional for the most of us most of the time.

Because they eliminate a source of calorie use, might the absence of walkable sidewalks be a contributing factor to the continuous rise in obesity? The Journal of the American Medical Association (“JAMA”) published a study in 2016 showing that residents living in walkable urban neighborhoods had a slower increase in obesity and diabetes than those living in less walkable ones.  For this specific research, almost 9,000 urban neighborhoods in southern Ontario were studied over more than 11 years.  This study’s “Walkability Index” was based on safety of the sidewalks, the residential and commercial density, cross walks at intersections, schools, coffee shops, banks, and other retail establishments which might be walkable destinations.  People living in the walkable neighborhoods, and New York City is another example; they use sidewalks not only to get to their routine destinations like work, stores and restaurants but as places for urban hikes. These city dwellers may spend an entire day outside, hiking and exploring different parts of their city. The seemingly limitless places to walk allow them to do so.

However, it’s important to note the benefits of walking by city dwellers are not available to residents of towns such as the one we visited in rural Vermont. The population density is too low to justify the expense of sidewalks, and indeed many of roads are not even paved. Of course there are numerous places to hike, but this activity is not only seasonally limited, but also limited to people whose stamina and age enable them to climb mountain trails.

Perhaps the answer is to emulate many European cities which have set aside parkland filled with paved paths for walking. From my limited experience of these parks which I have seen in Holland, France and Germany, they are usually filled with walkers early in the day and then especially in the summer, after dinner. Benches are numerous for those who need to rest or just admire a view.  Strolling through one of these walking parks has the additional advantage of allowing members of a community to see and talk with each other. People often walk in small groups, or stop and greet others coming in the opposite direction. When so many members of a neighborhood are out walking?  It is easy to see this activity as a routine and healthful aspect of the day.

Eating less to prevent weight gain and/or lose weight is difficult because potential temptation lurks in the next meal. Walking may not compensate entirely for excess calories, but it can have a positive effect on preventing weight gain… unless of course, one walks to the doughnut shop.

Cite: Association of Neighborhood Walkability With Change in Overweight, Obesity, and Diabetes. Creatore M, Glazier R, Moineddin R.  JAMA  2016, 315; 2211-2220

The Covert Bullying of Obese Adults

When I congratulated a friend on her promotion to the head of a non-profit organization, she smiled and then told me it almost did not happen. “I learned that someone on the board did not want me to get the position and campaigned actively against me,” she told me.

“Why?” I asked. “You were obviously the front-runner.”

“Because I am fat,” she replied. “He told everyone on the board that he would not hire anyone who was fat. At least he is not criticizing my competence, only my size.”

But she was wrong.

The board member was likely not rejecting her solely because he believed her size or shape might affect her stamina in wearing the hats of an administrator, fundraiser, and creative director of a mid-size organization. He may have believed that her obesity reflected a deficit in her overall ability. A review of many studies of employer attitudes toward obese workers presented evidence that obese people are thought to have less leadership potential than normal-weight individuals. The obese are viewed as lazy, undisciplined, slow, unmotivated, and incapable of advancing to positions of responsibility. Thus my friend, whose resume indicated an unusually strong record of leadership and creativity in a previous position, could have been judged as inferior on these traits simply because she was fat.

Had she been male and obese, her size may not have been considered a detriment unless the job required physical skills that were difficult to perform because of weight. But an obese woman whose job requires some visibility—while fundraising, representing the organization at meetings, or giving presentations—might be passed over because of her appearance.

Had she failed to win the position, a claim that she was being discriminated against would have had no legal impact in the state in which she worked. The state of Michigan and some cities, including San Francisco and the District of Columbia, have outlawed employment discrimination against the obese.

Proving that a job is not offered or advancement not received because of size discrimination is very difficult. The board member did not publicly announce the reason for his opposition to anyone, but secretly told other members of the search committee. Happily, there were leaks, and eventually everyone in the organization knew and so did she. But even though he wished to deprive her of the position because of her weight, there was little she could do about it. What real proof did she have?

Obese employees face the same type of discrimination that smokers do, although 29 states prohibit the non-hiring of smokers. However, one justification of the employment discrimination against smokers is based on health risks to the smoker and thus increased medical costs to the employer. Other reasons include leaving the work site to smoke in a designated area, although this is a weaker argument since breaks for everyone are often built into the workday.

Many assume that the smoker, or indeed the obese individual, could quit or lose weight if he or she wanted to. Thus discrimination against these groups is sometimes justified by the belief that it’s their fault.

An article in the New England Journal of Medicine refutes the argument that smokers irresponsibly raise healthcare costs because they don’t want to stop smoking. What is rarely understood, except by ex-smokers, is how hard it is to break the addiction to nicotine. Surveys have shown that 69 percent of smokers want to quit but are unable to do so.

Losing weight and maintaining weight loss is similarly difficult, and the same uninformed attitudes persist. “Just stop eating so much and start exercising!“ (As if they hadn’t tried to do so.) The reasons for gaining weight are so varied and often so psychologically complex that simplistic solutions make about as much sense as trying to prevent the oceans from rising by stacking sandbags on a beach. I have a neighbor who gained a substantial amount of weight while she was on large doses of prednisone to reduce inflammation, and a distant relative who gained 125 pounds on a combination of antidepressants and mood stabilizers. Would they be unemployable?

The laws protecting the obese from workplace discrimination are insufficient or nonexistent. Children bullied on the playground may have more protection, because sometimes there is a teacher who can intervene. No one is watching or reprimanding the adult bully who refuses to hire or promote someone who is overweight.

How Do You Know If Supplement Claims Are Hype or Truth?

At a recent university-sponsored conference on innovations in nutritional and fitness products, there was a discussion about the increasing number of fraudulent claims associated with such products in the market. When one speaker, a principal in a firm investing in start-ups specializing in fitness and nutrition, was asked how to detect ineffective or fraudulent products, he was unable to give a useful answer.

“It’s very difficult because often the claims are made up or supported by faulty research published in company-owned or for-profit journals. If it works, it is probably not a fraud,” he concluded. Someone from the audience responded with, “Yes, but placebos work also.”

The Food and Drug Administration (FDA) can barely keep up with the proliferation of fraudulent health products. Some make claims that cannot possibly be produced by the ingredients; others contain substances which are not allowed to be sold due to serious side effects, or must be prescribed only by a physician. Often states, as well as the FDA, step in to expose the deceptive nature of claims made by supplement manufacturers. In a well-publicized case a few years ago the New York State Attorney General’s office tested the contents of several popular herbal supplements and found either none of the advertised active ingredients in the product or levels too low to be effective. This past winter, the New York State Attorney General and the Federal Trade Commission (FTC) charged a company that claimed its product was shown in clinical trials to improve memory and cognition with making, “…False and unsubstantiated claims…” because the study cited by the company actually showed the product not working any better than a placebo. Yet the advertisements, seen frequently on television, were so compelling that the sales topped $165 million.

The most common claims seen on the labels of such dubious products are for weight loss, sexual performance (erectile dysfunction), memory loss, and mood.  Some claims are almost magical in the sweep of their promises: A New York firm claimed its dietary supplement treated senile dementia, brain atrophy, atherosclerosis, kidney dysfunction, gangrene, depression and osteoarthritis along with lung, cervical and prostate cancer. Alas, for anyone now wanting to buy a product that will cure all that is wrong with you, it is no longer available. U.S Marshals seized it after a request by the FDA in 2012.

Personal testimonials are often so compelling that they sell a product. Who hasn’t looked at the before and after pictures of someone who used a weight-loss product and marveled at the change? Statements like, “I am no longer hungry, depressed, diabetic, or bald!“ beckon to us from the internet, tabloid magazines, newspaper advertisements and television spots. These people must be real, one thinks…and if he grows hair, maybe I will also.

Health products claiming a quick fix such as, “Cover your bald spot by next Tuesday,” or, “Lose your double chin by this afternoon!” are also hard to resist, but should be regarded with as much suspicion as someone trying to sell you a bridge. Glue is a quick fix; health products rarely are. The FDA tells us to beware of health products attempting to gain a marketing edge by claiming that they are all natural. By the way, snake venom is also natural.

One easy way to detect whether a claim is legitimate or not is whether the term, “Miracle” is used on the label. Look at it this way, if the words “miracle cure” are attached to the ad, consider it a miracle that anyone is foolish enough to buy the product.

But of course there are many over-the-counter (non-prescription) supplements that work, are safe, contain the dose of active ingredients printed on the label, and don’t hide drugs deemed illegal by the FDA. If a combination of vitamin D and calcium promises bone health in the amounts recommended by physicians, such a supplement will help to restore bone cell growth and decrease bone fragility. Supplemental vitamins, minerals and protein will help restore depleted levels of these nutrients due to prolonged illness, chemotherapy, or gastrointestinal impairment. Again, it is imperative to check with a healthcare giver about quantities; more is not always better.

But what if you are not sure whether the claims are to be believed. What should you do?

Ask your health care provider. Take a picture of the ingredient label on a product you are thinking of buying, and ask whether any of the ingredients actually do what they are supposed to. Use the internet to look up the ingredients to see what studies support the claims of the product. Write to the FDA.

Example: A product relieving anxiety and stress claims that the ingredients, “…promote serotonin synthesis.” But the main ingredients are chamomile and valerian, herbal products that may cause drowsiness; these do not promote serotonin. A physician will know that the product is incapable of increasing serotonin synthesis.

Here’s another: A product containing saffron extract as its main ingredient claims, ”…Reduces cravings, boosts metabolism, blocks appetite, lowers blood pressure and increases energy.” Investigating whether there are any studies linking saffron extract to all these wondrous health effects may seem like a nuisance, but will save money and possibly, ill side effects.

Signing up for the FDA Consumer Updates page is essential for anyone routinely buying supplements because of their weekly descriptions of products containing hidden drugs, fillers, or bits and pieces of insects or twigs. Recently, the agency has warned consumers about more than 100 products containing illegal drugs; most of these products are sold for sexual enhancement, weight loss and bodybuilding.

Avoiding supplements that may not work, may not contain the ingredients listed, or contain ingredients that are harmful cannot be ensured. But a little homework and help from the FDA make the odds better that what you buy is safe and effective.

Meals in a Box: The Answer to Eating Your Vegetables?

More than a dozen companies will, for a price, send you the ingredients for a complete, relatively interesting dinner, or smoothie snacks even, if you choose that option. All you have to do is open the many large and small packages, read the instructions and in 30 minutes or so, eat your own freshly prepared entrée. The concept is practical for the many who do not have the time or energy after work to figure out what to prepare for dinner and then to make sure the ingredients are in the kitchen. Meal-in-the-box choices tend to be more imaginative than grilled chicken breast and frozen veggies because professional chefs devise the menus and make available the entire ingredient list from the main course protein to a tiniest pinch of some herb or spice that the customer probably never heard of and/or doesn’t have. No looking up recipes in a cookbook or on the Internet is needed, nor guess work about the cooking methods.  Detailed instructions are given, perishable foods are kept cold with icepacks, and preparation time is thirty minutes. The end product may not get you, the customer, a spot on the Food Network program “Chopped” in which professional chefs are given ingredients in a box and compete to make an original perfectly cooked entrée and sides in thirty minutes…But unlike the competitors who turn their food over to the judges? The customers of meals in a box get to eat their finished product.

However, making the meals from the ingredients in the box will cost about twice as much as making it from ingredients assembled yourself. According to Consumer Reports, one company’s blackened tilapia dish costs almost $12.00 per person, compared to a little more than $5.00 when put together oneself. A tofu and Chinese broccoli dish from another company costs over $11.00. These ingredients are very inexpensive and will cost approximately $3.50 if you buy the ingredients from the supermarket, and even less from a Chinese grocery store.  The prices for some of these dishes are less than in a restaurant (although perhaps not for the Chinese entrée) but add up quickly as the cost is per person. Moreover, unless the customers are small eaters, no leftovers for the next day’s lunch will remain. But it is also unlikely that there will be much wasted, thrown away, uneaten food. Nor will the refrigerator fill up with plastic containers full of tidbits from previous meals.

It is no surprise, given our current fixation of dietary restrictions that gluten-free, carbohydrate-free dairy-free, vegetarian, vegan, organic (of course) calorie-restricted meals are available depending on which company is providing the foods.

But are they healthy? Will eating a meal from a box provide you with some of the vegetable, fruit, grain, protein, and dairy servings you ought to be getting? It depends. Certainly compared to many takeout and restaurant meals that tend to be free of food groups containing nutrients your body needs, the boxed to-be-prepared meals often contain substantial amounts of vegetables, and sometimes whole grains. If you tend to ignore the vegetables in your refrigerator bin until they turn into a slimy green mass, then ordering meals with a substantial amount of vegetables will ensure that you are eating this essential food group.

Yet there is a possible nutritional caveat to some of the meals. The salt content may be higher than recommended, especially if some of the seasonings contain sodium, like garlic or onion powder, or if salt if added several times during preparation. Consumer Reports analyzed sodium content and found many dishes containing 30% more than recommended, and some dishes containing as much as 1 gram of salt per serving.

Are boxed meal ingredients a trend, or the beginning of a permanent shift in the way people prepare meals? Probably the latter because they appeal not only to those who don’t (and won’t) prepare meals from scratch, but also to a generation who have been preparing meals from scratch for decades. For those who have been afraid to boil water, learning how to cook from the boxes might eventually give them confidence to cook on their own. It is sort of comparable to shifting from paint-by-numbers to covering a blank canvas with one’s own creation. For those who are tired of figuring out what to cook for dinner and despair at the high prices and noise levels of most restaurants, boxed meals are an easy way of eating interesting food less expensively (and in a setting that doesn’t require either waiting or tipping.)

Many companies are selling meals for people on all sorts of diets and presumably are competing with portion-controlled, factory-prepared meals sold by some national weight-loss companies.  Since the meals in a box are portion and ingredient controlled, the dieter does not have to be concerned about going over a calorie limit. There is no guessing about whether the weight of the entrée or the teaspoons of olive oil will fit the calorie requirements for a particular meal. On the other hand, by requiring the dieter to get involved in food preparation, she may lose her fear of not being able to prepare a meal on her own that allows her to continue to lose weight and/or keep it off.

This trend is still relatively new, but its rapid growth indicates that it meets the lifestyles demands of large numbers of people. However, since spending a little time in meal preparation is still necessary, we should not be surprised if, a few years from now, some of the boxes will contain a robot that will do the cooking.

According to a 2016 Consumer Reports analyses, home delivery of meal ingredients is about a $400 million dollars a year industry. Although the major portion of the sales are focused along the coasts and in major urban areas, sales are projected to increase throughout the country. They may not be replacing all home delivered pizza and Chinese food, but certainly offer healthier and more varied options.