Getting the Super Obese to Lose Weight: It May Take a Family

Anyone who ever saw any of the television programs focused on the attempts of individuals 600 pounds (or heavier) to lose weight often wonders why their family members are enabling the obesity. The viewer watches the mostly bed-ridden obese individual demanding food, lots of it, and then being served large portions of whatever has been requested. The camera lingers over the individual crunching potato chips, spooning up macaroni dripping with melted cheese, or eating a gallon of ice cream. It is possible that the television crew doesn’t film the subject of the show when he or she is eating kale salad, or fat-free cottage cheese, so we get the wrong impression. But given the stated food demands of the obese individual, the viewer has the impression that if kale salad, or indeed anything resembling low-calorie healthy food were offered, he or she would be in the unique position of saying no to the food. The occasional trips to the supermarket by some of these TV stars who are able to ride in car (and use a motorized shopping cart) also focus on the purchase of junk food. Although it is obvious that some nourishing foods must be bought and eaten to avoid nutritional deficiencies like scurvy or anemia, the healthy menu items are rarely, if ever, shown being consumed.

The viewer wants to shout at the family members bringing food to the massively obese person, “Why are you enabling this?” Indeed, in one particularly poignant episode, a father buys a large pizza for his son who has been told he must lose 60 pounds before weight-loss surgery can be performed. The son has demanded the food and as the father watches the son gobble the entire thing, he asks for a piece for himself. “No,” was the reply, “I am going to eat the entire thing.”

Internet comments predictably share the bewilderment over the enabler function of family members as depicted on the show. As the fattening foods are prepared and served, the enabler expresses concern on air about the likelihood that the obese family member will die in a few years from the massive weight gain. And yet the food is served, and the concerned warning is absent. But to be fair, perhaps saying something is useless. The obese individual expresses concern over the pain caused by living in such a large body, and also worries about dying. So what good could it do if a family member states the obvious? It may even have the opposite effect. But still, we the viewers still wonder why the family members enable the continued weight gain.

What if the family member was a chronic alcoholic and developing liver disease, collapsing from frequent blackouts, and cognitive impairment? Would the same restraint be used, that is, “Don’t criticize, nag, cajole and threaten?” Would family members buy alcohol for the abuser who might be too drunk to get to the store?  Or drive the alcoholic to the nearest liquor store?

People say that one can’t compare alcoholics to excessive overeaters because the latter have to eat to live, so they cannot be abstinent. True, but one can live quite nicely without consuming highly caloric food in mega quantities, and drinking sugar-filled soda and juices.

Nevertheless, it is hard for family members to take corrective action alone. Professional help is needed, yet there is no process by which a concerned parent, for example, can force the adult extreme overeater to see a physician, dietician and/or therapist. Medical privacy laws forbid sharing the information with healthcare providers unless written permission from the family member is given. But waiting for the heart attack, stroke, skin infection, or cancer to occur in order to obtain medical intervention to start the weight- loss process is hardly an option either.

Family members of an alcoholic often turn to Al-Anon, whose meetings offer advice and support. Inpatient rehabilitation facilities often insist that family members be present for some of the therapeutic sessions to support recovery.

O-Anon is a spin-off of Al-Anon and runs with the same rules of privacy and espousal of the twelve-step process. But is this enough? Can a family take upon itself to provide only healthy, portion-controlled meals and beverages without medical and nutritional advice? Can the family handle the emotional fallout when the obese individual no longer has access to foods that for many are the only reason for living? What happens if anger, anxiety, and depression follow the imposition of a new eating regimen? Must someone be home all day to prevent fattening foods from being delivered, or the obese individual from finding these foods hidden in the house?

It is hard not to notice that often family members on the show are also obese, but may be 100 pounds overweight rather than 600. Will these folk be willing to change their eating habits to support the dietary changes they are imposing?

It may be as hard for the family to change its role with the patient as it is for the patient to lose the weight. In an ideal television series or world, such issues would be raised and solutions found. The bariatric surgeon would insist that both patient and family members meet privately, and as a group with a dietician, therapist, and even personal trainer instead of telling the patient to go home and lose sixty pounds.

People don’t gain 500 pounds simply because they like doughnuts or French fries. Their reasons for their morbid weight gain are complex, and their success in losing weight permanently depends on the family with whom they live and eat understanding these reasons. Maybe the producers of these television shows ought to realize this, even if it doesn’t make such interesting viewing.

Are You Merely Exhausted or Unrelentingly Exhausted?

My neighbor was sitting on the park bench watching her twin five year-old granddaughters feed bread to the ducks. After the obligatory remarks about the cuteness of the pair, I asked her how her weekend was. “Exhausting!” was her immediate response, “The twins stayed with us and I am bone tired. I may never get up from the bench!”

She did look exhausted, but we both knew that once the parents took the girls home, she would relax and by the next day feel, if not entirely rested, much better than today. She is one of the lucky ones. Her exhaustion is situational and an inevitable (but reversible) consequence of incessant care of two very active little girls.

Many of us can relate to her fatigue. We take upon ourselves too much to do both physically and mentally, and feel exhausted when our bodies and minds no longer can deal with yet another task. Sometimes we continue to do too much despite fatigue, because there is no other choice. Too long hours at work because of staffing problems, twenty-four hour care for a sick or elderly relative, a home renovation deadline that has passed: all kinds of situations cause tiredness. But eventually there comes a time when we can rest our bodies and minds and have our energy restored to us.

But what if the fatigue never goes away? What if the body feels weighted down with sleepiness, getting out of bed is a major accomplishment, or cutting through the mental fog seems an impossibility? What if instead of reversible weariness, the exhaustion is unrelenting?

According to a National Health Interview Survey about six years ago, more than 15% of women and 10% of men suffered from fatigue or exhaustion. Some reasons may be situational, such as excessive physical activity, lack of sleep because of insomnia, jet lag or shift work, medications that induce drowsiness like antihistamines and antidepressants, and excessive fat and alcohol intake. Some of these, such as shift work or constantly changing time zones because of work (like pilots and flight attendants experience), may be difficult to avoid and certainly diminish the quality of life.

Worse yet are medical conditions associated with unrelenting exhaustion: acute liver failure, anemia, chemotherapy and radiation, chronic fatigue syndrome, concussion, major depression, chronic infection, diabetes, underactive thyroid (hypothyroidism), multiple sclerosis, chronic kidney disease, fibromyalgia, stroke, drugs for hypertension, epilepsy, chronic stress, and major depression.

Some of these conditions, such as underactive thyroid, anemia and well-controlled diabetes, are correctable. And often the exhaustion will diminish as the body heals, for example, from a concussion or stroke (although it may take months for the post-stroke fatigue to disappear.)
The reason for the severe exhaustion is sometimes obvious and treatable, or disappears with recovery from the illness or treatment. Iron deficiency anemia responds to iron supplementation unless there is an underlying cause for loss of blood. Too low or high blood sugar in the diabetic that causes fatigue may require more intense monitoring of food intake and insulin dosing. Chemotherapy and radiation is usually of a limited duration, and people recover from concussions and infections.

But there don’t seem to be effective ways of overcoming the mental fog and intense tiredness of multiple sclerosis, major depression, chronic fatigue syndrome and other medical conditions, in large part because no one really knows what causes these symptoms. What causes cognitive sharpness to retreat into dullness? What causes well-nourished, developed muscles to feel too weighed down to move? How can a mental illness manifest itself in fatigue so great it is hard to get out of bed?

Because there is so much unknown about why fatigue seems to accompany illnesses from allergies to strokes, it is easy to point to available nutritional villains as the reason. Dairy products, gluten, fruits and vegetables belonging to the nightshade family like tomatoes, potatoes, peppers and gooseberries supposedly cause significant fatigue. Refined carbohydrates, saturated fats, and caffeine are also to be avoided. Conversely, foods that, not surprisingly, resemble those comprising a nutritionally sound diet, are recommended to fight fatigue: lean protein, fruit, vegetables, high-fiber foods, and low-fat dairy products. Of course, these food groups must be eaten not just for their supposed fatigue-fighting capacity, but also for the maintenance of general good health. Keeping hydrated is also very important.  However, there is little evidence that following a nutritionally sensible diet will alleviate the all-encompassing exhaustion associated with certain diseases.

Physical activity is recommended, although it should be low impact and of short duration. It seems counter-intuitive that using energy to exercise restores energy to the chronically tired, but it does seem to decrease fatigue. In fact, research showed athletes suffered from unrelenting exhaustion when they were not allowed to exercise for several weeks.

When exhaustion lingers, as it often does after a stroke or in chronic fatigue syndrome, the most usable advice is to accommodate to it. Frugality in using energy seems to be the most workable solution. Like budgeting one’s money, energy should be spent only on necessary activities. Simple things like sitting rather than standing to prepare a meal, consolidating errands, and avoiding unnecessary movements are helpful. Programming rest stops into the day’s routine and decreasing non-obligatory commitments are also important.  Meditation is thought to be helpful, as is simply sitting in a quiet room. When exhaustion includes a decrease in cognitive function, the so-called mental fog, it may be necessary to ask others to do the tasks, like paying bills, that seem impossible to carry out.

My friend’s exhaustion disappeared after a day without the grandchildren. Let us hope that research will make unrelenting exhaustion soon disappear as quickly.

If it is Easter or Passover, You Have Egg on Your Plate

I bumped into my neighbor at the supermarket checkout line, and commented on the three dozen eggs she was buying.

“I know!” she said. “What am I doing with all these eggs?” And then she recounted what she was going to be doing: one dozen or more for the egg hunt for her young nieces and nephews, two ricotta cheese pies that used at least 6 eggs each, also an egg yolk and flour mixture, deep fried and coated with honey, that’s called struffoli that used a dozen eggs. It’s early springtime holiday season, as evidenced by that a few days later? Another friend told me her menu for the Passover Seder she was hosting. Her use of eggs put my Italian neighbor to shame. The first course was hardboiled eggs in salt water, her soup had matza balls made with eggs, two vegetable casseroles made with matza pieces use several eggs as binding agents, and the meal was concluding with her mother’s recipe for a 12 egg sponge cake.

My cholesterol seems to bubble up in sympathy with this vast egg consumption.

Egg consumption statistics for 2015 found that across the United States, about 6.3 billion eggs were eaten during the Easter and Passover holidays (which fell that year between March 2 and April 5.) In Israel the average egg intake per person went from 20 to 22 a month during Passover, and that small country is the fourth largest consumer of eggs in the world.

So is there a problem with this? (No one is asking the chickens.)  A few years ago the answer may have been yes, because of the high cholesterol content of eggs. One egg yolk has 200 mg of cholesterol and until 2015, the recommended intake of cholesterol per day was 300 mg. Eat one egg for breakfast and you had better restrict your cholesterol intake from other foods such as dairy products and meat to very little.  Don’t even consider having bacon with that egg.

But recently, this has completely changed. A committee composed of nutrition, health, and medical experts decided that cholesterol from the diet was not a concern and had no bearing on levels of cholesterol in the blood.  (1, 2) This committee, The Dietary Guidelines Advisory Committee (“DGAC”) believes that cholesterol intake from an egg is not harmful if egg consumption is kept to moderate levels. Moreover, they regard the egg as an important and inexpensive source of nutrients. A large egg contains about 7 grams of protein ( more for extra large and jumbo), 70 calories,  about 5 grams of fat (mostly non-saturated, i.e. the good kind), vitamins A, D, E, and B12, as well as folate, selenium, choline , lutein and zeaxanthin. (These last two nutrients may be helpful in reducing age-related eye diseases).  Egg protein is considered the gold standard of protein because of its amino acid profile; the amino acids seems to meet our human protein needs as much as those of the developing chick inside a fertilized egg.

I asked a cardiologist friend who has been practicing long enough to have seen this drastic change in egg eating what he recommends to his patients.  “Eating two eggs a day, three times a week is fine,” was the response. “But don’t overdo it.” The DGAC says that eating one egg a day poses no risk to one’s heart health.  No one commented on how to handle the Easter/Passover glut of egg eating opportunities.

It would seem reasonable, however, for the more than 25% of Americans who are taking cholesterol lowering drugs ( according to 2010-11 statistics) to consider whether a second piece of ricotta cheese pie, or a second matza ball should be eaten.

“Heart disease and stroke remain the leading cause of illness and death in the United States,” said Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles.  But is there any relationship between the incidence of cardiovascular events and egg consumption habits during the spring holiday season?  Advice on egg consumption consistently limits egg intake to no more than 7 eggs per week. Eight days of Passover may easily double that amount because eggs are used in so many dishes to provide leavening, or a lightening of traditional Passover dishes. An Easter weekend of feasting may also result in week’s worth of egg intake over 36 hours. Might the holiday excessive egg consumer reap the negative effects months or years later by increased vulnerability to a heart attack or stroke?

An obvious solution is to maintain the healthy food choices that (one hopes) describe eating during the other 51 weeks of the year. Fortunately, spring increases the number of fresh vegetable and fruit options, and there is no law, religious or otherwise, stating that a 12 egg sponge cake or fried egg yolk and flour fritters must be consumed as part of a holiday celebration. These holidays are celebrated in a tradition spanning centuries of a baked foods with excessive numbers of eggs. Decreasing egg intake to more reasonable amounts will benefit the health of those celebrating them.

Sources for the scientific data reference are available upon request.

Eating Your Meals at Restaurants May Decrease Loneliness (But Increase Weight)

One of my neighbors, widowed about three years ago, never eats at home but goes to specific restaurants for breakfast, lunch and dinner. “I don’t want to sit in my kitchen and eat a microwaved dinner while watching the news,” she told me.

“Eating in restaurants makes me feel less invisible.”

Her social objectives to meet people and not eat alone are being met. She has made friends from the neighborhood who eat at the same restaurants, and she is less lonely.  But the cost of eating all her meals away from home has been a marked increase in her weight.  Never slim, she now had gained so much weight that her already compromised knees and back have made walking difficult without a  walker, and she is short of breath.

Her weight gain from eating in restaurants puts her in good company. It is thought that the doubling of the prevalence of obesity in the U.S. over the last 35 years is due in large part to the increase in meals eaten away from home. Fifty years ago, 30 percent of the food budget went toward meals at restaurants. Now it is almost 50 %.

Not all restaurants, of course, generate weight gain. But chain restaurants in particular promote calorically dense foods: fried chicken, chicken nuggets, double or triple cheeseburgers, meatball subs covered with cheese, sandwich fillings that are more mayonnaise than protein, and high fat salad dressings and special ‘sauces.’ Some food items may contain enough calories for the day, not just one meal.

But my friend, who after all had cooked for a husband and children and then grandchildren for decades, knows enough to avoid fried chicken, French fries, and a salad limp under a quarter of a cup of salad dressing. She thought she was making nutritionally wise food choices. The problem, when she asked me how to start losing weight, was that neither she nor I had much of an idea of what the foods she was eating contained.

“I try to avoid foods that I think will have too much salt or sugar but who knows what is in the food?, she told me. I try to pay attention to the calories if they are listed on the menu, but it is confusing. I don’t mind eating a lot of calories if they are from good protein, but what if the calories are from butter or mayonnaise, or some fatty meat like bacon? “

Jane (not her real name) did not want to stop going to restaurants and begin to eat at home in order to lose weight.  The cost of doing so would have been social isolation and even depression. The solution was to find out what she was eating, and to make some informed choices.

The solution: we spent a cold rainy afternoon in front of the computer looking up the nutrients and calories in the foods offered at the restaurants where she was eating. We were surprised at what we found. Oatmeal for example: She liked oatmeal for breakfast, and I couldn’t convince her to eat it at home. “If I don’t get out of the house when I wake up, I feel depressed,” she told me. She had been going to Dunkin Donut for coffee and a cup of oatmeal. The calorie content of the oatmeal was reasonable, 310 calories, but we were shocked to see that it contained more sugar than oatmeal: 40 grams of sugar and about 26 grams of the starchy carbohydrate. Choosing the flatbread veggie-egg white sandwich with diced pepper and cheddar cheese? She would be getting 18 grams of protein (the oatmeal had very little protein), and only 5 grams of sugar.  Had she gone instead to Au Bon Pain, a block away, for her oatmeal she would have eaten about the same number of calories, but only 1 gram of sugar.

On the other hand, when we checked the calorie contents of some calorically innocent sounding Au Bon Pain sandwiches, we were surprised at how many calories they contained.  A chicken sandwich which should have been a relatively low calorie option contained high fat ingredients like avocado and bacon and clocked in at more than 600 calories.  Other chicken or turkey sandwiches were also calorically high, especially for someone as sedentary as Jane.

“What about a roasted vegetarian wrap?” asked Jane, peering at the computer screen, “It sounds healthy.”  But that came through with a whopping 700 calories. Fortunately, half sandwich options were available, and if combined with a low calorie vegetable soup, this seemed like a good lunch option.

Eating dinner at a restaurant forestalled Jane’s returning to an empty apartment too early in the evening, so that meal became even more socially important than the previous two. Unfortunately, her favorite eating place served gigantic portions, which Jane tended to finish because she hated to waste food. She thought a solution might be to share an entree with a friend who also lived alone, and if her friend was not available, asking the waitperson for a half size portion. “They don’t have to put so much food on my plate,” she said. “Look, if you can ask for salad without dressing, or a dish without nuts or bacon or cheese, why can’t you ask for less food on the plate?“

The financial and caloric costs of eating away from home are higher than eating in one’s kitchen. But the social and mental health benefits, as in Jane’ case, are compelling.  If we can make nutritional information about restaurant food easier to obtain, portions smaller and healthier, then the choice does not have to be eating a lonely meal at home, or eating with the company of others away from home.

Are Corporate Shut-In’s as Vulnerable to Vitamin D Deficiency as Nursing Home Residents?

I live near a nursing home and regularly see the staff coming in and out during their shift change when I walk past. What I have not seen, despite the warm, sunny weather, are residents sitting outside in the garden, or being pushed in a wheelchair.

This is not surprising. Few nursing homes have the sufficient staff to permit taking residents outside, and so rely on visitors to do so. The residents themselves often prefer to stay inside. An elderly aunt of mine always had an excuse as to why she did not want me to take her out when I visited. I wanted to take her for a stroll in her wheelchair, but she preferred staying in.

One consequence of being a “shut-in” in a nursing home has been noted for years: a significant decrease in vitamin D levels because of the absence of exposure to sunlight.  The predictable osteoporosis, bone breakage from falls, and decreased mobility affects quality of life, making many unable to move independently, and so is linked to increased mortality. Vitamin D supplementation is strongly recommended, and shown in many studies to be effective in reducing this vitamin deficiency effects on bone strength.

But what about the staff? The nursing staff who leave the residence early in the morning, sometimes just as the sun rises, are going home to sleep. They will be back the next evening, but even though their time off is during the day? The need to rest for at least 7 hours of sleep and the necessity of managing their daily obligations leaves little time for outside exposure to sunlight. This, of course, is especially true during the short hours of daylight during the late fall and winter. Depression has a high incidence among shift workers, and their failure to be exposed to sufficient sunlight has been suggested as one possible cause.

Those who work a traditional daytime shift should not be vulnerable to vitamin D deficiency due to the absence of sunlight, but is this really true? The reality is that many are stuck in their offices from sunrise to moonrise and later. Exposure to the sun is limited to weekends and, in some employment situations, such as law associates (recent graduates from law school) priority to work supersedes any weekend plans (including going outside.) These employees could be described as ‘corporate shut-ins.’ They may be tethered to the “clock” that is tracking their billable hours, and like a galley slave chained to his oars, will not be released until their supervisor (task master) permits time off. Whatever leisure time they have is spent carrying out the essential tasks necessary for their daily life such as buying food, doing laundry, paying bills, and maybe cleaning their apartments.

As we have seen, clinicians are worried (and rightly so) about the low vitamin D levels of nursing home residents, at home elderly shut-ins, and anyone else who is unable to obtain regular exposure to sunlight.  But look in vain for concern about corporate shut-ins who don’t see the sun from Sunday to Saturday during the months of year when daylight is scarce.  According to Dr. Barbara Gilchrest, who discussed vitamin D status at a recent American Academy of Dermatology meeting in Orlando, sun and diet should be enough to supply adequate levels of this essential nutrient for most patients. But can her advice be applied to those whose exposure to sun is severely limited, and whose diet lacks vitamin D fortified foods?

In an ideal work setting, shift workers would be advised on how to eat to minimize the health problems associated with their work schedule such as obesity, high blood pressure, diabetes and depression. Taking vitamin D supplements or finding time during the day to go outside and get some sunshine might be suggested. Much of this advice, however, comes not from the workplace or health care providers, but from anecdotal reports posted on Internet sites by those who also do this type of work.

But even less advice is given to daytime employees whose work hours are long and who may go days without any time off. They will not find bottles of vitamin D on their desk, nor will their supervisors encourage them to go outside during lunch to get some sun. Indeed, they are encouraged not to leave the building. And the meals provided in these organizations so they can work late are probably not planned to ensure that they consume vitamin D fortified foods.

We know already the long-term health consequences of nursing home residents who are shut-ins and get no sun exposure. So too, we know the long-term health consequences of shift workers who rarely see the sun.

We do not yet know the long-term health consequences of the corporate shut-in, the Silicon Valley twenty-four hour programmer, the investment banker who works during Asian, European and American time zones, or the surgical resident who arrives at the hospital at 5:30 AM and leaves at midnight. They, like the nursing home resident, have too little exposure to the sun. Do we have to wait until this generation of workers ages into the nursing home before we start to worry about their vitamin D status?

Research Cites Supportive Available Upon Request.

Can Being on a Committee Make You Overeat?

The neighborhood association meeting started out benignly enough, with a non-contentious minutes read and acceptance, followed by people chitchatting as the chairperson droned on about some street maintenance issue. Someone had placed bowls of snack food on the table, along with diet and non-diet sodas, but all were ignored. About 20 minutes into the meeting an agenda item launched agitated discussions with people talking over each other and, when they couldn’t be heard, muttering to themselves. Just as suddenly hands dipped into the bowls of pretzels, chips, nuts, and crackers and cups of soda poured and gulped. Some people were talking through mouthfuls of chips as they attempted to enter the conversation and others, who were shut out, stuffed more food in their mouths.

The committee meeting was a living poster for stress-induced eating.

What was a little surprising was that the gobbling of snacks occurred in public. We tend to assume that those among us who resort often or even infrequently, to emotional overeating, do so in private. The ice cream, cookies, chicken fingers, pork rinds, or doughnuts are usually eaten alone or in the company of people who are sympathetic and supportive of the problem driving the eating.  But the behavior of this group shows that if the provocation is sufficiently strong, the eating response may be immediate, even if embarrassingly visible to others.

This is not to say that people in groups don’t overeat. Watch people at a meal listening to a speaker as they eat. Their interest in their food increases in proportion to their boredom. If a speaker notices that the members of the lunch or dinner audience are attempting to eat the crumbs of the roll from the tablecloth, it’s very clear signal that he or she ought to wrap up the talk immediately.

But people at the committee meeting were not eating out of boredom; they were eating because of stress. Each member of the committee felt that he or she had to influence the outcome of the discussion, and many were afraid that the outcome would not be to their advantage.

Were they aware of how much they were eating? If they had been asked to fill out a food diary a few hours later, would they have reported eating three handfuls of pretzels or nuts, or drinking 10 ounces of soda? Probably not.

Did the eating influence the intensity of the discussion?  The act of putting food in one’s mouth may have been somewhat calming, just as giving a whining child pieces of breakfast cereal to eat has a distracting and calming effect. And obviously chewing somewhat dry food made it hard to shout out comments without spraying a fellow committee person with bits of pretzels or chips.

The mainly carbohydrate snacks would have had a calming effect—if the meeting had gone on long enough for the food to be digested and serotonin to be made. But that would have taken at least another half an hour, and the meeting broke up before then.

Stress associated with group interaction is usually overlooked among the many triggers inducing overeating. And there are unspoken rules about eating behavior in the corporate culture that probably deem any unrestrained eating at a meeting as unprofessional even when food is available? If someone at a lunch meeting begins to munch on several chocolate chip cookies brought in with the sandwiches, others will notice and wonder at his or her lack of control. There is stress most certainly, but if it generates overeating, it is usually done afterward, in private. I once had a client whose presentation to her team was so criticized that she went to a gourmet chocolate shop in the lobby of her office building, bought five pounds of chocolate and ate it all in her office (with the door closed).

The advice I gave her might, however, be useful to those attending future meetings of committees where emotional discomfort is inevitable: Eat proactively to reduce future stress. She was to eat a small, non-fat carbohydrate, such as half a plain bagel, 30-45 minutes before going into her meetings, so that the serotonin made after she consumed the carbohydrate would be a little calming.

If my fellow neighborhood association members had followed the same advice would there have been a quieter, more restrained discussion? If they had “armed” their brain with more serotonin before the meeting, would they have ignored the snacks on the table?

But of course there is another solution to the problem of committee meeting-induced overeating: stay home.

 

How Much Vigorous Exercise Will Prevent You From Dying?

Two very busy professionals I know took some time off last Sunday to go cross-country skiing. The snow was mushy from a recent thaw, and the legs of the skiers a bit wobbly but, according to my friends, it was a vigorous workout and welcome relief from their 80-hours week of work. They had fun, but they also were doing good things for their health. Like most too busy people, fitting physical activity into the workweek is like squeezing a suitcase into an overfilled overhead bin on an airplane. Often it is impossible to do it. A forty-something year old paralegal whose commute to work on a good day takes over an hour, told me that she is lucky because her workday runs only from 8:30 to 6. After she picks her children up at their nearby after school program, drives home, gets dinner ready, does the laundry and other household chores, helps the kids with their homework, and takes a few minutes to talk to her husband…. she is ready for bed, not for a treadmill. The lawyers in the office are lucky if they leave by 9 p.m.

The weekend may be the only time when a few hours can be used for exercise. But until recently, experts have said that exercising over only two days was insufficient to have much impact on cardiovascular health and eventually longevity.  Rather, we have been told to be physically active almost everyday so that our total exercise time adds up to at least 150 minutes. And we should not assume walking to the car or commuter train station, strolling around the block with the dog, or taking out the trash meets the exercise requirement. We have to exercise with vigor: by running, climbing steps rapidly or taking a challenging aerobics class.

But now this assumption is being challenged. A recent article in JAMA Internal Medicine reported the results of an enormous study that collected information about the health and causes of death among 63,591 adults in England and Scotland from l994 to 2012.  The subjects were asked about the amount of time they exercised weekly, when during the week they did exercise, and to rate how vigorous their exercise was. All this information was self-reported rather than observed by a researcher.

The study found that people who managed to squeeze 150 minutes of vigorous weekly exercise into two weekend days, rather than over 5-7 days, seemed to have the same cardiovascular benefits as the daily workout folk. Both these groups (and a third that did less than the guidelines) all showed about a 45 decrease in mortality due to cardiovascular events compared to the group that did not exercise.

The good news from these findings is that it removes the urgency in finding time to exercise during an already overextended weekday schedule. The bad news is that it is necessary to find time to exercise in an already overextended weekend schedule. The data showing such a significant decrease in the risk of dying from a heart attack, stroke or other cardiovascular cause are too compelling to ignore. On the other hand, filling up the refrigerator, doing the laundry, spending time with the kids, parents, friends, and catching up with bills, phone calls and sleep are too compelling to ignore as well.

It is possible to extract two-and-a-half hours of time to exercise out of 48 hours of “time-off.” That is less time than it takes to watch the Oscars, Super Bowl, or an average movie including previews. And doing so does not necessarily mean playing 150 minutes of tennis or a 2½-hour bike ride or run. Any physical activity, from shoveling snow to removing rocks from a potential garden, would qualify as exercise. And the exercise does not have to be done continually. A seven-minute workout following the instructions on an App or 2 minutes of jumping rope counts toward the 150 minutes.

However, there is a problem with the exercise recommendations. What is vigorous exercise?

If you are still breathing but unable to talk or sing, if your heart rate is high and you are sweating, then you are engaging in vigorous exercise.  Straining to ride your bike up a steep hill and gasping for breath or running as fast as you can after a puppy that has just seen a squirrel and is heading for the street is vigorous exercise.  Jogging with a friend and having enough breath to talk about a television show you saw last night isn’t.

Lists of what comprises vigorous exercise are meaningless to someone who is relatively unfit. A physically well-trained individual may have to do an hour of boot camp, sprinting around a track, or bike at high speed to break a sweat. However, most of us would find any physical activity that pushes us out of our comfort zone vigorous: climbing several flights of stairs, carrying heavy bags of groceries from the car to the kitchen, walking against a strong wind, or pushing a heavily laden shopping cart across a large parking lot. And for someone who rarely moves, climbing the stairs from the cellar to the second floor a few times each day may cause rapid breathing and heart rate.

Were those 63,000 subjects in the UK all doing vigorous exercise according to the definition of exercise physiologists?  Or were some possibly a little vague about the vigor of what they were doing? Were they like some of us who, when asked about our weight and height, remove a few pounds from the former and add a few inches to the latter?  Because if they were really engaging in moderate or even light exercise, “I can still breathe and talk” exertions, then it means that cardiovascular benefits are possible for those of us who may not break a sweat in the gym.

How Can You Get Enough Nutrients If You Don’t Eat Very Much?

Some of the more popular reality shows on television display various mental health pathologies such as super rich housewives always fighting with each other (when they are not having their hair done and drinking wine), or a show about hoarding to the point of suffocation, or even a view into living inside a 600-pound body that is so heavy, any movement is difficult and painful. The latter program is particularly sad, in that it shows how obsessive eating is almost always the result of early trauma, and how difficult it is for the overeater to deal with the pain of such trauma when the emotionally deadening effect of food is removed.

 

What has not been depicted so far is a reality program on the struggles of people at the other end of the eating spectrum. These are the people who believe that, like the Duchess of Windsor, one can never be too rich or too thin. These are the people whose body weight is so low that they run the risk of death. These are the people whose obsession with being extremely thin is as unshakable as the 600-pound individual who seems to be addicted to food.  

 

Perhaps the stories of the too thin are not told because the viewer may not be interested in watching an anorectic chase an almost invisible morsel of food around the plate, before grudgingly eating it and then exercising for three hours to work off the 3 calories the food may have contained. Or perhaps it is because the fashion industry has convinced us that thinness is something to be coveted, even if the price of a too thin body may be malnutrition or, if it becomes anorexia, even death.

 

A few weeks ago I walked past a facility holding a fundraising event. What caught my attention was a group of extremely tall women wearing gowns that would have looked appropriate on someone’s red carpet. They must have been models; they had perfect features, either from genes or a plastic surgeon. I confess I stared at them, not just because they looked so exotic in my neighborhood but also because they were so THIN. They were not skeletal but just on the other side of being all bones and no flesh. Another woman stopped and looked with me. She said, “They don’t look quite real, do they? But it must be nice to be so thin.”

 

Somehow we don’t think of being model thin as associated with health issues. The warnings about the risks of eating too much or the wrong kinds of food are well known, they are hard to escape: Don’t eat too much, don’t eat too much sugar, exercise frequently, and get rid of belly fat.  But how many of us know what medical woes are awaiting the very thin? One has to go searching for them. And some can be as deadly as those associated with morbid obesity.

 

When very little food is eaten, as must be the case if someone is to maintain a weight 20 or so pounds less than normal, an inadequate consumption of nutrients can result. Calcium and vitamin D deficiencies are common, and can result in osteoporosis. This disease, which is mainly silent until the first of many bone fractures occurs, is characterized by the loss of bone mass. This disease usually shows itself around menopause, but the bone loss due to nutrient deficiencies may start decades earlier. Other symptoms of nutrient inadequacy such as thinning hair, fatigue, dry skin and bruising of the skin also may not show up for several years, but can be traced back to a very low nutrient sparse diet. A study of the nutritional adequacy of the Mediterranean Diet in Spain among thin women indicated that they were deficient in vitamins A, D, E, B2, B6 and folic acid, as well as several minerals such as iron. (Ortega, R, Lopez Sobaler, A, et al  Arch Latinoam Nutr. 2004 Jun54; 87-91.)

 

Even athletes, whom one assumes eat healthfully, may be nutrient deficient if they are dieting. Female volleyball players who play the game in the scantiest of uniforms were found to be deficient in a variety of vitamins and minerals, due to their dieting in order to reach a figure perfect weight. (Beals, K,  J Am Diet Assoc. 2002;102:1293–1296). And dancers who must maintain low weight and low body fat are particularly vulnerable to nutrient deficiencies ( Sousa, M, Carvalho, P et al ,Med Probl Perform Art 2013 28: 119-123).

 

Models, dancers and some athletes accept the necessity of maintaining an abnormally low weight as one of the demands of their profession. They may be able to compensate for their restricted calorie, and thus nutrient, intake with the use of supplements. However, supplements rarely provide all the nutrients they would get from food, if only they were allowed to eat more. 

 

Thinness is also prized among women whose weight is irrelevant to their profession but not to their social standing. And its potential nutritional toll and subsequent health problems may be ignored as thoroughly as by an obese individual who cannot stop overeating. A quasi-sociological analyses of the lifestyle of women who live in the rarified neighborhood of New York’s Upper East Side points this out. In her book, The Primates of the Upper East Side, Dr. Wednesday Martin describes the non-eating that takes place at social events. Women diet continually and subject their bodies to workouts that would make a Marine recruit weep in order to have a perfect body. So many foods are eliminated from their diet in order to achieve the desired thin state? It is a wonder that the residents of this neighborhood don’t suffer from scurvy, anemia and other nutrient deficiencies. They are not addicted to food, but rather they are addicted to their almost pathologically thin bodies.

 

And yet this bizarre eating behavior is not the subject of reality television, or urgent messages from health organizations warning about its long-term consequences of nutrient deficiency. We see the consequences of the massive overeating of the 600-pound individual and tsk tsk at what that person has done to his or her body. Maybe it is time to tsk tsk over the damage the too thin are also doing to their health.   

Can You Give a Man a Box of Chocolate for Valentine’s Day?

In former times, when women were courted (at least in books) with gifts, flowers, poems, and perfume, giving a box of ornately wrapped chocolate for Valentine’s Day was not only appropriate, but expected. Presenting a red velvet box tied with a glossy ribbon that contained fancy chocolates was a socially acceptable way of showing interest in the other, female, sex. Moreover, the price of chocolate varied sufficiently, so that brands and sizes were within most people’s budgets.

But this gifting of chocolate was, and seems still to be, unilateral.  Is it because women are not supposed to give Valentine gifts to men to express their interest in a relationship?  Is it because it is unmanly (whatever that means) to like chocolate, and thus giving a gift of chocolate raises the possibility of a diminished manhood?  Is it because cultural norms dictate that giving a six-pack of beer, tickets to a sporting event, or a chain saw are more acceptable gifts? Obviously, the traditional red ribbon wrapped box of chocolates might look out of place on a workbench, in the garage, or on the seat of a pickup truck. And the dainty flower-shaped, decorated chocolates that come in a sampler box are too small, and too  “precious” to appeal to someone who wants a brick-size chunk of chocolate to bit into. Before a woman can even consider giving chocolate to a man for Valentine’s Day, its size and packing have to look suitable for a man cave (maybe a chocolate chain saw?).

Giving Valentine chocolate to women (other than those in an older generation such as mothers, grandmothers and aunts) poses its own set of problems. Indeed, it can be quite tricky. If the recipient is thin, then the gift might be interpreted as a hint that the giver would like some soft curves over the bones and buff muscles. If the recipient is not thin, a can of metaphorical chocolate worms is opened: “Does he like me fat? “ “Does he assume that I will never lose weight?” “Do I look like someone who sits on a couch and eats bonbons?” “Doesn’t he know I am thinking of going on a diet?” “If he knew me better, he would know that I am addicted to chocolate and avoid it entirely.”

The problems do not end with the presentation of the gift. Is the box opened when it is received and chocolate offered to the giver? Does the recipient have to eat a piece of chocolate upon opening the box? Does the giver check to see how long the chocolate stays in the box? Too long a time and obviously the chocolate was not liked. Too short a time? The recipient must be a glutton.  If the box contains a sampling of chocolate pieces with different fillings, what does the recipient do with the chocolates whose insides are not appealing? Finally, Valentine chocolate is hard to re-gift. That red cloth covered box won’t do for Easter, and saving it for Christmas to give to a fellow worker is tricky. You have to take the chocolates out, and put them in a box with reindeer on the cover and hope they haven’t turned, by next December, a grayish color.

Centuries ago, chocolate was seen as an aphrodisiac… although double blind, placebo-controlled studies to see its effect on love relationships are still waiting confirmation. Chocolate comes from the cocoa bean, which is surrounded by a fibrous husk. The husk is broken and removed from the bean. Then the beans, called cocoa nibs, are ground up into cocoa liquor. (No, it is not the same as chocolate liqueur that forms the basis of several delicious and fattening drinks.) The liquor contains a caffeine-like substance, threobromine, which has similar stimulant effects as caffeine. Dark chocolate has more cocoa liquor than typical chocolate, and thus more of this stimulant-like substance. However, it is hard to see how caffeine or this first cousin has any effect on a relationship except to prevent sleepiness if the other person is boring.

The cocoa nibs also contain about 54% cocoa butter which may be similar in texture to peanut butter when ground. Trace amounts of mineral zinc or copper are found in the cocoa bean, along with phenethylamine or PEA. This substance can be made from an amino acid with the similar sounding name of phenylalanine, and results from microbial fermentation in the bean. Phenylalanine and PEA may have amphetamine-like functions, thus possibly stimulating the chocolate eater to say yes to another date. But the amount that actually reaches the brain is as vanishingly small as the amount of chocolate left in the box by a chocoholic.

The magic in chocolate comes in processing these ingredients with sugar, lecithin, an emulsifier made from soy, and vanilla or other flavorings into the final product.  Chocolate is considered a unique food, and to many there is no other food that can meet its immensely pleasing taste and texture. Indeed, so satisfying is chocolate that some might be tempted to exchange a mate for an eternity’s supply of this heavenly food. Years ago in a visit to Zurich’s finest chocolate store, my husband and I each consumed a just made chocolate truffle of such exquisite texture and taste that I thought I saw the pearly gates.

So perhaps the answer to whether men should get chocolate for Valentine’s day is this: Yes!
(as long as women get some too…)

Asking Why You Can’t Lose Weight After Your Medication?

The media is glutted with advertisements for weight loss: after all, this is January. And it is assumed that by denying calories and increasing physical activity, some weight will be lost by March at the very least. This assumption is based on the belief that the weight was gained because excess calories were consumed, and physical activity minimized.

But what if you were thin, fit, ate healthful foods, loved to exercise, and never been on a diet? Then sometime in 2016 you started on antidepressants for a variety of reasons: depression, anxiety, grief, fibromyalgia, or menopausal hot flushes. The medication helped, but there was a problem. Six weeks or so after starting treatment your clothes started to become tight. You no longer were satisfied with normal portions, but started eating larger amounts at meals. And, horrors of horrors, you could not stop snacking. Your physical activity decreased because the medication made you tired.  You ended up 23 pounds heavier at the end of 2016 than you were the beginning of last year.

So now you are off your medications, and you try one of the various weight-loss programs advertised. But weeks go by and you have lost practically nothing, even though you follow the plan exactly and exercise. Your distress is like someone who became bald during chemotherapy, and months later is still hairless.  You assume that like everyone else who is trying to lose weight in January, you should be successful. In fact more so, because unlike other dieters, you never had an overeating problem until you started taking antidepressants!

Help will not come from the people who develop the diet plans because the regimens are for the ordinary obese individual who gained weight the traditional way. Help won’t come from weight-loss support groups for the same reason. And so far no department of psychiatry has a weight-loss program for its patients who have gained weight on their medications, even though such programs are sorely needed.

So you alone are going to have to figure out how to lose the weight the medications caused you to gain.

Here’s what you need to know: Some medications stay stored in the body for some time after they have been discontinued. You can determine whether the medications are still affecting your appetite and physical activity even though you have stopped taking them; simply ask yourself if you are eating larger portions than you did before you started on the medication.

If you were craving and eating sugary, high-fat snacks when you were on the meds (cookies, cake, ice cream) do you still have these cravings?

Do you find it hard to feel satisfied even when you are eating enough food to make your stomach feel full?

Is your body still fatigued from the meds, or even from a residual depression? Does this make it hard to exercise with the same intensity and duration you had before you went on the medication?

Do you think you have lost muscle mass?

If you detect a lingering effect of your medication on your appetite and physical activity, then consider this one possible reason why it is so hard to lose weight.

Forget what the advertisements for weight-loss programs promise. They are not directed toward people whose appetite control and ability to exercise have been hijacked by their medications.

Instead, give yourself more time to lose your weight. If carbohydrate cravings persist, satisfy them with fat-free, healthy carbohydrates like steamed rice, oatmeal, whole grain pasta, polenta (an Italian version of grits, but without the cheese and butter), popcorn, pretzels, and whole grain bread. You need to eat only 30 grams of such carbohydrate on an empty stomach two or three times a day to take away your cravings, and increase your sense of being full.

And you may have to increase gradually your workout time and intensity since your body may not be able to jump into the type of exercise you did so easily before you took the antidepressants.

Be patient. Eventually the residual medication should leave your body, your control of appetite and ability to exercise will return, and you will lose weight.

But, if none of the above applies to you, seek medical advice. Before meeting with your health provider, accumulate data to show that your inability to lose weight is, a) not your imagination, b) not due to overeating and not admitting it, and c) not related to a sedentary lifestyle.

Keep a food log and exercise log. If possible, use apps that will do it for you and allow you to print out the results. The results will look more impressive than some pieces of paper covered with food stains or sweat. Allow at least three or four weeks of record keeping before presenting them to your physician. That is a long enough period of time to lose one or two pounds and if you have lost none, you can make a convincing case for something being wrong. At the very least, the health care provider should investigate possible reasons for the weight refusing to be lost.

Enough people have experienced difficulty in losing weight after they discontinued their antidepressants to make this a not rare occurrence. So far there has been mainly silence from both the psychiatric and obesity communities in response in part because of the belief that it should be possible to lose weight after the drugs are stopped. Presenting evidence that pounds gained during treatment are not lost with dieting after treatment is stopped, may indeed generate research to find a solution to this unwelcome side effect of antidepressants.