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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Should Cauliflower Be the Main Course at a Vegetarian Wedding?

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

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

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

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

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

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

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

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

Night Eating Syndrome: Is It Just Sleep That Is Disturbed?

Waking up in the middle of the night is an annoying event that most of us experience. Usually we are able to fall asleep again quickly, perhaps after drinking some water and/or making a trip to the bathroom. But for some, waking up is a signal to go into the kitchen and eat: a bowl of cereal, a peanut butter sandwich, or a dish of ice cream. And unhappily, going back to bed after the night time snack does not ensure that the remainder of the night will be restful. Waking may occur once again, or even several times during the rest of the night, and is always accompanied by eating. The next morning, the night time eater has no appetite for breakfast and may not eat for hours.

When the pattern of awakening and eating occurs regularly, it is defined as a type of eating disorder called Night Eating Syndrome (“NES”) described first by Albert Stunkard in l955. Dr. Stunkard was a professor of psychiatry at the University of Pennsylvania when he first put forth the criteria for diagnosing this poorly understood behavior. Simply eating leftover pie or pizza at midnight is not sufficient to meet the diagnosis, because people with NES consume about 25% of their total daily calories after the evening meal. The food can be consumed in the evening before sleep and/or during nocturnal awakenings. Those with NES suffer from insomnia at least four or five times a week and believe that they will not be able to go back to sleep unless they eat. Finally, if they have mood disturbances like depression and anxiety, their moods will worsen as the evening progresses.

Interestingly, as Stunkard points out in a paper he wrote on the subject almost fifty years later, people who engage in frequent night time eating are not necessarily obese, although it is a risk factor for obesity. Because they are unlikely to eat during the early part of the day, (skipping breakfast and delaying lunch) their total daily intake may be appropriate. On the other hand, many who are seeking help for their obesity often fail to report nighttime eating episodes. Plus, they are rarely asked about it, so it is not known to what extent this type of eating contributes to weight gain.

The inability to sleep through the night, or to do so with only infrequent awakenings of short duration, is certainly associated with NES, but is it the cause? Many people have insomnia, but they do not eat their way through every period of nighttime wakefulness. If the food eaten helps put the eater back to sleep, this would explain their seeking food once they wake up. But it is hard to find studies that test whether the foods chosen in order to put the insomniac to sleep actually work. Moreover, in a study that examined sleep cycles of NES subjects and controls, no difference was found in the duration of sleep, although the former did awaken earlier in the night and more often.

Perhaps the syndrome is not caused by disordered sleep, but by something else. Current research suggests someone with NES is not eating to go back to sleep, but rather waking up because of hunger. The “hunger” hormone ghrelin, which normally is secreted during the day when we normally feel hungry, seems to peak late in the evening and into the night in NES sufferers. Thus they may be awakening because of ghrelin-potentiated hunger.

A solution has been to reset the pattern of ghrelin secretion back to normal by exposing the patient to light very early in the morning. Anyone who has traveled east across enough time zones to feel out of sync and out of sorts during the first couple of days, knows the feeling of being forced to sleep and eat on another time zone’s timetable. It is hard to be hungry for breakfast when it is only 3 am back home, and it is hard to find food when you wake up hungry at 2 am because it is now 7 pm back home. If you stay in the new time zone long enough, your eating and sleeping hormones adjust. This is what researchers hope to accomplish for the night eaters using bright lights to make ghrelin levels high during daylight rather than at night.

Melatonin is also being tried because some studies have found that this sleep hormone is not as high as it should be in the late evening, and perhaps this is why it is so easy for the night eaters to wake up. There is a time-released melatonin preparation containing the low recommended dose of melatonin (0.3 mg); whether it might prevent frequent awakenings has not yet been tested. Anxiety and depression are also linked with NES, but it is unclear if they are the cause or consequence of disrupted sleep.

It is not unusual to wake up at 3 am and be assaulted with the worries that were successfully repressed 12 hours earlier. If one were prone to depression and anxiety, would these mood disorders cause sleep disturbances leading to frequent awakenings or, if awake, prevent the individual from falling back asleep unless something is eaten? Stunkard recommended antidepressants that increase serotonin activity to decrease anxiety and depression and calm the individual back into sleep. But a remedy that would help the sleep, as well as hunger and mood disturbances, is more simple and natural: a cup of low-fat, mildly sweet breakfast cereal eaten upon nighttime awakening. The carbohydrate will increase serotonin thus inducing relaxation, satiety and a more tranquil mood.

If the cereal is in a cup by the bed, it can be eaten without leaving it (as long as there are no crumbs.)


“The night-eating syndrome; a pattern of food intake among certain obese patients,” Stunkard, A.J.; Grace, W.; Wolff, H.,The American Journal of Medicine. 1955: 19: 78–86

“Two forms of disordered eating in obesity: binge eating and night eating,” Stunkard, A. and Allison, K.. Int J Obes Relat Metab Disord 2003, 27: 1-12

“Circadian eating and sleeping patterns in the night eating syndrome,” O”Reardon, J., Ringel, B., Dinges, D., et al, Obes Res. 2004; 12:1789-96

If Your Valentine Sweetheart is on a Diet, Should You Gift Chocolates?

Valentine ‘s Day is a sweet (pun intended) holiday. It comes in the middle of the winter doldrums; Christmas is long past and spring is nowhere to be seen. But the problem is that it also comes about six weeks into the weight-loss program many started after New Year’s Day.

“Give something to show your love,” we are told in a doughnut shop advertisement featuring heart- shaped pink doughnuts covered with white icing and pink sprinkles. Shelves in gourmet chocolate stores are filled with pinky-red, heart-shaped boxes decorated with tiny flowers; the boxes contain melt-in-your-mouth creamy chocolate that should be guaranteed to melt the heart of the recipient.  Russell Stover chocolates that are filed with hidden flavors revealed only when bitten into are waiting to be bought and sent to the relatives who remember the candy with fondness. M&M’s sport pink chocolate shells, while heart-shaped sugar candies waiting to cause instant tooth decay call to the drug store shopper who came in only looking for shampoo.

Not to be left out, bakeries feature several-layered heart-shaped cakes to be consumed with a glass or two of champagne.

To be sure, commercial romance for Valentine’s Day is not limited to food. Flowers are a welcome brightness in the gloom of early February and jewelry, especially diamond engagement rings, do not contain calories. Gifts of self-indulgence that the recipient may not get for her or himself, such as a massage, spa treatments, pedicures, and/or manicures, are also calorie-free and thoughtful.

However, sweet foods, especially chocolate, seem to be the most persistent symbol of romantic thoughts or intentions. Perhaps because for centuries chocolate has been considered an aphrodisiac. There is no scientific evidence for this, and even if it were true, there would be no reason to assume that chocolate consumed on Valentine’s Day has a greater impact on sexual arousal than if it were consumed on any other day. Perhaps if chocolate is wrapped in a heart-shaped box, it has more of an impact; nonetheless, this certainly has not been tested.

Giving a gift of chocolate also has its perils. What if the message it conveys has less to do with romantic intentions and more to do with the body image of the recipient? Give a pound of chocolate to someone skinny and it may convey the thought, “You need to gain some weight.”  Present that heart-shaped box to a chubby recipient and it can unintentionally convey the thought that, “You are fat already, so what difference does another pound of chocolate make?” instead of, “I like you the way you are.” Can you give chocolate to someone in the older generation who may be overweight, developing diabetes, or dealing with orthopedic problems because of excess weight?

Then there is the dieter. The continuing popularity of low or zero carbohydrate diets puts chocolate on the forbidden food list. The butterfat would be fine, and the more expensive the chocolate, the more butterfat it contains. But the sugar content that makes chocolate edible (otherwise it would taste like bitter cooking chocolate) would ruin the diet of anyone who is following a ketogenic diet in which fat, not carbohydrate, is used by the brain and body for energy.

But for those who are counting calories or the equivalent in food exchanges, there is good news. Small amounts of chocolate have fewer calories than they seem to have, given their luxurious taste and mouthfeel. A quick scan of Godiva, a popular gourmet brand of chocolate, reveals a lower calorie count for their chocolate than one would assume. Admittedly the actual pieces of chocolate are not large, maybe one or two bites. Still, you can eat four dark chocolate truffles for about 180 calories, and three pieces of assorted Belgian chocolates for 190 calories. A Lindt chocolate ball has 75 calories. To put this in perspective, a glass of champagne has 95 calories, an eight-ounce serving of fat-free yogurt around 80-90 calories, and 10 almonds, 70 calories. So certainly presenting your Valentine gift of chocolate to a dieter should not be a problem; one or two pieces of chocolate will not retard weight loss or cause the diet to fail.

But of course that is the problem. You can’t buy prepackaged chocolates wrapped in the colors of Valentine’s Day in amounts smaller than twenty or so pieces. Thus the recipient has to confront the problem of how to manage the consumption of the rest of the chocolate after February 14.  A highly disciplined dieter will be able to restrict consumption of a luscious piece of chocolate to one or possibly two a day. But this kind of restriction is not easy to accomplish, especially in the middle of the diet. And the romantic associations with the chocolate will be quickly dissipated when the dieter finds a “gift” of pounds after devouring the rest of the package.

One solution is to buy only one or two pieces of gourmet chocolate from the store; the chocolate can be boxed in the same fancy wrapping as would be used for a larger amount. But in this time of online rather than in person shopping, locating such shops and having the time to go to one seems much too inconvenient. Moreover, the dieter may misinterpret intentions behind the gift thinking that the giver:

1) Is cheap;

2) Thinks I am fat;

3) Thinks I will gobble everything in a bigger box; and therefore

4) Wants me to stay fat.

Maybe people should stick to flowers or diamonds.




Will the Bacteria in Sauerkraut Make You Thin?

Most of us pay less attention to the many colonies of bacteria living in our intestinal tract than we do to the possibility that there may be colonies living on Mars. Recent research suggests it is time to do so. Our gut contains densely packed colonies of bacteria that affect not only digestion and diseases of the intestinal tract, but also our immune system and, according to some research, perhaps hunger, weight, mood, and athletic performance as well.

According to an article by Drs. Zhang and Yang, our intestinal tract contains more than 1000 or more bacterial species. These varieties of bacteria, of which we are usually unaware unless we have “tummy troubles,” function to assist in digestion,  particularly of high fiber fruits and vegetables. They break down the chemical composition of fiber, thus transforming the indigestible carbohydrate to substances, as well as short chain fatty acids, which are used for energy. Our bacteria are also gatekeepers, helping the intestinal immune system deal with foreign antigens or proteins when they enter our body. Intestinal bacteria contain enzymes that make vitamin K, a critical component in the formation of blood clots. Intestinal bacteria also synthesize other vitamins: biotin, vitamin B12, folic acid, and thiamine.

That the bacterial flora can change is well known to anyone who has taken antibiotics for several days, and then confronted with less than optimal intestinal functioning. The antibiotic wipes out so-called healthy bacteria, and sometimes it takes several days or longer to restore normal functioning.

Zhang and Yang’s report asserts that diet also causes significant changes in gut bacteria. Consumption of a high-fat, high-sugar diet causes unhealthy bacteria to flourish. Conversely, diets low in those nutrients, but high in fiber, bring back a better class of bacteria. For somewhat obvious reasons, most of these studies are done on laboratory animals, since they require samples of intestinal bacteria found in the feces, and it is hard to find human volunteers for these studies.

Is it possible that our bacteria can affect our mood? Some scientists suggest that we can reduce anxiety and depression if we have the good kind of bacteria. This is based on evidence that intestinal bacteria make neurotransmitters, the chemicals that transmit messages in the brain. But it seems unlikely that our gut will control our mood since neurotransmitters made in the gut never get into the brain. (But interestingly, we do talk about our gut having feelings, i.e., our language is full of expressions that suggest our gut has moods: a feeling in my gut, gut response, gut reaction, etc…)

Intestinal microbes may affect the amount of ghrelin, a hormone that tells the brain whether we are hungry. But if so, no one has figured out what species of intestinal bacteria may do this—or whether they will make us feel so full we will eat less. Now athletes are allowing their intestinal bacteria to be analyzed to see if they differ from those of sedentary folk. According to an article in a recent issue of Outside magazine, some super-fit athletes do have varieties of bacteria not found in non-athletes. However, since they tend to follow extremely healthy, low-fat diets, is it their diets or their incredible athletic feats that change the bacteria? (Or, do the bacteria contribute to their athletic success?)

Much more research has to be carried out to show that intestinal bacteria are having a direct effect on hunger, athletic performance, or obesity before we can start manipulating our bacterial colonies to bring about certain desirable health effects.  To be sure, there are some studies now gaining interest, that have tested the effects of fecal transplants in which bacteria from healthy volunteers may be transplanted to the intestines of those suffering from an intestinal disease like irritable bowel syndrome. These studies are showing promise in helping people whose intestinal disorders do not respond to conventional therapies.

In the meantime, while we are waiting for more science to support some of the claims that our gut bacteria can alter our heath for better or for worse, we are told to load our intestinal tract with good bacteria. Supposedly, these good bacteria can be eaten if we consume fermented foods such as sauerkraut (fermented cabbage), miso and tempeh (fermented soybeans), kimchi (a Korean dish of fermented cabbage with hot spices), kombucha tea (a fermented drink made with tea, sugar, bacteria, and yeast). and kefir (a fermented yogurt drink). These foods contain probioticsor living bacteria, that when ingested populate our intestinal tract with good microbes. Pasteurization will kill the microbes, both good and bad, which is why many yogurts and canned sauerkraut are not on the list.

But there is a problem. Although scientists can identify many of the species of good intestinal bacteria, they are not listed on a package of tempeh or a bottle of kombucha. Moreover, how many bacteria are we actually eating? Probiotics may differ in their content of something called CFUs, or colony-forming units. CFUs describe the density of viable bacteria in a product. According to Dr. Shekhar K. Challa, a gastroenterologist who wrote Probiotics For Dummies, quantitating the CFUs of probiotics in most food products is almost impossible. CFUs are not listed under calories or any other place on the food label.

So will eating unpasteurized sauerkraut make enough good bacteria to make you thin (that is, if good bacteria will make you thin)? Probably not. But sauerkraut contains almost no calories, and chopping a cabbage, mixing it with salt and watching it turn into sauerkraut is something to do on a snowy afternoon. And after you eat it, its bacteria will have a happy home in you.


(“Effects of a high fat diet on intestinal microbiota and gastrointestinal diseases,” World Journal of Gastroenterology 2016, Oct 28; 22(40): 8905–8909)

Don’t Avoid Exercise Because It Makes You Hungry

Among the many kinds of advice given to those who are trying to lose weight, exercise usually ranks just below diet. But just as weight-loss advice can be contradictory and confusing, so too are the recommendations for exercise. No one disputes the benefits of physical activity on everything from improved digestion to better cognition. The adverse effects of ignoring the prescription to move ones body are just as compelling: no exercise equates to bad sleep, bad bones, and bad mood, among other unpleasant symptoms.

But many dieters and weight maintainers are reluctant to exercise because they fear the effect on their hunger. Exercise seems like an ineffective, and indeed unworkable, way of losing weight when post-exercise appetite may lead to eating many more calories than those worked off. Anecdotal reports by dieters of feeling ravenous after a stint on the treadmill or weekly Zumba class supports the erroneous belief that exercise while dieting should be avoided to prevent overeating.

Curiously, highly-trained athletes (who, of course, don’t have to worry about their weight) are the least likely to want to eat after their highly intense exercise routines are completed. In a study published a few years ago on appetite among female athletes, the scientists found that intense exercise actually decreased subjective hunger. Moreover, ghrelin, the hormone in the gut and blood that regulates hunger, was decreased and another hormone that shuts off appetite, increased. (“No Effect of Exercise Intensity on Appetite in Highly-Trained Endurance Women,” Howe, S., Hand, T., Larson-Meyer, D., Austin, K. et al Nutrients, 2016; 8 ) The same effect had been found earlier in studies carried out with male endurance athletes.

Since most of us are not likely to devote a good portion of our lives to training for competitive athletic events, we cannot rely on this for suppressing appetite after exercise. However, it seems that even unfit obese men may also experience a decrease in hunger after intense exercise, at least for 30 minutes after the exercise session completed. Whether they overate several hours later was not reported. (“The Effects of Concurrent Resistance and Endurance Exercise on Hunger Feelings and PYY in Obese Men,” Asrami, A., Faraji, H., Jalali, S., International Journal of Sport Studies, 2014 4; 729-)

But one may ask: what is wrong with being hungry after physical activity? Isn’t hunger a natural and inevitable response of the body after calories are used up? A Food Network show featuring life on a ranch in some unnamed cattle-raising part of the country often features recipes for the “hungry” family and ranch hands after a day of especially hard work. It would be absurd for the workers to avoid physical labor just because they are very hungry when they return home to eat a substantial meal.

But most of us have traveled far from the natural progression of physical activity to hunger to eating to a return of energy, and thus being able to work again. The “I am so hungry that I could eat a horse” (or whatever animal comes to mind) statement after hours of manual labor or recreational physical activity seems to many like a prescription for weight gain, rather than the way nature intended us to feel.

But it is not. Hunger is natural. The hormones causing us to want to eat are there to make sure we do so in order to live. If hunger disappears, as is the case for some with late stage Alzheimer’s disease, the individual will not survive unless others make sure to feed the patient.
In short, we should stop being afraid of being hungry. Hunger means our bodies need food the way being thirsty means our bodies need water. How we satisfy our hunger is what we have to improve if we want to stop gaining weight and begin to lose it. Just as we could, but should not, satisfy our thirst by drinking gallons of champagne or sugary sodas; we should satisfy our hunger not by consuming junk food, but by eating foods that not only supply calories (to replace those used up in exercise) but also needed nutrients into our bodies.

Dieters are told to try to eat fewer calories than needed so the calories in their stored fat will be mobilized to make up the difference. But unless the dieter goes on a drastically low-calorie diet, or a diet that eliminates certain categories of foods, it is possible to eat less, satisfy hunger, and still lose weight. We often eat beyond feeling full, that is, beyond the cessation of hunger; this is why we eat dessert. If eating stops when hunger disappears—even if all the food has not—weight can be lost.
Should you eat before or after exercise? It depends on your body. Some cannot exercise after eating and will eat breakfast after, rather than before, working out in the morning. Others find that they don’t have the energy to play tennis or go hiking unless they have eaten. Therefore, they will eat enough to give their muscles fuel for their workout, but not so much that they feel too stuffed to move.

Sometimes during long bouts of exercise, such as a long bike ride or hike, the first sign that the body needs food is not hunger but fatigue. I remember once when I was cross-country skiing all day, I become too exhausted to move my skis up a hill to get back to the lodge. As I stepped outside the track to let a woman behind me pass, she handed me an energy bar. “You need food,” she said. “Eat this.“ She was right. Within a few minutes I felt my fatigue lift, and I was able to continue moving.

We are told to be in touch with our bodies. Exercising, being hungry, and eating healthfully are excellent ways of communicating with ourselves.




Is the US Becoming More Obese Because of Medication?

Despite a blizzard of weight-loss programs, touting novel fat-reducing foods, and innovative exercise devices, the country is getting fatter and fatter. The Centers for Disease Control and Prevention reports that nearly 4 in 10 U.S adults, according to their body mass index, can be classified as obese. Obesity is not evenly distributed among the states. The losers; i.e. the thinnest states, are Colorado, Hawaii, Massachusetts, and D.C. The gainer is West Virginia where almost 40% of adults are obese.

We have been becoming heavier for so many decades that we forget how thin we were as a country 80 or more years ago. It is only when viewing newsreels of the first half of the 20th century in which most adults look extremely thin that you realize what we now consider thin was considered normal weight back then.

The same old reasons are brought out yearly to explain why we, and indeed the rest of the world, is getting fatter: junk food, sugary drinks, dependence on motorized transport rather than our two feet, humongous restaurant portions, intestinal flora that make our bodies store fat, too much time on electronic devices, and too little time in the gym.

Might our growing obesity be related to the weight gain after smoking withdrawal? Weight gain is common among ex-smokers, and studies as reported by the National Bureau of Economic Research (Sharon Begley, “Gut Check”) suggest that it may be 11-12 pounds on average. But a close examination of who gains the most weight indicates that smokers with the lowest BMI are most likely to gain the most, and 11 or 12 pounds is not enough weight gain to make them obese.

Could medications used to treat mental disorders be another, mostly overlooked cause of national weight gain? That psychotropic drugs—the medications used to treat depression, anxiety, bipolar disorderschizophrenia and other mental diseases—cause weight gain is established. Sometimes the weight gain is only a few pounds, stops after a month or two, and is lost as soon as the treatment ends. But many drugs cause substantial weight gain because the patient experiences a relentless urge to eat. Moreover, to the chagrin, indeed horror of some patients, stopping the medications does not always cause weight loss even with dieting and exercise.

Data on the use of psychotropic drugs comes from a 2013 Medical Expenditure Panel Survey discussed in a Scientific American article by Sara Miller.  One in six Americans is taking a psychotropic drug, although not all are being prescribed for mental illness. There have also been many studies showing that depression itself is linked to future obesity. A common depression, Seasonal Affective Disorder, is diagnosed in part by the overeating and weight gain of patients during the increased darkness of winter. Often the depression of PMS and pre-menopause is accompanied by overeating and weight gain as well.

Yet in the list of causes for our increasing girth, reasons such as genes, inflammation, bad gut bacteria and bread are more likely to be found than the weight-gaining potential of depression and the drugs that treat it.

Where are the weight-loss programs specifically designed to help those whose overeating is caused by lack of sunlight, or hormones affecting appetite control centers in the brain, or drugs that hijack control over satiety? Where are the support services for those who are embarrassed to go to the gym because their medications have turned their formerly fit and slim body into a much heavier one?  Recently someone who has been struggling to lose the weight gained on her medication for obsessive-compulsive disorder told me that her dietician put her on a low- carbohydrate diet. “I was craving carbohydrates all the time,” she told me, “so the dietician figured the easiest way to take care of that problem was to remove them from my diet. She did not realize that my medication had caused the cravings even though I told her. And since I couldn’t stop my drugs, I just craved bread and pasta so much on her diet that I began to binge.”


This story is typical in that this patient was not seen as needing specialized weight-loss help because her weight gain was the result of a drug, and not related to emotional issuesor an inability to make healthy food choices. Moreover, the dietician’s advice to remove carbohydrates showed lack of knowledge on the effect of eating carbohydrates on serotonin synthesis. Serotonin levels drop when carbohydrates are not consumed and often lead to a worsening of the obsessive-compulsive disorder, depression, or other mental disorders.

How long is it going to be before weight-loss professionals acknowledge that many of the obese in the United States are that way because of their medications? How long will it be before thought, labor, and money are put into programs to address their special needs?

Will 2018 bring about needed innovations in weight-loss therapy for these individuals, or will we just become fatter?

Will Reducing Your Dress Size Reduce Your Bone Size?

“She got so thin!” a friend whispered to me, pointing to a mutual friend we had not seen for several months. The thin friend came over, and when complimented on her size, she told us she had lost weight following a diet than eliminated most food groups. “It was easy to lose weight,” she said, “because all I could eat were lean proteins and vegetables. I think I will stay on this diet forever!”

“You might want to add some dairy products to your diet,” I murmured. “You know, osteoporosis and all that.”

“Oh, I get plenty of calcium from vegetables,” she answered, “and anyway, dairy is fattening.”

Feeling like the bad witch who predicts dire consequences, I restrained myself from pointing out that she was a perfect storm for losing bone mass and breaking bones. She was beyond her menopause, which meant that the protective effect of estrogen on bone density was no longer functioning. It was unlikely that she did weight-bearing exercise to increase muscle mass and subsequently bone mass. Her arms and legs showed no obvious muscular development; they were visually just skinny tubes. Vitamin D intake, the last piece of the triad of interventions that support bone density, was probably also lacking, as the foods she ate were not fortified with vitamin D.

At her age—she was almost seventy—she should have been consuming about 1200 mg of calcium a day and 600 IU (international units) of vitamin D to maintain her bone mass.  But because of her weight-loss diet, she wasn’t.

After a several month struggle to lose weight, it seems unfair that my now thinner friend is vulnerable to this debilitating disease. But she fits the profile of people likely to develop osteoporosis even without her weight loss. (Osteoporosis can occur in both men and women but women are more likely to have it. White and Asian women are most at risk that also increases with age.) If she had a family history of osteoporosis, smoked, consumed excessive amounts of alcohol, and had been severely underweight as an adolescent when bone mass is rapidly expanding, she would be facing an even greater chance of developing the disease.

It is not possible to diagnosis osteoporosis without a bone density scan. Despite her skinny appearance, her bones may have been fine. But the only way to tell is to have a type of x-ray called dual-energy x-ray absorptiometry (DXA or DEXA). Many women ten years or so beyond menopause will have the test so their physician can have a base line measurement of their bone strength. If the results indicate that osteoporosis may be developing, then the patient will be told to consume calcium-rich foods like milk, cottage cheese, yogurt or some vegetables such as kale…and also may be told to take a vitamin D supplement. Exercise is also important to promote bone density.

There are several drugs now available prescribed for osteoporosis but they have substantial side effects. The drugs are called bisphosphonates. Fosamax and Actonel are taken daily or weekly and another, Boniva, is taken monthly. One, Reclast, is given intravenously once a year; for those who have the early signs of the disease, once every two years. Most of the side effects, i.e., nausea, are tolerable, but a minority may developed osteonecrosis of the jaw or jawdeath. Fosamax and Boniva have been associated with this problem in which the bones in the jaw don’t heal after a minor injury like having a tooth pulled. Another equally rare side effect is a particular kind of fracture in the femur, the long bone of the leg.

Why drugs that promote bone growth and density should have the opposite effect on specific bony areas in the body is not yet known.The incidence is 1 in 1,000. It happened to an acquaintance of mine who had been taking one of the bisphosphonates.  She had a dental procedure, and a few weeks later experienced severe jaw pain that was finally diagnosed as osteonecrosis. Now she was faced not only with osteoporosis, but also the fact that she could no longer take the drug that was supposed to halt it.

Preventing, or at least decreasing, the possibility of developing osteoporosis has to begin in adolescence but it is hard, if not impossible, to convince an 18 year-old to drink more or any milk or eat more, or any, yogurt or cottage cheese or kale. The American Academy of Pediatrics has warned that children are not consuming enough calcium during puberty when most bone growth occurs. Young women who are anorectic, or because of excessive exercise and low body fat stop menstruating, are at risk for developing bone loss at a young age. Teens should be getting 1000 to 1200 mg of calcium daily. This amount of calcium is not difficult to obtain with fat-free or low-fat dairy products, or calcium-fortified milk substitutes like soy or almond milk, which are also fortified with vitamin D.  Unfortunately, a diet drink, instead of milk, is often the beverage of choice.

It seems as if the most compelling motivation to consume enough calcium and vitamin D in an effort to prevent osteoporosis is having a relative who fractured a hip or wrist because of this disease. There has to be a better way of promoting concern about this problem than the broken hip of an aunt. Bone density tests are expensive, time consuming and rarely offered to patients before menopause. What is needed is a simple, inexpensive test that detects the early stages of the disease, so nutritional intervention can start decades before the disorder develops—and perhaps an ad campaign showing that life can be “magical” after drinking milk.