Why Is It So Hard To Lose Weight After Antidepressants?

Side effects from medications are common, although usually not severe enough to halt treatment. Anyone who has listened, perhaps unwillingly, to a recital of side effects associated with a television advertisement for a medication is aware of the number of health problems that might arise while taking that particular drug.  But unless the side effect is death (the announcer always seems to mumble at this point), one assumes most of these adverse events go away when the medication is no longer taken.

Weight gain is a common side effect associated with most medications prescribed for depression, and/or anxiety, or the pain of fibromyalgia. We know that the weight is gained for the same reason weight is usually gained: more calories are consumed than needed by the body for energy. But even though most of the people gaining weight as a side effect of antidepressants and related medications may become overweight or even obese, they differ from the typical overweight or obese individual. The latter group struggle with their weight, often because of a lifestyle of eating too much, exercising too little, and in many cases using food to deflect emotional issues. But people whose obesity is a side effect of their medication never had a problem maintaining a normal weight and fit body prior to treatment.  To them gaining weight was as much of a shock and disruption to their body as losing hair is to a patient on chemotherapy.

They’d never dieted. Why would they? They never needed to.

Antidepressants, mood stabilizers, and atypical antipsychotic drugs seem to alter appetite by inhibiting serotonin-based regulation of the appetite function.  A persistent need to eat remains after the stomach is full of food, along with cravings for carbohydrate snacks. Sometimes the ravenous need to eat interferes with sleep, and leads to waking up in the middle of the night to eat.  Medication-associated fatigue frequently accompanies the overeating side effects, so the motivation, and indeed the ability, to exercise off the extra calories becomes difficult or impossible.

All this is well known, and even if a prescribing physician may not mention weight gain as a side effect, countless studies have confirmed it to be so.

So if weight gain is caused by the medication, then weight loss should follow its discontinuation.

And it does for most people. Once the medication is out of the body, normal appetite returns, fatigue diminishes, and the patient returns to eating and exercising normally. Increasing serotonin level and activity prior to meals diminishes any lingering inability to feel full after eating or an inability to control snacking.  Consuming small amounts of fat-free, low-protein carbohydrate foods such as oatmeal an hour before mealtime or as an afternoon snack increases serotonin sufficiently to resume normal appetite control. Returning to a vigorous workout schedule once the side effect of fatigue disappears accelerates weight loss.

But not everyone is able to lose the weight even months after the medication is stopped.

And no one knows why.

Formerly pre-treatment, thin/fit individuals are horrified to find that the 15 or 25 or 50 pounds they gained on their medication is hanging around like a relative who won’t leave the guest room.  Diets are tried and discarded for lack of success. Aerobic and strength-training workouts are increased in frequency and duration.  Yet the pounds stay on.

The result is a feeling of despair and desperation: “No matter what I do I cannot lose weight.” It is as if someone who loses her hair while undergoing chemotherapy learns that she will be bald the rest of her life. Patients who have become obese due to their medication believe their bodies will be permanently changed. They believe they will never return to the slim bodies they had before their medications, and grudgingly and often angrily resign themselves to accept being overweight or obese.

Some suggest that water retention may be responsible for the increased weight, but once the medication is out of the body, the excess water should be lost. Others point to some muscle loss before and during the early stages of treatment when depression has led to weeks of inactivity. However, rebuilding muscle mass doesn’t seem to produce any significant weight loss. It is possible that metabolic rate decreased as a result of treatment, and therefore is slowing weight loss. But studies on thyroid function with patients who were treated with Zoloft or Prozac did not show any functional change in thyroid hormones. So at this point, there is little to offer someone who has tried to lose the medication-associated weight by dieting and exercising, and is failing.

Is the weight finally lost, many months or even years after the antidepressants or related drugs are out of the body?  Are the extra pounds still attached to the body five or ten years later?

No one knows. There are no long-term studies following patients after they discontinue treatment to see if weight is lost and, if so, what produced the weight loss. Interestingly, there are many studies showing that after a weight-loss diet is over, people’s weight eventually returns to the heavier pre-diet weight or ‘set-point’.  Perhaps it is time to see whether people whose weight is a consequence of antidepressant treatment will also return to their weight ‘set-point’. If this turns out to be the case, it will certainly lessen the depressed feeling so many patients experience when they don’t believe their weight will ever come off.

Too Little Potassium May Lead To Big Problems

My friend, who is undergoing chemotherapy, was admitted to the hospital because of an infection but blood tests revealed another very serious problem. Her potassium levels were extremely low and, despite getting potassium intravenously, the unfortunate effects became apparent very quickly. Her heart began beating abnormally, her blood pressure shot up, and even though she was given a drug to prevent blood clots, one found its way to her brain. Consequently, she suffered a stroke. The infection was soon gone, but the effects of her low potassium remained many days later.

Potassium is one of those minerals that we usually don’t think about. If one eats a healthy diet with lots of vegetables and fruit, then potassium levels are usually within the range of what the body needs, about 4700 mg a day. But surveys of potassium intake in the U.S. population indicate that as whole, we don’t get enough of this mineral. Indeed, the average intake is 2640 mg a day, and that level has remained unchanged for decades.

“So what?” might be one’s response to this data. “I feel fine!”

Perhaps we should not be so complacent about whether we are getting enough of this mineral. Most of us, I hope, will not have to endure the toll of chemotherapy on the body and experience the side effects that can reduce potassium levels. My friend had mouth sores that prevented her from eating for days, along with gastrointestinal side effects, thus causing a significant loss of potassium from her body.

But also consider these other factors:

• A gastro-intestinal infection that causes prolonged dehydration may reduce potassium levels so much that it is necessary to get medical attention and potassium supplementation;

• Going on a high protein, low or carbohydrate-free diet can also drastically lower potassium levels because, as the body loses water due to diminished stores of carbohydrate, the body is also losing potassium. And it is almost impossible for such a diet to restore potassium because foods rich in this mineral — i.e. potatoes and bananas — contain carbohydrate and cannot be eaten. The effects of potassium loss on these so-called ketogenic diets is known as keto-flu. Followers of such diets feel ‘wasted’ and totally exhausted with flu-like symptoms. Since potassium is needed for normal muscle function including the heart (a muscle) experiencing such fatigue should be a sign to balance eating critically important nutrients with weight loss on an extreme diet;

• Prolonged fasting or cleanses and extremely limited food intake after bariatric surgery may also lead to low potassium. Post-surgery, bariatric patients are usually given potassium supplements;

• Alcoholics may have dangerously low potassium levels;

• Athletes engaging in prolonged strenuous exercise associated with excessive sweating also lose significant amounts of potassium;

• Medicines such as diuretics cause potassium loss (as does laxative abuse);

If potassium levels are marginally low to begin with, a further decrease may, as with my friend, generate potentially dangerous side effects. (Hypokalaemia, the term for low potassium, is defined as potassium blood levels below 3.5 mmol/L. If potassium is among the items measured when you have a blood test, the computer will list the potassium level as mmol/L and note if your level is below normal. ) However, an adequate potassium intake and blood levels are important for all of us, even if we are not strenuous athletes, recovering from bariatric surgery, following a carbohydrate-free diet or receiving chemotherapy. Too little potassium may lead to elevated blood pressure, kidney stones, and/or bone loss. Conversely, obtaining enough potassium in the diet may reduce the risk and severity of these conditions.

Consuming enough potassium is not hard, or at least should not be hard, if one is willing to eat vegetables and fruit every day. Bananas are high in potassium (everyone seems to know this). But for banana haters, there are many more options, some with considerably more potassium than bananas.

Here are a few high potassium foods: sweet and white potatoes, white beans, plain yogurt, milk, halibut, cod and tuna, winter squash, spinach, peaches, papaya, raisins, prunes, oranges, soybeans, tomatoes, melon, beef, peanut butter, and turkey (dark meat). There are many more foods with moderate potassium contents, mostly vegetables like mushrooms, Brussels sprouts, cooked zucchini, avocado, carrots, asparagus, and broccoli.

Let’s face it. Conversations about potassium are boring. People might boast about their good and bad cholesterol levels but I, for one, have never heard anyone boast about his or her potassium levels. In fact, potassium is usually only mentioned when someone needs to take a supplement and complains about the size of the pill, which is enormous. But, as the saga of my friend’s many medical problems indicate, we cannot be blasé and disinterested in our potassium levels. The potential health risks are too high. Eating enough of the foods on the list (and the list was not at all comprehensive) to meet the daily requirement should be given a high priority when planning meals or choosing what to eat at a restaurant.

When your mother told you to eat your vegetables, she was right.

Dividing a Daschund: Cementing a Friendship

This blog is for all caretakers and friends who look out for one another.

Simon, our long-haired dachshund, runs to Mary Lou’s apartment and makes low, moaning sounds of anticipation as we wait for her to come to the door. Once in her arms, he licks every inch of her face and then runs to her kitchen.

 “Simon, you know there won’t be any treats!” I call after him. Mary Lou, slender herself, is strict about getting Simon’s weight under control, but it’s a hopeless goal.

 Mary Lou and I hug. We have not seen each other since she left for Palm Beach and we, South Beach last fall. Now it is May, and Mary Lou’s turn to have the dog.  I hand her Simon’s heartworm and tick prevention pills, his leash and harness, and take the elevator to our apartment. I miss the dog already. He won’t return to our bed (literally) until next fall. 

 It is right and fitting that Mary Lou and her husband have Simon for six months. They own half of him, although which half it is, after almost 14 years, is still contested.  We bought Simon together, not long after Frieda, my wire-haired dachshund, died.

 Mary Lou and I became friends almost 30 years ago when we moved the same month into a new condominium building in Boston.  My husband and I were traveling frequently for work, and she offered to care for Frieda. Their condo became the dog’s second home, and Frieda spent so time at their medical supply company that her picture appeared on the cover of the company catalogue.

Frieda died at 16, and after we stopped grieving, Mary Lou and I agreed that it hurt too much to get another dog. Six weeks later we bought Simon. The breeder, named Jenn, was so fussy that she interviewed me on the phone before allowing us to visit. So we decided not to tell her that we were going to buy and share the dog. Our story was that I wanted a dog and Mary Lou was helping me find one.  It was a wise decision. I doubt that Jenn would have tolerated the dog being shared like a lawn mower. The puppy, whom we named Simon, seemed unconcerned. 

Sharing the puppy was the only way we managed to live through the two years it took to housebreak him. Like many of his breed, it mattered little to him that our carpets were not grass. “You take him; I am out of pee cleaner!” became a common refrain during the frequent hand-overs.  

Our somewhat erratic sharing of Simon eventually became fixed by season.  Mary Lou and her husband became snowbirds, and as their Florida apartment did not allow dogs, Simon lived with us from November to early May. We followed the snowbird migration a few years later living in a building littered with dogs.  

Dividing two dogs has cemented our friendship. Like an old married couple, we kvetch over the same things, share private details about our lives, comfort  each other, gossip ( too much),  and occasionally go hiking.  

We also get lost. Often.

There was the time we hiked with Simon on Blue Hill, a nearby 630 foot nano-mountain, and could not find our way back to our car.  Using an out of date map, (we didn’t know) and following a trail marked with barely visible dots (the trail had been abandoned) we were certain that the three of us would become a newspaper headline when our bodies were discovered. We were rescued by a hiker who pointed out our stupidity as she pointed us in the right direction.  

That was our last hike. But the reason was not our phobia about getting lost again. Simon is almost blind. He has a genetic disease similar to macronnuclear disintegration.  He walks slowly, his nose acting as a built in white cane, scanning the space around him for obstacles. He manages well enough in familiarly scented areas but rock strewn hiking paths, typical of those on Blue Hill, are no longer possible.

And the other reason is that Mary Lou has cancer. The double whammy of her treatment protocol, radiation and chemotherapy, is stilling her normally active life.  So the three of sit together in the library of our building, which is a social space for residents. Our armchairs are close enough so that Simon’s head is on one lap and his tail on the other. (He is a very long dog). We each rub him and talk and laugh and gossip and sometimes cry because that is what friends do. And our love for Simon and our love for each other passes through his furry body to each of our hands and our hearts and our memories. 

Will Sugar Take Away the New Baby Blues?

Eleanor, the daughter of a close friend, apologized for still wearing her maternity clothes when her mother and I went to her home to ooh and ahh over her adorable newborn.

“It’s crazy!” she said, pointing to her baggy pants and shirt. “In the two weeks since giving birth, I think I have gained 12 pounds. I can’t stop eating and I know it is not just because I am breast feeding. I don’t want any good stuff to eat, just doughnuts, cookies, ice cream and waffles drenched in syrup.”

When she left the room, her mother confided that her daughter had been very moody and complained of exhaustion, feeling overwhelmed, and worried that she would not be a good mother. “She is also so irritable…When I offered to take care of the baby so she could get out of the house, she told me to stop giving her advice!”

The mother then whispered, since she heard the daughter returning, “She must have the Baby Blues.”

Postpartum blues, or baby blues, are not the same as postpartum depression, although some of the symptoms are identical. The ‘blues’ affect about 80% of mothers during the first week after giving birth, and the symptoms peak between days three to five. The mood swings, food cravings, fatigue, and depression are blamed on a decrease in serotonin activity due to the new mother’s estrogen and progesterone levels readjusting. In some ways, the symptoms are similar to PMS, which occurs at the end of the menstrual cycle when hormone levels are shifting. The postpartum blues disappear about two weeks after childbirth, but the exhaustion and fogginess may continue much longer until the mom and baby sleep through the night.

Postpartum depression, in contrast to these postpartum blues, can last for months; the symptoms are much more severe and require medical/ psychiatric interventions. Women with postpartum depression are usually treated with SSRIs, the antidepressants that increase serotonin activity, along with talk therapy and assistance in taking care of the baby and the household.

Postpartum blues are not treated with antidepressants because of their temporary nature. But this doesn’t mean that the new mother has to suffer the unwelcome feelings of sadness, fatigue, lack of focus, not feeling like herself, anxiety, or irritability even for a few days. Sleep helps with all of these symptoms.  One does not have to be a nursing mom to feel the effects of too little sleep and when it goes on for days? The confusion and mood swings that follow can be very distressing.  Waking every two hours to nurse during the night, and then getting up in the morning to carry on the tasks of taking care of the rest of the family is sufficient reason to exacerbate these ‘ blues’.

Women in our culture are given little or no time off to rest from childbirth and the demands of a family and even work. Other cultures, such as the Chinese, insist that a woman be secluded for 30 days with little to do except keep warm, eating high fat, nourishing soups and stews to sustain nursing, and sleep when not feeding the baby. In our culture, the postpartum blues can be minimized by helping the new mom with her family and household tasks so she has time to sleep, making opportunities for her to leave the house, and participate in a healthy, non-baby-centric world… and when she feels physically able, to exercise.

Eleanor’s appetite for sweet carbohydrates led her to yet another quick and effective way of improving her postpartum blues.  The foods she consumed were acting like edible tranquilizers, because their consumption increased the level of the good mood chemical, serotonin.  She was eating sugary carbohydrates to increase serotonin activity, but starchy carbohydrates such as  instant oatmeal, a bag of popcorn, or baked potato are just as effective.  The path from eating carbohydrates (except fruit sugar) to more serotonin is a little complex, but the end result is that after the food is digested, more serotonin is made and the edge is taken off all those distressing symptoms.  Eleanor was probably eating larger quantities of carbohydrate than she needed to; about 30 grams (120 calories in a fat free food) would have been enough to raise serotonin levels for about three hours. Two or three small carbohydrate snacks during the day and evening would have made her feel less edgy and depressed.

One caveat: the carbohydrates must be eaten on an empty stomach or at least two hours after eating protein.  When protein foods are digested, their amino acid contents prevent serotonin from being made by preventing one amino acid, tryptophan, from getting into the brain.

Eleanor must of course make an effort to eat the nutrient packed foods her body needs to recover from giving birth and to nurse. A diet of cookies and brownies is incompatible with the nutritional demands of her body. But eating carbohydrates should, by increasing serotonin, decrease stress and induce calmness and tranquility. Which is exactly what the mother and infant need.

Are Baby Boomers Becoming the Walking Disabled?

We were at a museum in the Berkshires whose overflow parking lot was about a 12- minute walk to the entrance. The couple we were with were somewhat dubious about whether they could walk that far. They did, but, after a couple of hours strolling very slowly throughout the museum, asked if they could ride back to the parking lot on the museum’s golf cart.  They were not sick, and neither have any disabilities that would have prevented them from walking further….the weather not too hot to make being outside for long unpleasant. But they were not young and gradually, almost imperceptively, over the years they had decreased the amount of time and distance they could walk. So to them? The additional 8th of a mile to the car was more than their stamina and legs could handle.

Mary (not her real name) mentioned that she had started to record her daily steps and some days was managing to approach 5,000. Her goal was to double that amount, but she admitted that she was so unaccustomed to walking that she tired easily.

Unfortunately, our friends are not unique. As people age beyond their sixties, many are losing the ability to walk for more than a couple of blocks. If they cannot walk a quarter of a mile, seven blocks, without assistance, their lack of mobility is termed walking disabled.

The consequences of being walking disabled have been studied by Dr. Thomas Gill, professor of medicine at Yale School of Medicine. He and his associates followed about 640 people age 70 and older for 12 years and assessed their ability to carry out what is called activities of daily life. Their results, published in the January 2012 Annals of Internal Medicine, found that as people lost the ability to walk, they lost their independence, too. If the inability to walk follows an inability to drive, the effects on quality of life are obvious.

How does someone who can no longer drive and no longer walk more than a block or two manage to go anywhere? The supermarket, library, pharmacy, movies, restaurants, shops,  a local park, museums, and concerts are all out of reach. Even public transportation such as buses that can be boarded by someone with a walker are inaccessible if an individual can’t walk to the bus stop or do errands when reaching a destination. As Dr. Gill points out, the effect is social isolation, dependence on family and friends, and often depression and possibly cognitive decline due to lack of conversation and contact with others.  The walking disabled become shut-ins and, in a sense, shut away from the kinds of casual contact that those of us who are able to walk take for granted.

But physical immobility need not be an inevitable aspect of aging.

The proliferation of devices and apps that measure walking distance or steps should allow everyone to learn just how active or sedentary they are. Day-to-day variations are averaged into weekly totals, and these data are stored so the wannabe walker has a record of steps or miles walked over a long period of time. Variations can occur, of course, because of weather (too hot or cold, rain, ice, or snow) or other factors  such as lack of time.  But daily variations eventually smooth out and offer a good record for the individual, as well as a medical care provider, of average daily activity and how much it changes over time. For example, if Mary continues her walking regimen, she should find herself walking further simply because her increased muscle strength and stamina will allow her to go longer distances without getting tired.

But what caused Mary, an otherwise healthy individual, to be unable to walk to the parking lot from the museum, a distance that presumably was considered close enough for most visitors to cover without needing transportation?

One answer is the national attitude toward walking: why walk if you can drive? Why have sidewalks in suburban communities if everyone drives or is driven? Why enable anyone to walk across a highway to get to a shopping mall if everyone drives to it? Why have children walk to school when they can be bused or driven or eventually drive themselves? Why get out of the car to go to the bank when you can go to a drive-through teller?

A few days ago in the gym I watched a television program featuring prospective house buyers.  A woman, in her early forties, was shown what seemed to be a lovely property and told that a beach was a mile away. She said, “I am not going to walk a mile to the beach. It is much too far.”

“Really, lady…” I wanted to say, “If you can’t walk a mile when you are in your forties, you may not be able to walk around the block 30 years later.”

Fortunately, attitudes are changing.

Urban planners are developing walkable cities and towns. Properties located in walkable areas are considered desirable, not just because the sidewalks and parks provide opportunities for exercise but, just as important, they provide the opportunity to connect with neighbors and with the community. Walking groups are becoming popular now, so someone for whom walking is a boring solitary activity can interact with others in a moving vertical social group. For people like Mary, it is possible to regain the ability to walk long distances by walking in a pool or on a treadmill. Treadmills allow the emerging walker adjust the time and speed and obtain an accurate display of distance. Walking in a park or on sidewalks with available benches upon which to rest, in case of fatigue, removes the fear of not having the energy to get back home.

Changing the walking disabled into the walking enabled may take time, but doing so has benefits far beyond walking to a parking lot.

Might Covering the Skin Cause Vitamin D Deficiency?

It was a beautiful summer day, and the Boston Public Garden was filled with walkers, people feeding the ducks and squirrels and/or listening to the weekend saxophone player near the Swan Boats. But mostly? People were soaking up the sun to remove some of the pallor from six months of relatively sunless days. Most women were wearing typical summer outfits: sleeveless or short sleeve shirts, shorts, or short skirts. These outfits exposed enough skin to allow the ultraviolet rays to catalyze the process of making vitamin D.  Vitamin D is essential because it supports calcium absorption from the intestinal tract into the body. Without calcium, bone tissue cannot be made. In fact, insufficient vitamin D is responsible for rickets, a childhood disease first described in the 17th century. Bones fail to grow and mineralize sufficiently and as a result, they are soft and deformed. Adults need vitamin D as well to prevent osteomalacia, a weakening of the bones and the muscles to which they are attached. Osteoporosis, a disease in which fragile bones break extremely easily, is also linked to insufficient amounts of this vitamin.

But why should vitamin D levels ever be insufficient? It is provided, at no cost, from the effect of sunshine on the skin.

But some, indeed many, cannot rely on the sun to make this important nutrient.

Consider again the scene in the Boston Public Garden. To be sure most of the people have their arms, legs, and faces (and a few torsos) exposed to the sun. But here and there women are walking about or sitting on park benches with only the area between the bridge of their nose and the top of their eyes exposed to the sun. They are wearing a niqab, a small cloth, that covers all of the face except the eyes,  in addition to a scarf that covers their hair and neck. A heavy robe (it cannot be see-through), or long sleeves and pants cover other parts of the body that otherwise might be exposed to the sun.  And it is not only the Moslem women who are so covered up. So are ultra-Orthodox Jewish women and their daughters enjoying an afternoon stroll. Thick tights or stockings, long sleeved, high-necked blouses, long skirts and wigs or scarves cover their hair and limit the amount of skin exposed to the sun only to the hands, small neck area and the face.

Such concealing clothing has a negative impact on vitamin D levels.  Several studies among Moslem communities whose women wear the most extreme style of Islamic dress have found them to be chronically deficient in vitamin D. (Mishal, A.A., Effects of Different Dress Styles on Vitamin D Levels in Healthy Young Jordanian Women. Osteoporosis International, 2001. 12(11): p. 931-935.)

The same deficiency has been observed in Dearborn, Michigan among the Arab-American female population. Veiled women had levels of vitamin D well below the minimum necessary to prevent rickets in their children (their breast milk would have insufficient vitamin D) and osteomalacia.  (Hobbs, R., et al., Severe Vitamin D Deficiency in Arab-American Women Living in Dearborn, Michigan. Endocrine Practice, 2009. 15(1): p. 35-40.)

In one study, 40% of ultra-Orthodox women whose vitamin D levels were tested in a Tel Aviv hospital were found to be deficient in the nutrient. (Siegel-Itzkovich, J, Ultra-Orthodox Jewish women at risk of vitamin D deficiency British Medical Journal 2001 ;323, 10). The effect of skin concealment on vitamin D levels was also found among adolescents in an ultra-Orthodox community in Brooklyn, due to a combination of their clothing, and that boys are indoors studying from early morning to evening.

Vitamin D deficiency can be found among many other groups as well, due to inadequate sun exposure in general. The elderly and others unable to go outside because of sickness or lack of mobility, workers with schedules restricting outside access during the work week, people with skin conditions necessitating avoidance of sunlight, and those who live in geographical areas with weather inhospitable to outdoor exposure…they also suffer. And of course, using sun block is going to prevent most ultraviolet rays from reaching our skin.  Interestingly however, most people (according to dermatologists) do not use enough sunblock, or do not put it so thoroughly over themselves so as to block out some sun exposure. Air pollution also reduces significantly the amount of ultraviolet radiation that reaches the skin.

How long one has to be exposed to the sun varies depending on who gives advice. Dermatologists will probably say avoid sun completely, but other medical folk more concerned with bone breakage and the effect vitamin D deficiency may have on immune function will suggest a spectrum of 5-10 minutes to half an hour daily. Time spent outside walking to the mailbox or walking your child to school does not fit into these calculations. And of course skin exposure to the sun is seasonal and weather dependent. The good news is that Vitamin D is stored in our liver, so try to think about it like banking money in July for Christmas shopping in November in that vitamin D made in the summer should be around in the winter.

Since it is unlikely that people with limited or even non-existent exposure to sunlight are going to be able to alter their situation, or that most of us will risk skin cancer by avoiding sunblock and frying ourselves on the beach? The alternative is to obtain vitamin D from food sources or as a supplement. Having your vitamin D levels measured might be worthwhile if you suspect that you are deficient.

The daily requirement is 600 IU until age 70 when the requirement increases to 800 IU. The best source is the worst tasting and smelling: cod liver oil.  Salmon and swordfish are pretty good sources, while canned tuna in water is marginally good. Vitamin D fortified orange juice, milk, yogurt and even ready-to-eat cereal are reliable sources, but may not be eaten in large enough amounts to meet daily needs. It is important to check labels to see how many servings are needed to get l00% of the daily quota. Supplements that provide the recommended daily allowance should be taken if neither sunlight nor food are going to give the body the vitamin D it requires.

Weakening bones are silent—until they break. Don’t let covering up the skin cover up vitamin D deficiency.

Bringing Home Pounds as Well as Souvenirs from Your Vacation

Vacations should make it easy to keep from gaining weight, and indeed to even losing some. Designed to remove daily stresses, give time for adequate sleep, eliminate the endless chores, escape preparing meals, and all the other responsibilities that erode whatever free time we have; vacations provide a respite from the triggers that cause us to eat too much. Vacations also are opportunities for the kinds of physical activity unavailable (for most people) at home: hiking, long bike rides, scuba diving, water skiing, and more.

But then again vacations are times to indulge in alcoholic drinks with umbrellas, and seasonal treats like fried clams, lobster dipped in melted butter, and homemade ice cream bursting with butterfat. Vacations are times to lounge on a beach with a cooler filled with beer and bags of chips… or relax on a terrace in the moonlight enjoying a five-course dinner.  Vacations are also times to park yourself on a tour bus, car, or plane for hours, restrict walking because it is too hot to be outside, and sit even more at sporting events, outdoor concerts, and movies.

Unless the vacation is spent in a spa known for its 6 am hikes up nearby mountains and semi-starvation meal regimen, few people expect to lose weight while they are away from home. After all, why try to diet when the point of a vacation is to enjoy one’s self and not obsess over the calories in the hot buttery croissant served at breakfast or whether the crab salad has too much mayonnaise? But (and there is always a but) should the vacationer who may be somewhat or even more than a little overweight at the start of a much-needed break be oblivious to the possibility of gaining weight? Should the combination of a relaxing, sedentary week or two and deliciously fattening foods be noticed for its weight gain potential?  Should vacationers bury their heads in the proverbial sand about their weight?

I suspect the answer is, ‘Who cares?!?’

And one reason for this answer is that obesity is so common, it seems normal to be many pounds overweight. Recently I had to travel to Miami Beach for some work, and as the weather was very hot people were not wearing much. It was not unusual to see tourists on the streets in bikinis or shorts and skimpy T-shirts. Many were obese, perhaps not more than on the streets of any other American city, but more obviously so because of the lack of clothing. It was too hot to go for long walks or bike rides, and beach walks usually crowded in the winter months were almost empty by late morning because of the heat. Poolsides were packed, but the pools were empty, except for the kids. And crowds were heading toward the beach, pulling carts and coolers that were probably NOT filled with carrot sticks.

And so on the one hand, the answer, ‘Who cares?!?’ is appropriate. It is your vacation and time to be self-indulgent. You are already in a bathing suit so obviously it is too late to lose weight before you put it on, and hey, life is short so why not enjoy yourself!

On the other hand, when the vacation is over, and extra pounds are brought home along with your carved coconuts or mermaids in a snow globe, they may stick around longer than the souvenirs. You resume the life that caused you to gain weight, and now there are more pounds to get rid of. The weather will become cooler and the skirts or pants somewhat tight in early June may not fit over a stomach or hips enlarged by many Mojitos, taco chips with guacamole and chocolate lava cakes. And in not too many turns of the pages of the calendar, the days become noticeably shorter, windier, rainier, cloudier and eventually cold. Inevitably, a weight- gaining lethargy settles in.

So why not take a vacation from weight gain? If buffet breakfasts and multi-course dinners are part of the eating plan, then skip lunch or restrict it to a salad or fruit. Early mornings and evenings are usually cool enough for walks or bike rides (many cities provide bikes to rent at minimum cost) and air-conditioned museums and visitor centers allow for more walking during the day. Pack the cooler with containers of blueberries, raw vegetables, water, and low- calorie munchies like rice crackers, rather than fat-laden chips and sugar-filled sodas.

Yes, it is hard to resist impulsive purchases of ‘tourist’ food like fudge, fried dough and arepas (corn patties filled with melted mozzarella) while sightseeing. These small food items pack impressive caloric content, and their consumption is often overlooked when thinking about what may have been eaten during the day. Carrying your own snacks may prevent you from succumbing to the allure of these streets goodies. Sometimes thinking of possible food poisoning from snack foods baking in a warm sun and soaking up air pollutants is sufficient to make them unappealing. (Of course, food poisoning is one way of preventing weight gain… however, it is not recommended).

Coming back from a vacation weighing less than you were when you began it may not be possible. But if your luggage is the only thing that weighs more at the end, consider the holiday a success.

The Loneliness of the Solitary Dieter

Our table in the hotel dining room gave me the view of a quite large woman sitting quietly, watching her female friend eat through several servings from the breakfast buffet.  What made this woman’s behavior somewhat strange was that the seemingly endless offerings of the breakfast buffet caused most people to eat several courses, ranging from mundane cereal, fruit or yogurt to elaborate quiches, salads, smoked fishes, custom-made omelets and pastries. The gorging companion was demolishing several plates of food (she was not exactly thin) while the non-eater nodded, but remained with her mouth forcefully closed as though if once she opened it, maybe she would start eating.

I wondered, “Had she just had bariatric surgery so she could eat only tiny portions?”  My reason for thinking this resulted from a conversation with my nephew, who had bariatric surgery a year-and-a-half earlier. He told me how difficult it was to dine with others because his marshmallow-size stomach severely limited the amount of food he could eat.  He had to pretend to eat and drink normally when he took clients to dinner, but sometimes he felt socially isolated because of the restriction on his food intake.

Losing weight is an obstacle course with the dieter confronting endless situations that may cause the more healthful eating plan to be discarded, or only partially followed. Dieters need willpower, mindfulness, willingness to take on new and almost ritualistic behaviors. Now eating small portions, exercising daily, and not eating when they are not hungry? It’s a new adjustment which can be very hard when dining with others who pay little attention to how much they eat, or whether they are eating out of hunger or simply because food is presented to them…the way the post-op bariatric patient must function.

Recently I was on a daylong tour that included a visit to a multi-cultural community center. As our group entered the building after a long bus ride, we were offered a variety of ethnic foods along with coffee, pastries and fruit.  “Don’t worry about the small amount of food,” our guide told us, “this is only a snack. Lunch will be served later.” The group lined up to sample the foods. “Is anyone hungry?” he asked. I doubted it, but the group ate eagerly (well almost everyone ate while I took pictures because I wasn’t hungry…).  As the day progressed, an enormous buffet lunch was served and gorged upon, and late in the afternoon different ethnic pastries and cold juices were served.

If someone in our group were dieting, or simply refraining from gaining weight, it would have been hard to resist the many opportunities to eat. And not eating when everyone else did may have been a lonely, alienating experience.

Residential weight-loss programs such as Canyon Ranch work in part because the dieters are part of a community.  A participant eats the same low-calorie food, often at a communal table, participates in group exercise, and hears lectures about mindful eating, relaxation, and avoiding food based ‘temptations.’ But when the residential stay ends, the idyllic bubble of group weight loss is broken. Suddenly dieters no longer have the companionship of others who share in their caloric restriction, but must attempt to hold onto these constrained behaviors in the midst of others eating whatever they wish.

The difficulty of doing this may be under-appreciated, except by the dieters themselves. Not only must they be continually sensitive to their food intake as well as the need to exercise frequently; they are often assaulted by the urging of others to ‘break their diet, just this once, because, “It’s a special occasion!”’ Sometimes, perhaps too often, they are berated for making others look bad because their self-discipline contrasts strongly with the heedless eating of those around them. This is perhaps why I noticed the solitary non-eater in the dining room. Her lack of eating contrasted dramatically with the seemingly endless food intake of her companion.

Obesity experts talk about accepting and following a new, healthy life style if the dieter wants to lose weight and maintain that loss. Another way of putting it is that the dieter must ‘convert’ to a new way of eating. Changing drastically one’s eating behavior, i.e. converting to a different eating ideology, is something quite common these days. People become vegetarian, or vegan, gluten-free, Paleolithic, raw food enthusiasts, juicers, or members of a religious group with stringent eating rules.  Once committed (or converted) to the new eating ideology, the convert follows the rules: vegetarians do not go to steak restaurants, and Muslims do not eat during daylight hours for the month of Ramadan. In fact, surveys now show that dating relationships flourish or flounder in regard to a potential partner’s eating ideology, because a vegan and meat eater may be incompatible for long-term relationships.

Conversion to a healthy, weight-maintaining or weight-losing lifestyle should ideally give the dieter access to a community that follows a similar lifestyle. If dieters can find others who understand and support them in adhering to an eating and exercise lifestyle that will maintain a healthy weight, they may succeed in doing so themselves. The problem is that unlike vegans, raw food adherents or gluten-free eaters, individuals who follow a healthy eating and exercise pattern are effectively anonymous excepting people who write blogs on the subject or offer professional help. And even though a vegan or someone who keeps kosher will reject offered foods by invoking an eating belief system, I have never heard a ‘healthy eater’ invoke a healthy eating belief system and say, “Sorry, but this food has too much sugar/fat/calories, and so I cannot eat it.”

A Perfect Storm for Obesity: Depression, Drugs and a Bad Back

“Let’s go for a walk and catch up,” I replied to an email from a former weight-loss client whom I had not seen since she moved several years earlier. She was back in town and wanted to talk.  But the walk was not to be. “I can’t move very well,” she told me. “My back and leg hurt so much I can barely stand. If I want to go anywhere, I use the van for the handicapped. “

When we did meet, sitting down, I understood why walking was daunting. A cocktail of mood stabilizers and antidepressants had so intensified her overeating that she had gained over 200 pounds. The depression diminished her opportunities to find work, so she spent much of her time at home, alone and, as she admitted to me, eating. Earlier in the year she was still able to walk to do errands and see friends, but eventually her weight exacerbated a chronic back problem. Her pain became so intense she had trouble sleeping, and this further increased her depression.

I figuratively wrung my hands when I saw her. She needed to lose weight to relieve her back pain. But how? She was taking a mood stabilizer known to cause weight gain, and no physician would consider any type of surgical intervention to help her back pain until she lost weight. Substantial weight loss combined with physical therapy might be sufficient to allow her full mobility. But if she didn’t lose weight, or lose it sufficiently fast enough to prevent further stress on her back, she might need a wheelchair.

The good news and the bad news is that she now had to have her groceries delivered because it was too hard to go food shopping. Theoretically her food order could be limited to the healthy nutrient-dense, low-calorie fruits, vegetables, grains, lean protein and dairy products that will support weight loss. If she doesn’t keep junk food in the house, she can’t eat it. But of course she could order junk foods from the supermarket and supplement that with high-calorie take-out. Some hints about what she has been eating confirmed that she was doing the latter.

I had to keep reminding myself (and her) that she was not paralyzed. She had not suffered a stroke, progressive neurological and muscular damage, or spinal injury from an accident. Exercise was still possible, albeit limited to movements she could make sitting or lying down along with whatever walking she could manage. If she remained inert because of her back pain, and to some extent because she was depressed, then weight loss would be frustratingly slow—and maybe too slow to prevent further damage to her back.

She had been thin once, many years earlier, before her mood disorders and treatments to ameliorate them led to her massive weight gain. The problem now is that adding or subtracting medications cannot remove her unemployment, medical issues, social isolation and pain. And there is no support network to help her or indeed countless others like her who are isolated and unable to stop eating.

Where to begin to reverse and improve her situation? A psychiatrist was overseeing her mood disorder and her physician was aware of the obesity and back problems. But what Jane (not her name) needed was belief that she had the ability to do improve her situation herself. Attaining weight loss significantly great enough to relieve her back pain will probably take months, but every pound lost will help.

How can she be convinced to start?

The answer may be in advice I was given decades ago when I started recreational running. An experienced runner told me, “When you start your run, don’t focus on how far you have to go.  Measure your progress not in miles, but in houses or telephone poles. Every time you pass a telephone pole or a house, you are getting closer to your goal.”

Jane should regard her weight-loss efforts like counting telephone poles. Even if it takes weeks to lose a pound, that pound is lost just as running past the telephone pole means some distance has been covered. Every day that she increases her physical activity, even if it is for five more minutes than the day before, she passes another ’telephone pole.’ Every time she wills herself not to order high-calorie takeout and eats healthy, low-fat, low-sugar foods, she is passing another telephone pole.

She won’t be able to do it alone. When I began to run in road races, usually coming in toward the end, there was always someone shouting, “Looking good, you can do it.” I knew I was not looking good and sometimes I wasn’t sure I could do it. But the encouragement helped me continue to the finish line, even if I was almost the last person crossing it.

Jane probably will be able to cross the finish line of weight loss if she believes that she can lose a pound, and then another, and then another, especially if someone is telling her, ‘You can do it!’

Now she just has to start.

‘Don’t Ask, Don’t Tell’ : Convincing Grownups to Eat Their Vegetables

Conversations about eating vegetables are usually infrequent, unless one is at the farmer’s market wondering how to cook a strangely striped squash or white baby radishes. Yesterday, however, I had a long-ish discussion about produce with an elderly Navy veteran seated by me on a van ride to a local hospital.  His passion was growing a large assortment of vegetables in his ½ acre backyard. Despite the vagaries of a New England spring and summer, his planting is so successful he has to give away much of what he grows. One reason that he distributes his harvest to his neighbors is that his wife is, “…Strictly meat and potatoes…She will only eat iceberg lettuce that she buys in the supermarket, even though I grow several varieties of lettuces,” he told me rather sadly.  He was convinced that his superb health, except for some arthritic aches and pains, was due in part to his healthy eating: large salads every day and cooked vegetables as well for dinner. His wife, sort of like Jack Spratt and his spouse, was overweight, hypertensive and diabetic.

“Can’t you convince her to eat what you grow?” I asked, wishing I was a neighbor and could receive some of his harvest. “Nope, she won’t listen to anyone,” he replied.

Later on that morning I sat in on a weight-loss group meeting of mostly obese males, aged about 68 to 80. The dietician leading the meeting suggested I attend in preparation for some research we were planning to do together.

Eating vegetables was the topic du jour.

Brightly colored charts listing vegetables according to their nutrient components were on the screen, and copies of the charts also appeared in front of each participant. The guys were quiet and attentive but, as I listened, I wondered how many would translate the information they were hearing into food on their plates. Some cooked for themselves, as I learned after the meeting; others relied on their spouse or partner. If they increased their consumption of vegetables, it probably would not only improve their nutritional status; it might help them lose weight, the point of the dietician’s talk.

My conclusion at the end of the session was that most of these men, probably like the Navy vet’s spouse, would still prefer their meat and potatoes. No one asked how to prepare vegetables like kale, winter squash, beets and turnips. No one asked whether frozen or canned vegetables could be substituted for fresh, whether sweet potatoes were better than white potatoes, or was corn considered a vegetable or just starch. No one asked how to get enough vegetables when eating out in a restaurant, especially a fast-food chain. No one asked if it was all right to cook the vegetables in butter or oil, or to add cheese or bacon bits to the dish. I suspect that no one asked these questions because few of them seriously decided to buy the vegetables that the dietician told them to eat.  No one said, “I don’t like vegetables.” But I wonder how many were thinking that?

The distance between making a sensible nutritional recommendation to eat X and avoid Y, and having the recommendation translated into eating, can be insurmountable. The recipients of nutritional information may be adults, but they maybe just as resistant to trying new vegetables, or eating them at all, as children. Perhaps even more so because like the wife of the Navy veteran, it is what they have been doing all their lives.

A better approach might be to figure out with the recipients of the information, i.e. the guys in the nutrition class, how, when, and where they might increase their vegetable consumption.

Might they be encouraged to drink their vegetables in a juice that includes enough fruit as well as spinach, carrots, and kale so the drink is tasty?

Should they be encouraged to try vegetables from a supermarket salad bar so they can learn what they like and are willing to eat without having to prepare the vegetables at home?

Could they go to a farmer’s market or supermarket, take pictures of vegetables that are unfamiliar and at the next meeting discuss with the dietician how these vegetables can be prepared?

Perhaps the person cooking for them could sneak vegetables into mixed ingredient dishes like stews, meatloaf, tomato sauce, and blended soups. To borrow a well-known phrase, ‘Don’t ask, don’t tell.’ This may be the easiest way to increase their consumption. I should have mentioned this to the Navy veteran as he told me he does much of the cooking.

Ethnic cuisines do a good job of turning vegetables into carefully prepared, well-seasoned dishes. Think of Japanese tempera, which, if correctly prepared, is greaseless…what an interesting way to introduce asparagus or string beans or carrots to the recalcitrant vegetable eater. Other Asian cuisines also do magical things with vegetables. They suddenly become as tasty (or tastier) as protein. Middle Eastern cuisines rely on vegetables as vehicles for flavorful fillings, or mixed with unlikely pairings like yogurt and garlic.

I wonder if the dietician had shown a video of how to grill vegetables from a cooking network show, passed around cookbooks featuring pictures of mouth-watering vegetable dishes, or asked the participants to cook some produce during the following week for a potluck vegetable session, so that interest and enthusiasm might have been increased.

Getting non-vegetables eaters to allow some room on their plate for vegetables is not hopeless. But it will take more than colored charts and a monologue about eating kale and carrots to bring this about.