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.

A Stomach Drain: The New Level of Combatting Obesity

The FDA approved, in mid-June, a new obesity device that seems to come from a medieval concept of how to prevent overeating. A tube is inserted into the stomach and the outside end fitted with a valve that can be opened or closed, sort of like a faucet. After eating, the patient opens the valve or faucet so the contents of the stomach can empty into the toilet (or a bucket or some container that can be washed out). The procedure is like throwing up to get rid of the contents of the stomach, but with this device you don’t have to gag. Just open the valve.

When I saw an announcement of this device I thought it was a hoax or something thought up by people who compete in ‘all the hot dogs you can eat’ contests. But no, the device, called AspireAssist, is recommended for those who cannot control their food intake. Instructions for its use are quite specific: At least 20 or 30 minutes have to elapse between the completion of a meal and the emptying of the stomach. This is to make sure that some nutrients and calories are passed into the intestines where they are absorbed into the body. If the stomach was emptied immediately, the result would be similar to starvation.  Moreover, the binge eaters and others with eating disorders such as anorexia are not to be allowed to use the device, as it would only enable such individuals to continue on with their disordered eating. And it is not to be used for a short period of time like a few weeks. It is not the modern day equivalent of the way Roman nobles would eat at one of their banquets when, if they had eaten to their full, they would disgorge the contents of their stomach (there really is no way of saying this euphemistically) so they could feast all over again. This means that you cannot take this device with you if you are going on a cruise, for example, and want to make sure that you are eating enough to justify the cost of the trip.

The FDA is limiting use of the device to patients who are obese with a body mass index of 35 to 55, and who are unable to lose or maintain their weight loss through non-surgical interventions.  In clinical trials of the device, it was very effective in supporting weight loss in this very obese population. After a year, patients using the stomach-emptying device lost 12 percent of their weight compared to control patients who lost 3.6 percent. The amount of weight loss is less than what is typically found among people who have had bariatric surgery such as the gastric sleeve. There are many obese patients who have too many health problems to risk having general anesthesia, yet their obesity is so severe that unless reversed it will shorten their life. An acquaintance who must be at least 250 pounds overweight can barely walk, and now has been diagnosed with a heart problem. She is unable to lose more than 10-15 pounds even when living in a residential weight-loss clinic and would be a candidate for bariatric surgery except for her cardiovascular problems. So perhaps a tube that empties partially digested food from the stomach into a pail might help her.

Safety features are built into the use of the AspireAssist device to make sure it is not abused by, for example, someone who sees it as a way of eating unlimited quantities of everything. It can only be used for a certain number of ‘drains’ and then will stop working. The patient must return to the physician who inserted it to get a replacement part and be evaluated for weigh-loss progress.

Aside from the mechanical disposal of food that otherwise would contribute unneeded calories, how will the patient benefit from this new obesity device? Ideally, food intake, or perhaps the frequency of eating, might decrease. Stopping for coffee and a pastry or piece of pizza while shopping is tempting, but the mechanics of draining the stomach in a small bathroom stall in a mall could be awkward. Also, there is the time factor. Does one go out to eat with friends and then on the way home, thirty minutes after dinner is over, look for a public restroom? Maybe there is a manual that comes with the device that answers these pesky questions.

But an obvious question remains: Why would a device, really a plumbing tool, that removes food from the stomach affect how the brain controls eating? If eating is an almost automatic response to stress – and who doesn’t have stress – this response is not going to be altered by draining the stomach.  If eating is a response to lack of sleep, or boredom, or too much work, or too little relaxation time, how can a device that removes semi-digested food in the stomach change this?  In a sense, allowing the stomach to feel somewhat empty after the food is removed may promote another bout of eating as it did with the Romans.

There has to be a better way to allow fewer calories into the body. A tapeworm perhaps?

Can Antidepressants Turn You Into a Food Addict?

What is a food addiction? Having heard several people explain their inability to lose weight due to this problem, I searched out the answers on, where else? The Internet. It appears there are addictions, and there are addictions.  Apparently, being addicted to your grandmother’s strudel or your brother-in-law’s barbecue is one type of addiction to be put in the same category as your impulse to drive 40 miles to eat homemade ice cream, or a fresh-from-the-sea lobster roll.  But these are not real addictions because if they were, you would be driving to eat the ice cream daily, even when the temperature was colder than the treat.

Real food addictions, according to many so-called food addict experts, are more grim and relentless. If you are a food addict you are unable to stop eating sweet, sometimes starchy, high-fat carbohydrates. Indeed, simply by consuming these foods, if you are susceptible, you will be thrown into the abyss of food addiction. If you have the misfortune or mindlessness to eat some refined carbohydrates, say some jelly beans or a piece of birthday cake, you will be assaulted by uncontrollable urges to continue to eat. You may find yourself eating the entire birthday cake or leaving the party to search out more carbohydrates.  Eventually, unable to stuff any more food in your stomach, you will stop…but the longing and urge to continue to eat will remain.  Not only will you experience a constant craving for more food, especially sugary snacks, you will, according to some food addiction websites, suffer from  emotional, social and spiritual deterioration. (Curiously, television networks do not seem to realize the profound damage caused by eating sugar as evidenced by programs devoted to making incredibly decorated cakes, or people fighting over who makes the best cupcakes.)

The solution, or sobriety, if this word can be applied to the sugar and refined carbohydrate addict, requires a life-long total abstinence from these addictive foods. Organizations like Food Addicts Anonymous exist to help people recover from their addiction.

Is it possible that for some, eating cookies or a slice of bread causes them to become food addicts? Maybe. But it is also possible that the reasons driving a compulsion to eat are more complex, and have to do as much with psychological and physiological factors as swallowing a piece of bread. Binge eating disorder and bulimia, two eating disorders characterized by compulsive overeating, are associated with complex psychological problems, not a simple food addiction. Someone who weighs 750 pounds or more, and cannot stop compulsive eating needs solutions to lose weight far more complex than eliminating flour and sugar. Self-described chocoholics (people addicted to chocolate) usually manage to eat normal amounts of ordinary non-chocolate foods most of the time.

Are there reasons people may find themselves with a compulsion to eat sugary carbohydrates other than the random digestion of a sugar cube? Below are some situations that cause people to crave carbohydrates:

People treated with antidepressants and related medications report intense cravings for carbohydrates, especially sweet ones. Why the medications cause these cravings is not understood, but the cravings are recognized as a side effect of the medications, not a food addiction. When medications are stopped, the cravings disappear.

Women crave sugary carbohydrates toward the end of their menstrual cycle, right before menstruation begins, and for some it is all they want to eat. Their longing for these foods are so intense that a cartoonist named Boynton pictured a premenstrual woman saying ‘I could kill for chocolate.’

Is this an addiction? Doubtful, since women return to eating normally as soon as menstruation begins.

A decrease in hours of daylight characteristic of late fall and winter is associated with a type of depression known as Seasonal Affective Disorder. A milder form is simply called the, ‘Winter Blues.’ Typically, the mood change is accompanied by an almost insatiable need to eat sweet carbohydrates; indeed, this is one of the ways this depression is diagnosed.  But how can it be an addiction if it mysteriously disappears as soon as daylight increases, and is usually gone by late spring?

High-protein diets that forbid or limit carbohydrate consumption may cause a sugar addiction due to a decrease in brain serotonin levels. Serotonin, a neurotransmitter responsible for affective mood, appetite, and pain perception, is made only when the consumption of carbohydrates allows the brain to receive the tryptophan it needs to make new serotonin. Craving carbohydrates, like thirst when not enough water has been consumed, may be the signal sent to indicate that the brain needs to make serotonin.

Stress and carbohydrate consumption go together like peanut butter and chocolate. Studies in which people were given, covertly, carbohydrate or protein-containing beverages decreased their feelings of depression only after consuming the carbohydrates. This is probably due to an increase in serotonin production. People tend to self-medicate with carbohydrates to decrease the emotional discomfort of stress. If the stress doesn’t go away, neither does the carbohydrate consumption. Therefore a so-called food addiction may last as long as the stress. The best way to stop the overconsumption of carbohydrates, if indeed that is occurring, is to stop the stress.

Is that plausible, really?

Our bodies and minds can certainly exist without the consumption of sugary carbohydrates. But let’s wait until there is evidence from a placebo-controlled, double-blind studies (neither the subject nor researcher know what is being consumed) that eating a graham cracker, a pancake with a drizzle of maple syrup or their equivalent in sugar grams is generating a food addiction. The situations that cause a craving for sweet carbohydrates such as depression or PMS are difficult enough without the additional burden of worrying that a few gumdrops are going to turn these eaters into addicts.

It’s Time to Give Your Exercise Some Fresh Air

Move your body out of the gym and go outside, into the fresh air. Soon, in a month or so, it may be too hot and humid to exercise outside, or in certain parts of the country, too wet and/or buggy. But now, despite the sometimes yo-yo effects of late Spring weather that bounces around the temperature scale, the weather is usually sufficiently benign to make walking, biking, running or playing tennis possible and enjoyable.

Switching to outside physical activity from the cardiovascular, weight-lifting machines, dance and yoga classes, may seem like an excuse to decrease the intensity and even duration of exercise. Obviously a stroll through a nearby park to look at the ducklings will not increase your heart rate or make you break a sweat, and it is doubtful you will enlarge your arm muscles plucking dandelions from the grass. And unlike a gym cardiovascular machine that measures your caloric output, your wearable activity-monitoring device may be unable to calculate accurately the calories you are using when sweeping out the garage, pushing your bike up a hill too steep to ride, or turning over the soil for spring planting. But the benefits of transferring at least some of your workout time to outside activities goes far beyond knowing exactly how many calories you are expending.

The most obvious benefit from exercising outside is fresh air (unless you are allergic to pollens, or the only air available is polluted from car and factory exhausts).  Replacing the recirculated air of a gym that probably contains the sweat of many members with the freshness of an early morning breeze on your face has to make you feel good.  Changing the exercise environment from the four walls of a health club to the openness of your neighborhood, park, nearby river bank, or lake, decreases boredom and makes physical activity feel more natural. Running or walking on the treadmill is excellent exercise, but after months of doing so, you begin to wonder whether you should be arriving at some destination after all the miles you have covered. When you do the same activity outside, you actually arrive at a destination and enjoy changes in scenery along the way, rather than only seeing old Kardashian reruns on the machine’s monitor.

And then there is always the shock to find that your well-trained body, capable of doing miles on an indoor bike or elliptical machine or treadmill, is struggling against wind gusts, uneven pavements, long hills, and not always winning.  A fellow gym member was amazed at how hard it was for her to bike during a weekend on Cape Cod. “First the wind was blowing in my face on my way out, but somehow it changed direction when I did… so it blew in my face on my way back! And then the hills…Endless. I thought I was in good shape, but by the time I reached the top of the last one, I was panting so hard I had to stop riding to catch my breath.And I can bike miles at a high resistance indoors.“

Another great aspect of an outdoor workout is that you are forced to exercise in a non-climate controlled environment, which sometimes makes physical activity more difficult, but of course, more realistic.You may have to adjust your exercise to unseasonably cold or hot temperatures, or plan what you are going to wear so you can shed clothes when you become hot, and put them back on when you stop and cool down.This adds another dimension to your exercise and in a sense, makes it feel considerably more natural than exercising inside.

Physical activity is not limited to an outdoor version of activities in the gym; obviously there are many activities that, with rare exceptions, cannot be done in a health club such as kayaking, mountain hiking, and softball.  Many of the chores that pop up like dandelions during the late spring require physical labor: washing windows, painting…with all the scraping and sanding that precedes it, yard and garden work (this can be endless), hauling stuff to the dump, cleaning and repairing boats, bikes, and prepping the backyard grill.  Several hours of washing windows may challenge even the best gym exercised arms and back. Digging and pulling out weeds and then raking winter debris from the lawn can feel like more of a workout than soul cycle.

Having a well-exercised body from a winter of exercising inside will make it easier to adapt to any type of outdoor activities. But if you are one of those people who thought about going to the gym but that’s about as far as you got, consider this: If you start now, doing some exercise outside – long walks, bike rides, gardening, a day hike through a nearby conservation area, painting the metal lawn furniture – and keep it up… by the time the weather gets cold, you might like it enough to continue, even inside a gym.

 

Relieving Pain Without Gaining Weight

Eating to deal with chronic pain is often overlooked as a cause of weight gain, overlooked by everyone, that is, but the over eater. Individuals who experience pain for days, or even years, also often suffer from the collateral damage of obesity or being overweight. The overeating occurs either as a response to pain itself, depression, and/or sleeplessness due to pain. Too much weight may exacerbate pain in bones, joints and muscles,* and make even gentle exercise difficult because it is so much harder to move.

Pain often seems less bearable at night; perhaps because there are fewer distractions. Often pain drives us from bed and we wander around the house hoping the pain will recede so we can go to sleep. Munching on snacks to relieve pain and the anxiety and frustration at not being able to go to sleep is common.  And the overeating carries over to the next day in an attempt to feed wakefulness into a drowsy body and mind.

Lack of sleep and chronic pain, not unexpectedly, are often accompanied by depression. Who wouldn’t be depressed if neither a good night’s sleep nor a life free of pain was attainable?  Anti-depressants are often prescribed, but they may cause intense cravings and overeating.

And, of course, pain itself may provoke excessive food intake.

I still remember the frantic way a co-worker raced into our office asking if anyone had any chocolate. Someone handed her a chocolate bar, and she tore off the paper and gobbled it down in seconds. She normally was extremely controlled and deliberate; the most impulsive thing she might do is kill a mosquito, so we were amazed at her behavior.

“I am getting a migraine,” she explained, after the chocolate had been eaten. “I usually carry something sugary with me to eat when I feel one coming on, but I didn’t have anything with me.  If I manage to eat some sugar, sometimes I can stop the pain from worsening. ”

Overeating as a result of chronic pain is probably even more common than eating during an acute painful episode. A young woman who came to me for weight-loss counseling after a painful recovery from a sinus operation told me, “I just wanted to eat sweets! I don’t know why, but they made it easier to bear the pain, and gaining weight was not as important as having some pain-free moments.”

Is it possible to eat to endure a painful condition and not gain weight?

Yes. If eating is not indiscriminate, but rather focused on foods which will reduce pain and are eaten in the correct portion size.  There is a specific class of foods that will decrease pain: these are sweet and starchy carbohydrates.  Protein has no effect mitigating pain, nor does fat. Eating a bacon cheeseburger or barbecued spare ribs may act as a distraction from pain because of the pleasure of eating these foods, but will not diminish your brain’s perception of painful signals from your nervous system.

Carbohydrates however, (except fruit sugar, fructose) will decrease discomfort by bringing about an increase in brain serotonin. Carbohydrates do this by potentiating the entry into the brain of tryptophan, the amino acid from which the brain makes serotonin.  (Even though tryptophan is found in protein, eating protein prevents serotonin from being made.)

Serotonin, a multi-tasking neurotransmitter involved in mood and eating regulation, is known to  diminish pain. In fact, this is why anti-depressants that increase serotonin activity are sometimes prescribed for the chronic pain of fibromyalgia, and even back pain. However, these drugs do not increase the amount of serotonin in the brain; only eating carbohydrates can do this.

Twenty-five or thirty grams of a fat-free or very low-fat carbohydrate food like pretzels, Cheerios or oatmeal are sufficient to raise brain serotonin levels. Eating two or three 25-gram snacks a day to reduce pain contributes no more than 300-400 calories to the day’s calorie total. This is less than the calorie content of a modern day bagel. It is important that the carbohydrate be consumed on an empty stomach, however, to speed up digestion so pain is decreased more quickly. It is also important to avoid carbohydrates that are processed with fat such as cookies, ice cream, piecrust, fries, chips, and chocolate, because fat slows down digestion and adds unwanted calories. Of course it is more pleasurable to snack on these foods than steamed rice or rice cakes. However, the long-lasting comfort carbohydrates provide comes not from their effect on taste buds, but from their effect on increasing serotonin.

Anyone who has suffered acute or chronic pain yearns for its end. Eating carbohydrates won’t bring this about. But doing so might make the pain bearable at least for a few hours and that small relief is welcome.