Monthly Archives: October 2015

Why Are Health Care Workers Unhealthy?

A friend of mine moved to a new city and obtained a new primary care doctor, along with a new hairdresser and gym. She writes, “I was somewhat appalled at the size of the receptionist and nurse in the doctor’s office. The doctor was a little pudgy, but the two others verged on morbidly obese. It was like going into a hair salon and seeing all the hairdressers with split ends and gray roots, or going to the gym to see the personal trainers sitting in the gym smoking and watching television.”

Her observations were not unique. I have been making weekly visits to a local VA hospital because of a research collaboration and noticed that many of the employees, both administrative and clinical, are also overweight or obese. The unhealthy weight of health care workers is now well documented in a research study published in 2014 in the American Journal of Preventive Medicine (vol 46: 237-248). The lead author, Sara Luckhaupt, analyzed data from the 2010 National Health Interview Survey and found that 35 percent of health care workers, both in medical offices as well as clinics and hospitals, are obese. The study was very careful to eliminate factors such as gender, race, smoking, and age as contributing to their excess weight.

Long hours, stress, limited access to healthy food, excessive commuting time, and sedentary jobs push us toward eating the wrong foods and/or eating too much and avoiding exercise. But all these factors operate across most work situations. And in some respects, health care workers who can stop working when their shifts are over are better off than the corporate worker, who is expected to be on call and meet work obligations 24/7.

Yet my friend wondered why the people working in her new doctor’s office were so overweight. Was it because there was a large container of Hersey’s Kisses on the counter where the patients check in and, in the small room where coffee was available for the staff and patients, a basket of highly caloric cookies stood next to the coffee machine?

“I feel as if I am receiving a dual message,” she told me. “I don’t need a medical degree to know that excess weight may affect my blood pressure and make me vulnerable to diabetes since I have a family history of that disease. So why the candy and the cookies? You wouldn’t expect a dentist to offer sticky sweet snacks to the patients unless business was poor. It was hard for me to resist eating the chocolate. It must be much harder for the office staff who stare at the container all day.”

Obviously my friend wasn’t going to cancel her appointment with her new physician because the person checking her in was overweight. As she told me, “I take full responsibility for my weight and I don’t need to be in a medical office with a skinny staff to motivate me to eat healthy foods.” But then she went on to wonder if someone who is struggling with her weight would decide that it is all right to be obese if surrounded by hospital and medical office employees who are also obese.

Seeing hospitals and medical offices filled with very overweight employees gives the impression that this profession is not taking care of its own. It is hard to understand how health care workers can see evidence of the medical consequences of obesity, and yet fail to maintain a healthy weight themselves.

Imagine going into the orthodontist’s office and seeing the dentists and office staff with pathologically bad teeth alignment. Or being examined by an optometrist who can’t read the figures on the machine because she needs glasses. What if the hospital staff never got flu shots and consequently they all come to work with fevers, bone aches and coughs?

No one in the health care profession has the right to impose weight standards on anyone else in the profession anymore than a dentist has the right to insist that the staff use dental floss. But given the multitude of health problems associated with obesity, it should not be necessary for the health care worker to become a patient, before his or her obesity is addressed.

It begs the question, this contradiction of obesity in the health care industry… Could changing the work environment help reduce the high incidence of obesity among health care workers? Do current work schedules contribute to overeating, stress, and too few healthy food choices, especially for evening and overnight shift workers? Should exercise facilities be made available on the premises, or at least a room for yoga, Pilates and relaxation techniques? Should employees who are morbidly obese be offered weight-loss strategies, including bariatric surgery?

Ironically, the health care profession is in the best position to implement a healthier work environment among its employees, because it is the health professionals who are telling the rest of us how to eat, exercise, decrease stress, and live more balanced lives. If they take care of their own by making it easier for them to maintain a healthy lifestyle, the health profession will be an example for the rest of us. But if they are not interested or fail, then the take-away message for the patient is, “Do what I say, not what I do.”

If You Eat Carbs When You Are in a Bad Mood?

Eating a dish of chocolate-sauced ice cream or a large bag of potato chips when feeling sad, angry, tense or worried is pretty standard behavior for people who turn to food rather than alcohol, nicotine or recreational drugs when their moods go south. Women with PMS know all too well the impulse to chow down a bag of chocolate chip cookies or half a sheet cake when the hormones are ‘raging,’ i.e. the end of the menstrual cycle.

But few of these eaters would put the blame for their bad moods on the carbohydrates they are inhaling. Rather, they know that a social disaster, financial problem, cranky mother-in-law, their teenager, or even the early sunsets of winter is driving them to food.  Chocolate cravings appear with great regularity among some premenstrual women, along with the feeling that all is wrong with the world. But few who may brave a blizzard to get a chocolate bar would blame their moods on the chocolate. (Of course, if the chocolate were unobtainable, their bad mood might worsen.) But now some scientists, and the carbohydrate overeaters themselves, are suggesting that the trigger to the bad moods is the carbohydrates themselves.

Isn’t it true? After all, what do depressed people eat and overeat? Not celery, kale, cottage cheese and boiled chicken. Not gobs of mayonnaise, lumps of butter or hunks of lard. Carbohydrates, either sweet/gooey or crunchy/salty, are the feel-good foods of choice. And of course, we all know where this type of eating leads: weight gain, obesity, a multitude of medical problems and depression because of the obesity. Certainly someone who looks at the empty quart-sized ice cream container, crumpled bag of potato chips or the crumbs of a depleted box of cookies feels remorse, depression, anger and even helplessness at the eating that just occurred: “Now I am really depressed,” thinks the overeater. “I probably just gained 10 pounds on top of the twenty I already need to lose.  It is all the fault of the carbohydrates. “

But is it? Does eating carbohydrates in association with negative mood mean that eating carbohydrates causes the negative mood states?  When we drink water in association with thirst, do we assume the water causes the thirst?  When we put food in our bodies in association with feeling hungry, do we assume that food causes hunger?  When we take a pain-relieving medication in association with back pain or a headache, do we assume that the medication is causing the pain?

Fortunately, we don’t have to rely on word play to answer this charge.

It is possible to test the carbohydrate-mood link in the laboratory.  The format for such research is to measure the moods of volunteers when they are not in particularly good moods, for example people who get grumpy every afternoon around 4pm or women with PMS. Volunteers fill out self-reports on their mood and then are asked to consume a beverage containing carbohydrate or protein. They don’t know what the beverages contain because the taste and textures are identical. An hour or so later, after the carbohydrate or protein has been digested, the volunteers fill out the same mood reports. We did such an experiments at MIT with people who always ate a carbohydrate snack late in the afternoon when they started to feel irritable, restless, impatient, distractible, tense, and even a little depressed. After they consumed the carbohydrate-containing beverage, their moods improved significantly. But their moods did not get any better after drinking the beverage containing protein.

Several years later we did a similar test with women whose carbohydrate intake (we measured this directly) increased enormously when they were in the throes of their mood-altering PMS symptoms. These women also consumed a carbohydrate or protein-containing beverage and, as in the earlier study, did not know what each beverage contained.  The carbohydrate beverage significantly decreased their anger, depression, tension, confusion, and even fatigue. None of these moods was altered after they drank the beverage containing protein.

There goes the ‘carbohydrates cause depression’ theory.

Was it the taste of the carbohydrates that put them in a better mood? Unlikely. Their moods were measured an hour and more after they finished the drink. Moreover, the drink had a mild fruity taste but would not be a contender for best tasting drink.  The reason for the improvement in mood was due to the increase in the ‘feel-good’ brain chemical, serotonin. The carbohydrates did not produce the serotonin, but their consumption triggered a series of biological events in the blood and brain that caused more serotonin to be made. And that produced a better mood.

What is wonderfully curious is how we know to eat carbohydrates when we are feeling blue, despondent, upset, stressed or anxious. It is not something we are taught and indeed, given the current anti-carbohydrate attitude of self-proclaimed nutrition experts, we have been told to avoid eating those dreadful foods. But (Thank you, Mother Nature!), there must be some sort of signal from the brain, to our emotional self, to our mouth and eyes that says: Now it is time to have some crackers, or an English muffin or a small bowl of oatmeal. I call it a ‘carbohydrate-thirst.’ Indeed, one of our early volunteers said, “My mouth is calling out for carbs.”

Whatever the signal, the outcome is the same. A small amount of carbohydrate, no more than 25 or 30 grams, is enough to perk up our serotonin and take the edge off whatever bad mood we are experiencing. Like thirst, or hunger, or the need for sleep, eventually the carbohydrate hunger will come back when, for a variety of reasons, mood begins to deteriorate.  But for several hours after eating the carbohydrate, we will feel a little less stressed, a little calmer, and even a little happy.  And that, fortunately, is not going to change.

Surgery Can Remove Hunger, But Can It Also Remove the Emotional Need to Eat?

Dieting may be the traditional method for losing weight. Yet more and more obese individuals are giving up counting calories and measuring their food and instead are turning to surgery. Advances in bariatric surgery over the past 10 or so years has made possible a relatively short, simple operation to turn the pouch-like stomach into a skinny sleeve that holds no more than 2 to 7 ounces of food. The operation, called the gastric sleeve, is done laparoscopically, which means recovery is quicker than conventional surgery.  According to the American Society for Metabolic and Bariatric Surgery, almost 42 percent of all bariatric surgeriesperformed in the United States in 2013 were sleeve gastrectomies,i.e., it’s currently the most popular weight loss surgery.

The operation is non-reversible; the major part of the stomach, which looks like a mildly curved banana pouched at one end (as if the banana swallowed a golf ball), is cut away. The original stomach cannot be reconstructed any more than a pair of jeans can be reconstructed after the legs have been cut off to make short shorts.  The stomach still functions, but eating has to be miniaturized. Eventually, the stomach may stretch somewhat so food does not have to be measured with an eyedropper. Still, people who have had this operation will be unlikely to be able to eat a large pizza or a 12-ounce steak unless they spread the eating over several days.

Fortunately, one of the biggest advantages to this type of weight loss surgery is that when the fundus, that bulge at the bottom of the stomach, is removed, so too is ghrelin (rhythms with melon). Ghrelin is an appetite-stimulating hormone produced in the fundus. Normally, when the stomach is empty or (and this is bad news for a traditional dieter) when low calorie diets and/or chronic exercise regimens are followed, more ghrelin is produced. Hunger does not make dieting easy. Ghrelin goes up before meals and, not surprisingly, decreases after food is eaten. But the gastric sleeve surgery significantly decreases this hunger hormone.

The resulting lack of hunger is so striking that for months after the surgery, patients must remind themselves to eat. Consequently, during the post-operative year, weight is lost easily and many of the medical complications of obesity-like diabetes are lost as well. But as with other types of bariatric surgery, getting to a goal weight is not always attainable. It is possible to gradually restretch the stomach enough to hold more food and more calorically dense food.

But for most, the hunger may be gone, but the need to eat remains.  As a woman wrote on an Internet site devoted to bariatric surgery, the operation does not ‘mend the mind.’ She was describing her need to eat sweets when she was tired or stressed. Others chimed in with their stories of being unable to control their eating when they experienced the mood and appetite changes of PMS. A man wrote in about drinking alcohol again as a substitute for eating candy to which, he said, he was addicted.

Will power, the surgically imposed inability of a now skinny stomach to hold much food at a time, and motivation to reach a healthy weight, keeps many from giving in to these cravings. But for some, not capitulating is like not taking a pain reliever during a bad headache or backache. These individuals use food as a sort of self-medication; they eat when they are depressed or anxious, or in an irritable mood and by doing so, feel better. The improvement in mood is not wishful thinking or a placebo effect.   

Nature gave us a way of eating our way out of stress. We can do so by consuming carbohydrates that, in turn, results in the production of the brain neurotransmitter, serotonin.  Serotonin is made when the amino acid tryptophan enters the brain. It does so only after starchy or sweet carbohydrates are eaten. (Eating fruit does not have this effect.) Eating small amounts of carbohydrate increases serotonin levels within about a half an hour.

Serotonin levels may fluctuate during the day, leading some people to feel a serotonin low in the afternoon. Serotonin is also lower during PMS and the dark days of winter.

However, nature never intended for the carbohydrates to be consumed in the form of cookies, chocolate, ice cream, pie, doughnuts, muffins, cinnamon rolls or strudel. The effect on producing serotonin is just the same if steamed rice, plain pasta, unadorned bread, unsweetened cereal, and boiled potatoes are eaten, rather than the fat and sugar-filled pastries or salt and fat-filled crunchy snacks. Again, it is unnecessary to eat large amounts of carbohydrate; about 25-30 grams, the amount in a small bag of fat-free pretzels, is sufficient. Presumably someone could consume this amount with a sleeve-like stomach once enough months passed since the operation, and real food is once again being eaten.

Of course it would be better not to eat out of emotional need. It would be wonderful if those of us who think ‘I have to eat something’ when confronted with a distressing situation or experiencing PMS, stopped feeling this way and managed to get through the stress or PMS without giving in to ourselves.  But our brains are not all alike in this regard, and there will always be some of us who really need to eat some carbohydrate when we are upset. Only a brain transplant will stop us from doing so!

Post-operative gastric sleeve patients are given detailed instructions on how to eat to recover, regain their strength and not alter the size of their tiny stomachs. Would it not be helpful for these instructions to include how to eat to minimize stress without risking weight gain? Shouldn’t women be helped to get through their premenstrual days without imploding by showing them that tiny amounts of carbohydrate can have a enormously positive impact on their mood? The same remedy applies to people suffering from the winter blues, as well. Information about post-op refeeding should include the fact that the absence of carbohydrate will decrease serotonin, and perhaps lead to depressed or anxious moods.

Patients who eat out of emotional need can be taught to consume controlled, small portions of non-fat, non-sugary carbohydrates. By doing so, they will find that their emotional well-being will match their improved physical well-being.