Monthly Archives: April 2017

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

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

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

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

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

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

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

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

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

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

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

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

Are You Merely Exhausted or Unrelentingly Exhausted?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sources for the scientific data reference are available upon request.