Monthly Archives: March 2018

Peak Physical Fitness as Protection Against Dementia

“Good news,” a friend in the gym said, waving her cell phone in my direction. She showed me a news release about a study on the positive effects of exercise in preventing dementia among women. The article published in Neurology (link is external) showed the somewhat startling relationship between being very fit and reducing by almost 90%, the chance of becoming demented.
An air of self-congratulation rippled through the treadmill walkers as the news passed from machine to machine, and there seemed to be a perceptible increase in the intensity of the exercise we were all doing.

Unfortunately, a closer reading of the study revealed that even those who went to the gym pretty regularly were not guaranteed a dementia-free future. Unless we were extremely physically fit we were still vulnerable to cognitive problems as we age.

The study was initiated in l968 when researchers tested the cardiovascular capacity of Swedish women ranging in age from 38 to 60.  The women exercised on an exercise bike that monitored their cardiovascular stamina, and they were told to exercise until exhaustion. One hundred and ninety-one women participated and, based on how well they did on this test, were divided into high, medium and low fitness levels. Some in the low fitness group were unable to complete the exercise because of cardiovascular problems. Forty placed in the high fitness group, ninety-two in the medium-fitness group and fifty-nine in the lowest group.  Those in the high fitness group were not competitive athletes, but their physical stamina and energy utilization measured during the initial testing period indicated their ability to endure strenuous exercise.

Women were tested six times over the subsequent 44 years of the study to determine if and when dementia appeared. The bad and good news is that 32% of the least fit developed dementia, as did 25% of the medium-fit. However, only 5% of the fittest group were affected.

Dementia is not the same as memory loss, although it can be associated with it. Dementia is not a specific disease, but instead describes a cluster of symptoms that affect intellectual functioning, emotional control, the ability to solve problems, maintain language skills, and carry out the functions of daily life. One example of the difference between memory loss and dementia is a person who cannot remember the name of a fork but can still use it to eat. This person has memory loss, but may not be demented. A person who doesn’t know the name of a fork nor its function would be considered to be suffering from dementia.

In the Swedish study, the most common cause of dementia was Alzheimer’s disease (eighty women), although twelve women developed vascular dementia. The latter is usually associated with strokes, some so small they are not even detected. The other causes of dementia were not described.

Before giving up one’s day job to spend more time in the gym to increase physical fitness, it is important to consider that the authors of the study were not sure how being especially fit protected the women from dementia. Nor did were they able to explain why the least fit women were so vulnerable. Moreover, the study did not record whether the women continued to be fit or not during the several decades that followed the initial assessment, and their physical fitness was never measured again.

This sort of study is frustrating on many levels. It is not a cause and effect study, i.e., exercise causes something that protects against dementia. Rather it shows the linkage of two conditions: peak fitness in middle age and significantly decreased incidence of dementia almost 50 years later.

So is it the exercise itself that may alter the brain to prevent cognitive decline? If so, how? Do women with outstanding stamina have different lifestyles? Do they also do crossword puzzles more often or speak several languages, activities that are supposed to improve brain function? The study was done in Sweden, but perhaps the high fitness subjects followed a Mediterranean diet eating mostly grains, fish, olive oil and vegetables. Such a diet has loosely been linked to lower rates of Alzheimer’s disease.

Was there a connection between the levels of their female hormones and their exercise activity? Maybe those who exercised so well didn’t suffer from menopausal hot flashes. Or maybe they did. Who knows?

Does their fitness at fifty result from a childhood and early adulthood spent in strenuous physical activity?  If so, might the positive change in their brain preventing dementia be a result of decades of peak exercise performance and perhaps, along with that, food intake designed to enhance this performance? Should we encourage our children and grandchildren to take on sustained high levels of physical activity, so by the time they are fifty, their brains may be protecting them against dementia?

This study probably took fifty or more years to carry out because of the time spent gathering and testing subjects before it began, and the time spent analyzing the data after it was over. Such studies are difficult to do, and certainly repeat, which is impossible to do in the lifetime of the original investigators. The results are tantalizing and sufficiently compelling to make some, perhaps with a family history of dementia, commit to more exercise, more frequently, and with greater intensity. And if it works to prevent Alzheimer’s disease and other causes of dementia, then regardless of why or how it will be worth doing.

References

“Midlife cardiovascular fitness and dementia,” Hörder, H., Johansson, L., Gu, X., et al, Neurology Mar 2018, 10:1212

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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