Monthly Archives: October 2018

What’s the Best Way to Help People Lose Weight?

If weight-loss programs advertised on television were to be believed, then it is obvious that the best way to get people to lose weight and keep it off is to eat commercially available, calorie-controlled packaged meals and snacks. In just [insert number of days] you, the consumer, will drop at least 10 to 20 pounds, lose your hunger completely, and never have another food craving, according to the promises in the ads. Two runners-up would include an FDA-approved weight-loss drug that takes away appetite and replaces the pleasure you get from eating with something not defined, and/or an exercise device that melts off pounds and replaces them with a “ripped” body that looks good in a minuscule bikini or swim trunks.

Despite the allure of such advertisements, and the wish to look like the models proclaiming the efficacy of such weight-loss interventions, extensive research indicates that they are not the best way to lose weight and keep it off. No surprise.

A few days ago, the Journal of the American Medical Association (JAMA) published a paper that summarized several years of analyzing current interventions on weight loss and maintaining weight loss. The report did not include results from surgical interventions that reduce the size of the stomach, such as putting a balloon in the stomach or removing food from the stomach through a tube that empties into a receptacle. The criterion for review of the weight-loss interventions was whether or not they could be “provided in or referred from a primary care setting.”

The report stressed the importance of identifying the most effective means of bringing about weight loss because of the alarming prevalence of obesity in the states. The commonly accepted definition of obesity is a body mass index (BMI) of 30 or higher. (This is weight in kilograms divided by height in meters squared; there are websites that help with this calculation for the arithmetic-challenged reader.) More than 40 percent of women and 35 percent of men in the United States today meet the criterion for obesity.

Intensive, multifaceted weight-loss interventions were found to be the most successful based on the authors’ review of published studies. Such interventions lasted one to two years, with monthly or more frequent meetings. Although food plans that would support weight loss were part of the intervention, the report did not single out any particular type of diet, other than inferring it would have to be a food plan that could be followed for many months. People were encouraged to monitor their weight and exercise levels, to use food scales to weigh their food, and behavioral support was consistently offered. The settings ranged from face-to-face meetings with individuals or a group to remote interactions via Skype or other computer-assisted interactions.

Even though the review looked at programs that could be carried out in a primary care setting, as opposed to surgical interventions, primary care physicians were rarely involved in the programs. A “village” of behavioral therapists, dieticians, exercise physiologists, and life coaches offered a variety of services designed to enhance not only the weight loss but also its subsequent maintenance.

The study rejected the use of weight-loss drugs because the authors wanted to find interventions that caused the least harm. Such drugs come with a long list of side effects: anxiety, gastrointestinal symptoms, headache, elevated heart rate, and mood disorders, to name a few. The side effects from behavioral interventions might be aching muscles from a new exercise or a longing for highly caloric foods. The authors did note that when pharmacological interventions were combined with behavioral ones, the results were better than with either intervention alone. But there was a high rate of attrition, i.e. withdrawal from the studies among those taking weight-loss drugs, perhaps due to the side effects.

The takeaway message from this comprehensive report is that the thousands of people in need of weight loss should locate a primary care physician who will then direct them to an intensive and comprehensive behavioral weight-loss program meeting at least once a month for 18 months or longer. The program should help them buy and prepare the foods they should be eating, make sure that they have the time and money to participate in frequent exercise, identify or solve problems causing emotional overeating, and make sure that weight-loss successes are supported by family and friends and not sabotaged. The report did not mention cost; the studies the authors reviewed were free to the participants.

“When pigs fly!” might be the somewhat cynical response to this paper. Yes, of course, all these interventions will presumably work, except perhaps for those patients whose weight gain was a side effect of their medications. It is very hard to lose weight when drugs such as antidepressants and mood stabilizers cause hunger that does not go away.

But how many primary care practices have the money and time to formulate and carry out the intensive programs recommended? How many hospital-based weight-loss clinics have exercise physiologists, life coaches, therapists, and dieticians to pay personal attention to the participants? Where does one go to find such programs?

And yet, what are the alternatives? The list of medical problems associated with obesity, ranging from orthopedic disabilities to cancer, is not getting smaller. Might technology be the answer? Smartphones allow us to monitor many aspects of our daily lives, from how we sleep to whether we feel stressed. Might robots or some other form of artificial intelligence prevent us from eating portions that are too large or moving too little (some do already), or ask us what is really wrong when we open the freezer to look for the ice cream? Can a robot remind us to do our exercise routine, or meditate, or stop working and give ourselves some private time…or turn off the computer or television and go to sleep? And would we be less likely to deny that we have just eaten a bag of cookies to a robot?

Human interventions have not worked all that well; perhaps it is time to turn to the other.

References

“Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults,” US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force JAMA, 2018; 320(11): 1163-117.

Does Your Mood Fall Before the Leaves Do?

When fall officially arrives on September 22, the number of hours of daylight and darkness are equal. As we proceed further into fall and early winter, hours of darkness overtake those of light, and a well-rehearsed (because we sing this every year) chorus of “It is so dark in the afternoon!” will be heard.  By the end of November, the refrain of, “It’s so depressing!” is added to our song of complaint.

And every year, even before the leaves change color, we noticed changes in energy, appetite, sleep and mood. At first, these changes are hardly noticeable: sleeping a little longer, disinterest in new activities or commitments, feeling tired, craving for starchy comfort foods rather than large salad, and a bit of irritability, annoyance, impatience, and gloominess. That’s seasonal affective disorder, SAD or the winter blues,  arriving.

This seasonal disorder with its symptoms of overeating, fatigue, sleepiness, and grumpy mood is provoked by a decline in hours of daylight. Inhabitants of our northern states are more vulnerable than those in the south because the southern states have more daylight in the late fall and winter. For example, on  December 21, the first day of winter, Chicago has a little over 9 hours of daylight; Key West, Florida, 10 and a half hours.  The symptoms of SAD are not weather related (although there is a variant called summer SAD that seems to be linked to heat and humidity). Indeed, the early symptoms may begin during the early days of fall with its sunny crisp days, and naturally cool nights.

SAD was first described in the mid-l980s, but not much more is known today about how an environmental input like sunlight is able to bring about so many changes in our well-being.  The hormone that puts us to sleep, melatonin, has been implicated because daylight naturally reduces its levels in the blood. It was thought that the late sunrises of the fall and winter seasons delays melatonin destruction and leaves us sleepy, but how this would affect the other symptoms such as mood and overeating was (and is) not understood.

One of the first therapies offered to patients was exposure to artificial light that mimics the spectrum of sunlight. Sitting in front of a lightbox or “sunbox” for thirty minutes or so in the early morning upon awakening was shown to relieve the symptoms of SAD. Lightboxes are still used, and some who work in windowless offices often keep them on throughout the morning to brighten their mood. Treatment with antidepressants that increase serotonin activity is now an alternative treatment based on studies showing that serotonin activity seems to be reduced in patients with seasonal affective disorder.

However, many people fortunately never experience the clinical depression of SAD; rather they have milder symptoms which now have taken on the name “winter blues”. Although their weight, sleep, work productivity, and mood are all changed (not for the better), their symptoms may be relieved in part simply by using light therapy.

One of the problems with winter depression is that it creeps up silently, triggering an almost imperceptible change in behaviors that seem to have their own justification, rather than associated with diminishing daylight. Fresh fruit desserts are less appealing than the fruit baked in a cake or pie; fall activities make a good excuse for skipping the gym; new projects or commitments are better off delayed until spring because the holidays will be coming; the irritability, depressed mood, anger symptoms are justified because of work/kids back to school/ family or financial stress; and sleeping longer is necessary because of a persistent tiredness.

Recognizing the early symptoms of winter blues, such as cravings for sweet carbohydrates or increased fatigue, allows strategies to be put in place (like rakes before the leaves drop) to decrease their impact on quality of life.  For example, weight is often gained due to the dual effects of craving high-fat sugary foods (like chocolate and cookies) and drastically decreasing exercise because of fatigue. Recognizing this should lead to removing highly caloric carbohydrate snacks like chocolate and ice cream from the kitchen. Once the full blown carb cravings of winter blues hit, it will be difficult to resist eating cookies or ice cream or chocolate, especially when the sun sets by late afternoon.  Replacing these highly caloric foods with very low fat breakfast cereal—such as oat or wheat squares or cornflakes—will increase serotonin, turn off carbohydrate cravings, and increase satiety without doing damage to your weight.

Fatigue and disinterest in taking on new activities may shut down any commitment to frequent (if any) exercise. Plenty of excuses will be available as weather, early afternoon darkness, work, holiday, and family commitments erode time for a workout at home, at the gym, or outdoors. It is all too easy to stop going to a yoga or Pilates class or cancel a walk with a friend. One solution is to use an APP, or wearable exercise tracking device that will nag you into taking 10,000 steps a day, or indicate how many calories you are eating and how many you are using for energy. The APP doesn’t care what your excuses are for not moving, but if programmed correctly, will ping and alarm and buzz until you do move.

Better yet, be competitive with someone at work or in the family so that you have to display daily (or at least weekly) whether you met your exercise goals. If you start doing this before the fatigue of the winter blues sets in, it is possible that you will continue with the exercise even if one part of you is begging to lie down on the couch and watch Netflix. There is no cure for SAD or the winter blues other than moving to states where the days are longer. Fortunately, the days start to get longer on the second day of winter, and the symptoms will go into remission by mid-spring.

We can’t keep the leaves from falling, or snow, for that matter. But it should be possible with the right interventions to keep weight from rising, mood from falling, and energy levels intact until that happens.

References

Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy Rosenthal N, Sack D, Lewy A et al Archives of General Psychiatry  1984 ;41: 72-80

(β-CIT SPECT imaging shows reduced brain serotonin transporter availability in drug-free depressed patients with seasonal affective disorder  Willeit M, Praschak N, Rieder A et al Biological Psychiatry  2000 ; 47: 482-489

Can Being Put on Hold Cause You to Gain Weight?

It is entirely possible to spend an entire week talking to computers, or whatever records the messages that act as an impenetrable wall between you and communication with a human. My problem was trying to reach a human employee in a county courthouse to trace a seemingly lost file for a minor, but important, transaction. Various phones were answered, but by robotic voices and the one time, after at least a dozen calls, a human answered, I was put on hold for about 20 minutes.   Unlike the old days when my wall-mounted kitchen phone had a cord that barely reached to the sink, now I could wander over to the refrigerator or kitchen cabinet while waiting for the human voice on the phone. It was only worrying that when or if someone would respond I would be too busy chewing to talk that prevented me from eating my way through these hold times. But I wonder: Is frustration at being put into cyberspace, instead of personal space when a problem needed to be solved, an overlooked cause of obesity?

A friend who works at a large US government agency complains incessantly at computer problems that no one is able or willing to fix. Another friend, a doctor, was visibly shaken when he could not understand the information given at a mandatory orientation on how to use the hospital’s new computerized record keeping system, and muttered about early retirement. An office mate goes into a high-stress mode about every 3 ½ days when a document he spent hours revising is nowhere to be found in the Cloud or Dropbox or wherever those files are stored. And an aunt moans constantly about having to navigate her way through online forms every time she wants to refill a prescription for her dog’s heartworm medication. The animal hospital’s pharmacy no longer takes refill orders by phone.

A recent talk by the New York Times columnist Thomas Friedman, at an endowed lectureship at MIT, provided the not too shocking information that we spend on average over 60% of our time in cyberspace. Presumably only a small amount of this time is spent stressing over glitches in our cyber interactions.  And given the intensity and severity of stress previous generations experienced in their jobs, family, and communities, stressing out over confrontations with recorded messages or errant computer programs seems frivolous.

And yet: not being able to talk to a human when a problem really needs to be solved, now. Not being able to get through to a physician’s office because the recorded message does not allow the patient to say, “It is not a crisis, but I have to talk to the doctor.” Not understanding the accent of the technician who is attempting, valiantly, to figure out why the cell phone is not responding and is simply not communicating.  These, and other situations too numerous to count, impose a stress on our lives.

And what do many of us do when we are stressed? Eat, of course. To be fair, we often don’t eat when we are attempting to follow directions as to what to click to fix a computer problem, because our hands are busy (one on the phone and one on the mouse). And when our adrenaline is extremely high because we are not sure we will ever get a human on the phone or a technician to resolve a phone issue, we are not eating, because the our stress and agitation has taken away our appetite. But afterward, to calm ourselves when the problem is fixed, or to calm ourselves when the problem cannot be fixed, we eat. And we are not racing to the refrigerator to steam broccoli or rip open a container of fat-free cottage cheese. We eat the foods we always eat when we are stressed: sugary or salty high-fat carbohydrates like cookie or chips, ice cream or French fries.

If technology is causing our stress and overeating, might technology take it away?  There are apps that monitor our stress levels by picking up changes in heart rate, and some other physiological measures of distress. However, then what? Wouldn’t we know we are stressed without the app telling us? There are apps that will keep track of our caloric intake, so if we are munching on peanuts while listening to the on-hold recorded music, we will know how much we are eating. But of course we have to do mindful munching; otherwise, how can we tell the app how many handfuls of peanuts we have thrown in our mouth?

But perhaps someone will/can develop apps that help us meditate when we are on hold to calm our breathing, to speak to us in reassuring tones when we cannot get through the. “Listen carefully because our menu choices may have changed…” message without grinding our teeth, to detect when we are opening a bag of cookies or the freezer to get at the ice cream and gently remind us that eating isn’t going to fix the computer.  Another exercise-oriented app can suggest useful pacing techniques, and record the number of steps we are taking while waiting for a technician to come on the line. A third should tell us to stop hunching over the computer or tablet and to relax our neck and shoulders and remind us that even though we think having our computer crash, or never being able to though to a human on the telephone, is not the end of the world.

It only feels like it is.