Monthly Archives: April 2019

Can We Stop Becoming More and More Sedentary?

The past several decades have seen us becoming a country of sitters.  We spend less and less time in physical activity because on the one hand we don’t have to and, on the other, we don’t want to. Getting to work, to shops, supermarkets, social and religious events, movies, concerts, or restaurants is rarely accomplished by walking or bike riding to the destination. This is changing in urban area where bike lanes are gradually replacing traffic or parking lanes. Still, bike riders are still very much in the minority, and even more so when inclement weather makes riding uncomfortable or dangerous. Walking is still a preferred mode of transporting oneself in cities like New York, where the pedestrian often arrives sooner than a car due to traffic congestion. But many cities, and certainly suburban and rural areas, are too spread out or lack sidewalks to make walking to work or the supermarket possible. And then there is a matter of time. A few weeks ago, I decided to walk to a supermarket located about 2 ½ miles from where I live. It was a beautiful spring Sunday and the walk was in lieu of a visit to the gym. The five-mile round trip took a good part of the morning and, combined with carrying a knapsack heavy with groceries back home, I am disinclined to repeat the experience.

We also don’t move enough because work or school necessitates sitting at a desk in a meeting or lecture, in a library, or in an office seeing clients or patients. To be sure, some occupations require physical activity such as running after toddlers in a daycare center or hammering sheet rock in a construction site.  But many occupations now require less physical activity than in the past. Our mail carrier uses a small van to deliver the mail; several years ago he would have walked.  We no longer have to walk to a bank to deposit a check or withdraw money. The cell phone takes care of money-less payments and our groceries, along with everything that we need, can be delivered to our door. Devices, which send signals remotely, like the television remote and the more sophisticated smartphone, have further reduced our need and desire to move. Why get up to turn off a light if your phone will do it? Why sweep the floor if your cute robotic device takes care of the dirt?

Of course, our almost constant use of the cell phone has also reduced our physical activity. In a nearby park people sit on benches hunched over their cell phones rather than walking, or sit on workout benches in my gym checking messages, rather than lifting weights.

Thus it is not surprising that our population is now even more sedentary than it was ten years ago.  A report in last week’s JAMA (April 23) analyzed sedentary behavior or, more simply, hours sitting, in almost 52,000 participants who took part in a National Health and Nutrition Examination Survey (NHANES). Three age groups were involved: children from 5-11, adolescents 12-19, and adults 20 years and older. People were asked how much time they spent each day sitting at work, with friends, commuting, reading, playing cards, watching television or using a computer.

About two-thirds of the participants in each age group spent at least two hours a day watching television. The survey did not include people who might binge watch all the episodes of a particular program for hours.  About half the people surveyed sat in front of their home computer for an hour or more each day. This time spent sitting was in addition to the time spent at their computers at work or at school. Moreover, the amount of sitting time may have been underestimated because the survey did not look at time people spent with their cellphones and tablets at home, in coffee shops, or while traveling. When all the sitting time was added up, the researchers found that as a country we are sitting about 8 hours a day compared with about 7 hours ten years ago.

The report describes such stark consequences of sedentary behavior that the reader feels compelled to stand up and walk around while reading about the increased risk of obesity, cardiovascular disease, cancer, diabetes and overall mortality.  However, the authors offer no specific countermeasures to decrease our sedentary behavior.

Since increasing the time we spend not sitting should have positive effects on our health, it is surprising that so little has been done to accomplish this.  Apps will monitor our activity and may increase our motivation to move more, but in a passive way. There is no app that acts as one’s mother to say, “Turn off the computer and go outside and play.”

It should be possible to program computers, tablets, phones and even television sets to make us move. If cars brake when we are too inattentive to do so ourselves, and keep us from drifting from one lane to another, our devices should be able to make us stand up, walk, stretch and maybe do some exercises. My computer shuts down to install an update even when I don’t want it to.  What if my computer or tablet shut down when it detected my inertia for 50 minutes and won’t go back on until I move?  My cell phone tells me how much screen time I use, but why not tell me to stop bending over the screen, stand up straight and go for a walk?  We all get fidgety watching televised advertisements for drugs that will allow us to float through a field of butterflies with our partner, or scenes of cars driving through deserts or up mountain-sides. What if we could program our television to substitute a virtual reality show that gets us moving through that grassy field, or hiking up a mountain for five minutes?

Technology has made us sit too much. Now is the time for technology to get us to move.

“Trends in Sedentary Behavior Among the US Population 2001-2016,” Yang L, Cao, C, Kantor E, et al, JAMA 2019; 321: 1587-1597

Excess Skin After Major Weight Loss: Might Removing It Prevent Weight Gain?

The financial officer of an organization to which I belong decided to have bariatric surgery. Bob (not his real name) needed to lose about 200 pounds and the operation, called the gastric sleeve, narrowed his stomach and decreased the production of ghrelin, a hormone that increases hunger. He lost about 190 pounds, significantly improved his food choices, and now exercises several times a week. But despite his success, and with it his improved health and energy, he told me that he was unhappy. “I had an image of myself as a thin person, which motivated me to always stick to the diet and work out. But now that I have lost all this weight, I feel encased in suit of loose skin. I have to force myself to go to the gym because I think everyone is staring at the skin hanging from arms and sagging down my thighs.  I have to buy clothing in a size too large. My loose flesh prevents me from getting my arms in the sleeves of my jacket and zipping up my pants unless my clothes are baggy.”

Bob’s problem is not unique.  Many patients who undergo bariatric surgery and are successful in losing very large amounts of weight are confronted with bodies distorted by excess skin. This is not a problem for those who lose much smaller amounts of weight. The skin regains its elasticity after being stretched, and regains its normal shape as it does, for example, after pregnancy. If large amounts of weight are lost very slowly, sometimes the skin regains its original shape, although this is less likely to occur in an older individual.

Surgery to promote rapid and massive weight loss, or extreme dieting and exercise, as seen in the television show program, “The Biggest Loser,” can leave pounds of skin behind.  Although those of us who have not gone through the massive gain and then loss of weight might view the problem as merely cosmetic and a small price to pay for the weight loss, the problem is not simply cosmetic. (“Surgical solutions to the problem of massive weight loss,” Spector J, Levine S, and Karp N, World J Gastroenterol. 2006 12: 6602–6607.) In their article describing surgical solutions to help the newly thin deal with their excess skin, Spector and his co-authors point out that patients who have large amounts of skin draped over their limbs and the torso may be in chronic pain and the skin can be easily infected.  Giodano reiterates their views in an article (“Removal of excess skin after massive weight loss: challenges and solutions,” Open Access Surgery 2015; 8: 51-60) and adds that physical impairment, including difficulty exercising or indeed even walking, and low self-esteem are some of the other problems caused by the excessive skin. Moreover, dieting and exercise are unable to bring the skin back to its original elasticity.

There is a solution. It is called body contouring, a plastic surgery that removes the skin, and by doing so, reveals the body shaped by the weight loss. Bob underwent several plastic surgical procedures over a period of many months but the results, giving him a body that finally revealed its nearly 200 pound weight loss, was attained only after a considerable cost in pain and money. He had to take time off from work, required a brief hospitalization for one procedure and, in his words, ‘”I won’t be taking a vacation for decades to pay for everything.” He justified going through this in part because he believed his professional appearance would be improved if he were able to wear clothes in the appropriate size for his weight and not to house his excess skin.  But he admitted another more personal reason: “I was afraid that I would gain back the weight because I was so disappointed in how I felt and looked. In fact, my body was so distorted that I think I looked worse than when I was obese. ”

The failure of patients undergoing bariatric surgery to maintain their weight loss beyond one year post-operatively has been reported. (“Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy,” Golomb I, Ben David M Glass A, et al JAMA Surg. 2015; 150:1051-1057.) According to the Golomb et al report, a significant amount of weight is gained relatively early, i.e., within the first few years, and many of the patients did not lose enough weight to reach their goals before they started to gain again.

However, for those who did reach their weight-loss goal like Bob, would having body-contouring surgery support their efforts to maintain their weight loss?  There is no answer. Indeed, the way to provide an answer would be to carry out a study comparing weight maintenance of patients whose excess skin is removed with patients who do not get the body contouring surgery. Both groups would receive the same nutritional counseling, personal training and psychological help so the only difference between the groups would be the removal of excess skin. Of course, the problem with such a study is that the results may show a positive effect on weight maintenance of skin removal. And then what?  The cost of such operations is almost prohibitive for most people and rarely covered by health insurance.

But perhaps this will change. Bariatric surgery is paid for by many insurance plans because studies have shown that the medical costs of obesity are much higher in the long run than the cost of the surgery. If body contouring is shown to have a significant effect on preventing weight gain after bariatric surgery, then perhaps this too will be covered by health insurance.

The better solution, of course, is to prevent the excessive weight gain necessitating the surgery.

The Silent Cause of Tiredness

Too often the response to the question “How are you?” is, “Tired.” A list of reasons justifying the fatigue usually follows: working hard and late, a household of children and/or visitors, too many outside commitments with deadlines, school papers and exams, inadequate sleep, recovering from a cold, and, of course, stress. The list could go on. Missing from this list, however, is a silent but potent cause of tiredness: iron deficiency anemia.  Iron is needed by the body to make hemoglobin, the constituent of red blood cells that transports oxygen from the lungs through the blood and delivers it to the cells. If, over a period of time, too little iron is consumed to make hemoglobin in amounts necessary to meet the needs of the body, iron deficiency anemia results.

Extreme fatigue is one of the symptoms of iron deficiency anemia, along with decreased stamina, increased vulnerability to infections, sensitivity to cold, increased heart rate and dizziness. Pale skin is also a symptom, but like so many of these signs, especially fatigue, other reasons for their presence can easily be summoned.  Many of us assume that we are suffering from some yet identified virus if we feel dizzy or out of breath climbing stairs. And, for many people, being pale in the winter is hardly considered unusual. And we often respond to our tiredness by eating. “Maybe if I eat a snack, I will feel more energetic,” we tell ourselves as we reach for a cookie or bag of chips.  We are unlikely to consider that maybe our fatigue is caused by an insufficient amount of iron in our diets. Unnoticed and unchecked, the depletion of iron stores continues to cause persistent fatigue that does not respond to more sleep or getting over a viral infection.

The National Institutes of Health Office of Dietary Supplements recommends that men and women of non-childbearing years obtain 8 mg of iron daily and 18 mg for premenopausal women. The larger requirement for women of childbearing age is based on monthly blood loss from menstruation.  Blood losses from medical conditions may also decrease iron stores. I had a neighbor who had a silent bleeding ulcer for months and was found to be severely anemic.

Iron deficiency anemia is not uncommon.  (“Iron Deficiency Anemia,” Killip S, Bennett J, Chambers M, Am Fam Physician 2007 1: 75: 671-678) According to a recent publication in the American Family Physician, “ The prevalence of iron deficiency anemia is 2 percent in adult men, 9 to 12 percent in non-Hispanic white women, and nearly 20 percent in black and Mexican-American women.” The trend toward intermittent fasting or cleanse diets may increase these numbers as a one or two-day fast cleanse diets, has been shown to rapidly deplete iron. (“Effect of short-term food restriction on iron metabolism relative well-being and depression in healthy women,” Wojciak R, Eat Weight Disord. 2014; 19:21-327)

Obtaining the necessary amount of iron from the diet is not as easy as, for example, getting enough vitamin C.  Although many foods contain iron, not all the iron in the food gets into the body. There are two types of iron: heme iron and non-heme iron. Heme iron comes from animal sources and is considered more “bioavailable” than non-heme iron. This means that the iron in the food is more able to get into the body from the intestinal tract than non-heme iron.

Liver is a good source of heme iron, but this food is not universally enjoyed (except, perhaps, by cats).  Lean meat and seafood, especially octopus, are also good sources, although the latter is also not particularly popular. Indeed, for most non-vegetarians as well as vegetarians and vegans, more of our iron comes from plant sources than animal foods.  According to the Office of Dietary Supplement report, about half of the iron we eat comes from fortified bread, cereal and other grains. In fact, cereal is a good source of iron:  one cup of bran flakes contains 4.5 mg of iron which is about half the amount men and post-menopausal women need each day. An avoidance of grain products means that the vegetarian and vegan eater must depend on obtaining iron from vegetables, lentils, dried beans, soy products like tofu, and nuts and seeds. The amount of iron in plant foods that are not fortified is low so that large quantities must be eaten each day to meet iron intake requirements, especially for women of childbearing age.  Moreover, there often is a misperception of how much iron is in the foods we think of as good sources of this mineral.

“I eat plenty of spinach and nuts,” a friend will say, “so I am not worried about getting enough iron even if I try to avoid eating meat.“  But an entire cup of cooked spinach (which is a large amount raw since it shrinks when cooked) has only 6 mg of iron. A cup of cashew nuts has 4 mg and lots of calories. Two large eggs have less than 2 mg of iron and one would have to eat an entire cup of hummus to get 5 mg of iron.

Iron in plant foods is also less “bioavailable” than the iron in animal foods. There are phytates and other substances in plant foods that grab hold of the iron and prevent much of it from being absorbed into the body from the intestinal tract. In fact, studies on the iron status of vegetarians have shown that they tend to have lower iron stores than non-vegetarians.   (“The effect of vegetarian diets on iron status in adults: A systematic review and meta-analysis,” Haider L, Schwingshackl L2, Hoffmann G3, Ekmekcioglu C ,  Crit Rev Food Sci Nutr. 2018; 58(8):1359-1374)

Fortunately, eating foods that are high in Vitamin C counteracts the effect of phytates on preventing iron from entering the body. Eating a vitamin C-rich food such as citrus fruits or juice, strawberries, broccoli, cauliflower, Brussels sprouts, and peppers including chili peppers, with an iron-containing food like oatmeal or tofu, significantly increases the absorption of iron, especially for people with low iron reserves.

However, if blood tests show that iron deficiency or iron deficiency anemia is present, it may be necessary to take an iron supplement and doing so should be under the care of a physician.  For many, this may be an easier solution than eating chopped liver or grilled octopus.  Once the problem is resolved and iron stores are back to normal, fatigue and the other symptoms of the anemia should disappear.

Eating Late: Will It Make Us Gain Weight?

Is it true that when we eat may influence our weight? For years, some nutritionists and diet consultants have told us “…not to eat dinner later than 6 pm,” or “…If you eat late at night you will gain a pound while you sleep,” or “…it is better to eat most of your calories early in the day.”  Now that daylight saving time has arrived, we may find ourselves eating dinner much later than we did a few months ago when it was dark by 5:30, or even much earlier. Indeed, as the hours of daylight extend into the evening, and the weather becomes benign, dinner may be pushed back even further as we are reluctant to go inside and settle down for the evening. If the timing of our meals does make a difference, might this have an impact on our weight? Should we stick to eating dinner no later than 7 pm because if we ignore this time limit, we will be gaining weight?

Compelling evidence supports the idea that the timing of meals may affect weight. A large study examining meal times among Seventh-Day Adventist church members in the United States and Canada suggests that we should consider rearranging our meal schedule. Researchers looked at food records of 50,660 adult Seventh-Day Adventists and their BMI ( body mass index), a measurement of their weight status. Would there be a relationship between the number of meals consumed, the timing of the major and smaller meals, which meals were usually skipped and their weight? Their results might make one reconsider when to eat.

People who ate breakfast had lower BMIs than those who habitually skipped this meal. Moreover, people who made breakfast their major meal of the day, rather than lunch or especially dinner, had a significantly lower weight than those who ate their largest meal at dinner. Eating a bigger lunch than dinner also produced lower body weight, although the differences were not as striking as between those who made breakfast their main meal of the day and those who ate their largest meal at night.  Snacks were counted as meals and, no surprise, people who ate more than three meals a day were in the heaviest category.

Breakfast consumption has also been linked to weight loss in a study in which dieting subjects ate most of their calories at breakfast or at dinner. Both groups ate the same number of calories but those who ate most of their calories at breakfast lost significantly more weight than the other group.

These results suggest that populations that traditionally eat tiny breakfasts and large evening meals might have a high rate of obesity. In two such countries, Spain and Argentina, breakfast is often only coffee and perhaps a roll or pastry, and dinner usually begins, at least in restaurants, no earlier than 10:30 pm. However, despite their late dining and inadequate breakfasts, the prevalence of obesity doesn’t even come to close to what we have in the States where we finish our dinners before they have picked up their forks to begin theirs. The prevalence of obesity in both Spain and Argentina is around 14%.

In contrast, one out of every four Americans is obese. Moreover, articles lamenting the increase in the numbers of overweight and obese individuals in these countries do not mention the lateness of the dinner hour, but instead focus on the same factors that are responsible in part for our rise in obesity: too many high calorie snacks, too little exercise, too much watching television, too little consumption of fruits and vegetables and too much fast food. Sound familiar?

Nevertheless, can we disregard the studies indicating that consuming the majority of our calories before sunset might help us in the obesity battle? Should we stop having people over for dinner or celebratory occasions involving food in the evening, and switch to brunch or breakfast instead? Should lunch be the default main meal and dinner limited to soup and a salad, or yogurt and fruit?

One problem with transferring information from studies with compelling results such as the one with the Seventh-Day Adventists is that life gets in the way of implementation. Early mornings, filled as they are with getting breakfast for the family, walking the dog, long commutes, getting the kids to daycare or school, and the myriad obligations that arise between waking up and being at work seem incompatible with preparing and consuming a large meal. Moreover, lunch, the other opportunity to eat the major meal of the day, is rarely a complete meal. Do people go home for a hot meal at lunchtime anymore? Most of us content ourselves with a salad or sandwich and consider ourselves lucky if we can eat it at a table rather than at our desk or sitting on a curb near a construction site.

Perhaps the real problem is being too hungry at dinner. If breakfast and lunch are skipped or skimpy, late afternoon-early evening hunger hijacks our control over eating while preparing dinner, at the meal itself, and afterward. We may justify our grabbing and gobbling because we have eaten so little earlier in the day. And we munch on cookies or ice cream after dinner because “they couldn’t have any more calories than the breakfast or lunch we skipped.”

It is unlikely that breakfast will become the new dinner, regardless of research on its impact on weight. But we should not minimize the importance of this meal as well as lunch in controlling our hunger late in the day. It really might work.