Travel Can Leave You Well Fed, But Not Well Nourished

The group of women with whom I was traveling stared at the menu in some dismay. For those who shunned gluten, meat, dairy, and a category of vegetables known to cause intestinal discomfort to some, there was almost nothing to eat.

“Maybe we can find a supermarket somewhere,” one suggested, but then realized that to do so required driving to a shopping mall a few miles away from the gift shop-congested town center. Fortunately, a few protein bars were discovered at the bottom of someone’s tote bag, and hunger was relieved momentarily. We were in a geographical part of the country noted for heat-infused food from chili peppers, the liberal use of melted cheese with pork products, beans refried in lard, gluten-containing flour tortillas, and a notable absence of soy or almond milk for those lactose intolerant.  Although the women were athletically fit and had traveled to spend a few days hiking in remarkable landscapes, their digestive systems did not have the same robustness as their muscles. Eventually, our finding a ride to a large supermarket provided enough food for dinner, as well as snacks for the hikes; an Internet search of restaurants revealed a few that met most of their dietary needs.

But their experience demonstrated how difficult it can be to obtain foods from restaurants in places not accustomed to altering menu options for those whose stomachs need special foods. These days, we assume when we travel, we will be able to get our personalized food needs met.  After all, it is no longer the early part of the 20th century when people traveling on the new highways had to content themselves with eating in small Mom and Pop restaurants their typically questionable cleanliness and food preparation skills.  Standardization of food for highway travelers came only when restaurants like the Howard Johnson franchises opened around the country. Today the ubiquitous fast-food restaurants and the next generation sandwich shops that make salads and sandwiches to order make it relatively easy to find safe and reasonably tasting food.

But even now, eating as a traveler may mean giving up trying to eat a well-balanced diet. The recommended five servings of vegetables and fruit to be consumed each day may not even be consumed in five days. Vegetables rarely appear on the plate with the main entrée, or are reduced in size to microscopic versions of the natural object. Salads and side orders of vegetables are costly, and the vegetables may come coated in cheese, drenched in butter, or breaded and fried.  It is possible, sometimes, to get fruit as a dessert but often the fruit is a few raspberries garnishing chocolate cake or in syrup topping a dish of ice cream. Foods we can obtain at home, such as low or fat-free dairy products (and milk substitutes), may also be hard to find. Many restaurants serving breakfast do not provide low or fat-free yogurt, cottage cheese and milk for cereal and coffee. And finding high fiber foods to maintain healthy and predictable digestion is harder than finding kale in a MacDonald’s.

When traveling is relatively brief—less than a couple of weeks—the scarcity of nutrients or fiber or food items suitable for a limited diet is not going to plunge the traveler into a state of malnutrition. We start our trip well-nourished and certainly are not going to develop scurvy or osteoporosis in a couple of weeks. But many people travel constantly for work and some have the time and financial freedom to travel for long periods for pleasure.  This type of travel can result in more than just piles of dirty laundry to take home; it can affect the nutritional status of the traveler. And curiously, we tend to ignore this problem when packing for a trip.

Packing requires anticipating weather conditions, activities ranging from work to sightseeing and entertainment and even sleeping comfort. But how many of us pack to ensure that we are not surprised by eating environments as unpredictable as the weather? Are we making sure that the eating culture at our destinations will provide food meeting our personal dietary needs? And if not, do we have in our carry-on luggage food items that will prevent us from returning several weeks later in a state of sub-optimal nutrition?

Some simple steps to take before a long trip:

Check out the types of foods typically eaten at the destinations. The Internet will provide this information both from a description of the food highlights of the destination, and also from a brief scan of moderately priced restaurants (these are the ones most likely to be visited, not the very pricey ones).

If breakfast is included in the lodging, try to learn what is served. Sometimes a breakfast buffet will provide foods from all the food groups. (Israeli hotel breakfasts have done this for decades.)

Pack multi vitamin-mineral supplements as insurance against many days of vegetable, fruit and dairy deficient menu options. Lactase pills to digest the milk sugar lactose are tiny, fit into a toiletries bag and allow you to add milk to your coffee or cereal if you have lactose intolerance.

Pack gluten-free baked goods if you must avoid gluten, because eventually a need for some digestible carbohydrate will arise.  Baby carrots, vacuum-packed apple slices, and a sandwich bag filled with high fiber breakfast cereal will provide some fiber. Oat bran cereal can be put in a sandwich bag as wel,l and if the hotel has a coffee maker, the hot water will reconstitute it as hot cereal.

Pack protein bars that contain 15 to 20 grams of protein. These will be useful when the protein on the menu is incompatible with a vegetarian, pescetarian (fish only), kosher, or low-fat diet.

Although these extra items take up space on the outbound trip, their consumption frees up space for the return home to be filled with whatever your heart, not stomach, desires.

Can You Lose Weight If You Don’t Know How to Diet?

Our formerly thin, physically active friend had gained close to 80 pounds following two years of debilitating orthopedic problems that left him with chronic back pain. His previous constant exercise, which included tennis, skiing, long bike rides, hiking, and running had kept his weight normal, but became no longer possible. Now he was able to move only with the help of a back brace and two hiking sticks that he used as canes.

“I am trying to lose weight,” he told us, “but it is slow going.”

When we were guests at his home, it was obvious how physically impaired he was as well as how hard it was going to be for him to attain a weight that would help relieve his back pain. The one day he walked on his long hilly driveway to point out a particularly beautiful landscape, he paid for it in increased pain the next morning. Simply moving from living room to dining room was difficult for him. He talked about how he never needed to diet before he developed a back problem because his level of physical activity kept his appetite down and burned off excess calories. A review of the relationship between physical activity and weight change confirms his experience. (“The Role of Exercise and Physical Activity in Weight Loss and Maintenance,” Swift, D., Johannsen, N., Lavie, C., Earnest, C., Church, T Prog Cardiovasc Dis 2014, Jan-Feb; 56 (4): 441-447.)

Routine physical activity like the type my friend used to do slows, or even prevents weight gain, without any change in calorie intake. And the long duration of many of his physical activities may even have dampened his appetite according to a very recent study published in the Journal of Endocrinology. (“Acute effect of exercise intensity and duration on acylated ghrelin and hunger in men,” Broom, D., Miyashita, M., Wasse, L., Pulsford, R., King, J., Thackray, A., Stensel, D., J Endocrinol. 2017; 232 (3): 411-422.)  Now, however, the beneficial effect of exercise, when added to a reduced calorie diet on hastening weight loss is out of reach for him.

Told by his physician that a substantial weight loss might lessen his back pain has motivated him to decrease his calorie consumption. His strategy, as he told us, is to consume less than he had been eating.  But he has lost very little weight over the past few months of attempting to do just this.  His lack of success may be due to his inexperience in dieting. He doesn’t know how much he is eating, nor does he know whether what he is eating is particularly high or low in calories (he does know the difference, however, between salads and cake.)  Another family member, who has never had a weight problem and likes to cook dishes containing high calorie ingredients, prepares his food. Butter, heavy cream, and cheese are routinely added and her sweet tooth motivates her to bake or buy cakes, cookies, pies and other desserts that are offered to our friend.  Eating in restaurants for dinner (and occasionally both lunch and dinner) occurs frequently, and this adds to the uncertainty of how many calories are being consumed. Overly large restaurant portion sizes, and the habit of chefs to add butter or oil to food to keep them moist, also inadvertently boosts his calorie intake. And, unlike experienced dieters, he has not developed an eye for judging portion sizes and not eating the entire amount if it is too big.

None of this would matter if losing weight were for cosmetic rather than medical reasons. However, when weight loss is crucial to improving health, and, in his case, restoring lost freedom of movement and removing his pain? Dieting must be done with the same care and knowledge as any other intervention to improve health. The approach cannot be casual or haphazard, and would probably benefit from the professional services of a dietician or nutritionist. The type of diet must also be sustainable and balanced nutritionally for the many weeks it takes to lose the necessary weight. Many alleged quick weight-loss diets, so tempting because results after only a few weeks are supposedly so dramatic, often lead to weight gain as soon as the diet is over. (Remember the Oprah Winfrey’s famous fast weight-loss from a low calorie liquid diet, and the subsequent rapid regain several years ago?) Regaining weight is not an option when it may bring about a return of the medical problem like intolerable back pain. Thus the diet plan has to be malleable enough to change into a long-time maintenance program to keep the now lower weight stable.

Being honest with family and friends about how hard it is to lose weight and consequently asking for help will improve the chance of success. Imagine how much more weight our friend would have lost if his meals had been significantly lower in calories and size. Preparing meals at home that that could be made without the addition of fat-dense ingredients such as cheese would help reduce the calories he was eating. If others wanted to add more cheese to their dishes, for example, they could do so after the food was prepared.  His problem in reducing calorie intake in restaurants could be solved by either eating in establishments that served normal-size portions, or ordering appetizers for a main dish or splitting an entrée. The temptation to eat dessert would disappear if it were not on the table in front him.

Dieting is like any new activity. As it is with playing the piano, speaking a foreign language, or planting a successful garden, it has to be learned. Instruction is needed, along with patience, the willingness to practice and make mistakes, and encouragement from others. And like taking on any new activity, even small successes are worthy and worth striving for.

Would Walkable Sidewalks Keep Us Thinner?

A few weeks ago on a trip to a picture perfect Vermont town, we asked the proprietor of our B&B if we could walk to the concert that night.

“You can, sure… it is less than a mile, but it will be dangerous walking home in the dark. There are no sidewalks and no street lights,” she told us.  So we drove, despite feeling silly at using the car for such a short distance, but happy we had done so when we left the concert. Ground fog was adding to the darkness in concealing the road, and we were sure we would not have felt safe walking back up the hilly, winding route.

The next day, we chatted about the lack of sidewalks and street lights with our hostess. She told us that daytime walking on the roads was manageable in the non-snow months, but not in the winter; the snow banks reduced the width of the roads and eliminated any possibility of stepping off the pavement.  “See, there’s is no side of the road to stand on when a pick-up truck comes speeding down the mountain….no one walks; it’s just too easy to be hit.”

There is no lack of activities in Vermont to provide opportunities to exercise, even if taking long walks in the winter is not one of them (Unless it is on a packed snow trail.) But unlike the quick convenience of going out the door to take a walk when sidewalks (plowed, of course) do exist, the lack of sidewalks in suburban or rural areas makes this simple activity difficult to carry out.

For the exercise committed, there are, of course, numerous opportunities to engage in physical exercise regardless of weather or environment. Not so for those who prefer being sedentary and are unlikely to seek out opportunities to move. In an episode of a television program focused on finding a house to buy, the client announced that she was too old (she was in her fifties) to buy a house with stairs. “Too much walking, “she told her realtor. Not surprisingly, the community in which she was house hunting had no sidewalks. If this woman had been advised to walk for her health and weight, she would have had a ready excuse. “Where? There is no place to walk where I live!”

No one has to be told about the rising incidence of obesity. Simply looking around confirms its prevalence, although the effects such as diabetes, back & leg pain, as well as the increased risk of certain types of cancer are silent.  One obvious culprit is that we eat too much, in part because portion sizes of just about everything have increased. Another fault lay in that we no longer live a lifestyle readily allowing us to burn off those excess calories. When physical activity was unavoidable in order to earn a living and maintain a household, a large caloric intake provided the fuel for the constant physical activity.  Now caloric intake has remained the same, or most likely increased, while physical activity has become optional for the most of us most of the time.

Because they eliminate a source of calorie use, might the absence of walkable sidewalks be a contributing factor to the continuous rise in obesity? The Journal of the American Medical Association (“JAMA”) published a study in 2016 showing that residents living in walkable urban neighborhoods had a slower increase in obesity and diabetes than those living in less walkable ones.  For this specific research, almost 9,000 urban neighborhoods in southern Ontario were studied over more than 11 years.  This study’s “Walkability Index” was based on safety of the sidewalks, the residential and commercial density, cross walks at intersections, schools, coffee shops, banks, and other retail establishments which might be walkable destinations.  People living in the walkable neighborhoods, and New York City is another example; they use sidewalks not only to get to their routine destinations like work, stores and restaurants but as places for urban hikes. These city dwellers may spend an entire day outside, hiking and exploring different parts of their city. The seemingly limitless places to walk allow them to do so.

However, it’s important to note the benefits of walking by city dwellers are not available to residents of towns such as the one we visited in rural Vermont. The population density is too low to justify the expense of sidewalks, and indeed many of roads are not even paved. Of course there are numerous places to hike, but this activity is not only seasonally limited, but also limited to people whose stamina and age enable them to climb mountain trails.

Perhaps the answer is to emulate many European cities which have set aside parkland filled with paved paths for walking. From my limited experience of these parks which I have seen in Holland, France and Germany, they are usually filled with walkers early in the day and then especially in the summer, after dinner. Benches are numerous for those who need to rest or just admire a view.  Strolling through one of these walking parks has the additional advantage of allowing members of a community to see and talk with each other. People often walk in small groups, or stop and greet others coming in the opposite direction. When so many members of a neighborhood are out walking?  It is easy to see this activity as a routine and healthful aspect of the day.

Eating less to prevent weight gain and/or lose weight is difficult because potential temptation lurks in the next meal. Walking may not compensate entirely for excess calories, but it can have a positive effect on preventing weight gain… unless of course, one walks to the doughnut shop.

Cite: Association of Neighborhood Walkability With Change in Overweight, Obesity, and Diabetes. Creatore M, Glazier R, Moineddin R.  JAMA  2016, 315; 2211-2220

The Covert Bullying of Obese Adults

When I congratulated a friend on her promotion to the head of a non-profit organization, she smiled and then told me it almost did not happen. “I learned that someone on the board did not want me to get the position and campaigned actively against me,” she told me.

“Why?” I asked. “You were obviously the front-runner.”

“Because I am fat,” she replied. “He told everyone on the board that he would not hire anyone who was fat. At least he is not criticizing my competence, only my size.”

But she was wrong.

The board member was likely not rejecting her solely because he believed her size or shape might affect her stamina in wearing the hats of an administrator, fundraiser, and creative director of a mid-size organization. He may have believed that her obesity reflected a deficit in her overall ability. A review of many studies of employer attitudes toward obese workers presented evidence that obese people are thought to have less leadership potential than normal-weight individuals. The obese are viewed as lazy, undisciplined, slow, unmotivated, and incapable of advancing to positions of responsibility. Thus my friend, whose resume indicated an unusually strong record of leadership and creativity in a previous position, could have been judged as inferior on these traits simply because she was fat.

Had she been male and obese, her size may not have been considered a detriment unless the job required physical skills that were difficult to perform because of weight. But an obese woman whose job requires some visibility—while fundraising, representing the organization at meetings, or giving presentations—might be passed over because of her appearance.

Had she failed to win the position, a claim that she was being discriminated against would have had no legal impact in the state in which she worked. The state of Michigan and some cities, including San Francisco and the District of Columbia, have outlawed employment discrimination against the obese.

Proving that a job is not offered or advancement not received because of size discrimination is very difficult. The board member did not publicly announce the reason for his opposition to anyone, but secretly told other members of the search committee. Happily, there were leaks, and eventually everyone in the organization knew and so did she. But even though he wished to deprive her of the position because of her weight, there was little she could do about it. What real proof did she have?

Obese employees face the same type of discrimination that smokers do, although 29 states prohibit the non-hiring of smokers. However, one justification of the employment discrimination against smokers is based on health risks to the smoker and thus increased medical costs to the employer. Other reasons include leaving the work site to smoke in a designated area, although this is a weaker argument since breaks for everyone are often built into the workday.

Many assume that the smoker, or indeed the obese individual, could quit or lose weight if he or she wanted to. Thus discrimination against these groups is sometimes justified by the belief that it’s their fault.

An article in the New England Journal of Medicine refutes the argument that smokers irresponsibly raise healthcare costs because they don’t want to stop smoking. What is rarely understood, except by ex-smokers, is how hard it is to break the addiction to nicotine. Surveys have shown that 69 percent of smokers want to quit but are unable to do so.

Losing weight and maintaining weight loss is similarly difficult, and the same uninformed attitudes persist. “Just stop eating so much and start exercising!“ (As if they hadn’t tried to do so.) The reasons for gaining weight are so varied and often so psychologically complex that simplistic solutions make about as much sense as trying to prevent the oceans from rising by stacking sandbags on a beach. I have a neighbor who gained a substantial amount of weight while she was on large doses of prednisone to reduce inflammation, and a distant relative who gained 125 pounds on a combination of antidepressants and mood stabilizers. Would they be unemployable?

The laws protecting the obese from workplace discrimination are insufficient or nonexistent. Children bullied on the playground may have more protection, because sometimes there is a teacher who can intervene. No one is watching or reprimanding the adult bully who refuses to hire or promote someone who is overweight.

How Do You Know If Supplement Claims Are Hype or Truth?

At a recent university-sponsored conference on innovations in nutritional and fitness products, there was a discussion about the increasing number of fraudulent claims associated with such products in the market. When one speaker, a principal in a firm investing in start-ups specializing in fitness and nutrition, was asked how to detect ineffective or fraudulent products, he was unable to give a useful answer.

“It’s very difficult because often the claims are made up or supported by faulty research published in company-owned or for-profit journals. If it works, it is probably not a fraud,” he concluded. Someone from the audience responded with, “Yes, but placebos work also.”

The Food and Drug Administration (FDA) can barely keep up with the proliferation of fraudulent health products. Some make claims that cannot possibly be produced by the ingredients; others contain substances which are not allowed to be sold due to serious side effects, or must be prescribed only by a physician. Often states, as well as the FDA, step in to expose the deceptive nature of claims made by supplement manufacturers. In a well-publicized case a few years ago the New York State Attorney General’s office tested the contents of several popular herbal supplements and found either none of the advertised active ingredients in the product or levels too low to be effective. This past winter, the New York State Attorney General and the Federal Trade Commission (FTC) charged a company that claimed its product was shown in clinical trials to improve memory and cognition with making, “…False and unsubstantiated claims…” because the study cited by the company actually showed the product not working any better than a placebo. Yet the advertisements, seen frequently on television, were so compelling that the sales topped $165 million.

The most common claims seen on the labels of such dubious products are for weight loss, sexual performance (erectile dysfunction), memory loss, and mood.  Some claims are almost magical in the sweep of their promises: A New York firm claimed its dietary supplement treated senile dementia, brain atrophy, atherosclerosis, kidney dysfunction, gangrene, depression and osteoarthritis along with lung, cervical and prostate cancer. Alas, for anyone now wanting to buy a product that will cure all that is wrong with you, it is no longer available. U.S Marshals seized it after a request by the FDA in 2012.

Personal testimonials are often so compelling that they sell a product. Who hasn’t looked at the before and after pictures of someone who used a weight-loss product and marveled at the change? Statements like, “I am no longer hungry, depressed, diabetic, or bald!“ beckon to us from the internet, tabloid magazines, newspaper advertisements and television spots. These people must be real, one thinks…and if he grows hair, maybe I will also.

Health products claiming a quick fix such as, “Cover your bald spot by next Tuesday,” or, “Lose your double chin by this afternoon!” are also hard to resist, but should be regarded with as much suspicion as someone trying to sell you a bridge. Glue is a quick fix; health products rarely are. The FDA tells us to beware of health products attempting to gain a marketing edge by claiming that they are all natural. By the way, snake venom is also natural.

One easy way to detect whether a claim is legitimate or not is whether the term, “Miracle” is used on the label. Look at it this way, if the words “miracle cure” are attached to the ad, consider it a miracle that anyone is foolish enough to buy the product.

But of course there are many over-the-counter (non-prescription) supplements that work, are safe, contain the dose of active ingredients printed on the label, and don’t hide drugs deemed illegal by the FDA. If a combination of vitamin D and calcium promises bone health in the amounts recommended by physicians, such a supplement will help to restore bone cell growth and decrease bone fragility. Supplemental vitamins, minerals and protein will help restore depleted levels of these nutrients due to prolonged illness, chemotherapy, or gastrointestinal impairment. Again, it is imperative to check with a healthcare giver about quantities; more is not always better.

But what if you are not sure whether the claims are to be believed. What should you do?

Ask your health care provider. Take a picture of the ingredient label on a product you are thinking of buying, and ask whether any of the ingredients actually do what they are supposed to. Use the internet to look up the ingredients to see what studies support the claims of the product. Write to the FDA.

Example: A product relieving anxiety and stress claims that the ingredients, “…promote serotonin synthesis.” But the main ingredients are chamomile and valerian, herbal products that may cause drowsiness; these do not promote serotonin. A physician will know that the product is incapable of increasing serotonin synthesis.

Here’s another: A product containing saffron extract as its main ingredient claims, ”…Reduces cravings, boosts metabolism, blocks appetite, lowers blood pressure and increases energy.” Investigating whether there are any studies linking saffron extract to all these wondrous health effects may seem like a nuisance, but will save money and possibly, ill side effects.

Signing up for the FDA Consumer Updates page is essential for anyone routinely buying supplements because of their weekly descriptions of products containing hidden drugs, fillers, or bits and pieces of insects or twigs. Recently, the agency has warned consumers about more than 100 products containing illegal drugs; most of these products are sold for sexual enhancement, weight loss and bodybuilding.

Avoiding supplements that may not work, may not contain the ingredients listed, or contain ingredients that are harmful cannot be ensured. But a little homework and help from the FDA make the odds better that what you buy is safe and effective.

Meals in a Box: The Answer to Eating Your Vegetables?

More than a dozen companies will, for a price, send you the ingredients for a complete, relatively interesting dinner, or smoothie snacks even, if you choose that option. All you have to do is open the many large and small packages, read the instructions and in 30 minutes or so, eat your own freshly prepared entrée. The concept is practical for the many who do not have the time or energy after work to figure out what to prepare for dinner and then to make sure the ingredients are in the kitchen. Meal-in-the-box choices tend to be more imaginative than grilled chicken breast and frozen veggies because professional chefs devise the menus and make available the entire ingredient list from the main course protein to a tiniest pinch of some herb or spice that the customer probably never heard of and/or doesn’t have. No looking up recipes in a cookbook or on the Internet is needed, nor guess work about the cooking methods.  Detailed instructions are given, perishable foods are kept cold with icepacks, and preparation time is thirty minutes. The end product may not get you, the customer, a spot on the Food Network program “Chopped” in which professional chefs are given ingredients in a box and compete to make an original perfectly cooked entrée and sides in thirty minutes…But unlike the competitors who turn their food over to the judges? The customers of meals in a box get to eat their finished product.

However, making the meals from the ingredients in the box will cost about twice as much as making it from ingredients assembled yourself. According to Consumer Reports, one company’s blackened tilapia dish costs almost $12.00 per person, compared to a little more than $5.00 when put together oneself. A tofu and Chinese broccoli dish from another company costs over $11.00. These ingredients are very inexpensive and will cost approximately $3.50 if you buy the ingredients from the supermarket, and even less from a Chinese grocery store.  The prices for some of these dishes are less than in a restaurant (although perhaps not for the Chinese entrée) but add up quickly as the cost is per person. Moreover, unless the customers are small eaters, no leftovers for the next day’s lunch will remain. But it is also unlikely that there will be much wasted, thrown away, uneaten food. Nor will the refrigerator fill up with plastic containers full of tidbits from previous meals.

It is no surprise, given our current fixation of dietary restrictions that gluten-free, carbohydrate-free dairy-free, vegetarian, vegan, organic (of course) calorie-restricted meals are available depending on which company is providing the foods.

But are they healthy? Will eating a meal from a box provide you with some of the vegetable, fruit, grain, protein, and dairy servings you ought to be getting? It depends. Certainly compared to many takeout and restaurant meals that tend to be free of food groups containing nutrients your body needs, the boxed to-be-prepared meals often contain substantial amounts of vegetables, and sometimes whole grains. If you tend to ignore the vegetables in your refrigerator bin until they turn into a slimy green mass, then ordering meals with a substantial amount of vegetables will ensure that you are eating this essential food group.

Yet there is a possible nutritional caveat to some of the meals. The salt content may be higher than recommended, especially if some of the seasonings contain sodium, like garlic or onion powder, or if salt if added several times during preparation. Consumer Reports analyzed sodium content and found many dishes containing 30% more than recommended, and some dishes containing as much as 1 gram of salt per serving.

Are boxed meal ingredients a trend, or the beginning of a permanent shift in the way people prepare meals? Probably the latter because they appeal not only to those who don’t (and won’t) prepare meals from scratch, but also to a generation who have been preparing meals from scratch for decades. For those who have been afraid to boil water, learning how to cook from the boxes might eventually give them confidence to cook on their own. It is sort of comparable to shifting from paint-by-numbers to covering a blank canvas with one’s own creation. For those who are tired of figuring out what to cook for dinner and despair at the high prices and noise levels of most restaurants, boxed meals are an easy way of eating interesting food less expensively (and in a setting that doesn’t require either waiting or tipping.)

Many companies are selling meals for people on all sorts of diets and presumably are competing with portion-controlled, factory-prepared meals sold by some national weight-loss companies.  Since the meals in a box are portion and ingredient controlled, the dieter does not have to be concerned about going over a calorie limit. There is no guessing about whether the weight of the entrée or the teaspoons of olive oil will fit the calorie requirements for a particular meal. On the other hand, by requiring the dieter to get involved in food preparation, she may lose her fear of not being able to prepare a meal on her own that allows her to continue to lose weight and/or keep it off.

This trend is still relatively new, but its rapid growth indicates that it meets the lifestyles demands of large numbers of people. However, since spending a little time in meal preparation is still necessary, we should not be surprised if, a few years from now, some of the boxes will contain a robot that will do the cooking.

According to a 2016 Consumer Reports analyses, home delivery of meal ingredients is about a $400 million dollars a year industry. Although the major portion of the sales are focused along the coasts and in major urban areas, sales are projected to increase throughout the country. They may not be replacing all home delivered pizza and Chinese food, but certainly offer healthier and more varied options.

How Do You Know Whether Supplement Claims are Hype or True?

At a recent university-sponsored conference on innovations in nutritional and fitness products, there was a discussion about the increasing number of fraudulent claims associated with such products in the market. When one speaker, a principal in a firm investing in start-ups specializing in fitness and nutrition, was asked how to detect ineffective or fraudulent products, he was unable to give a useful answer.

“It’s very difficult because often the claims are made up or supported by faulty research published in company-owned or for-profit journals. If it works, it is probably not a fraud,” he concluded. Someone from the audience responded with, “Yes, but placebos work also.”

The Food and Drug Administration (“FDA”) can barely keep up with the proliferation of fraudulent health products. Some make claims that cannot possibly be produced by the ingredients; others contain substances which are not allowed to be sold due to serious side effects, or must be prescribed only by a physician. Oftentimes states, as well as the FDA, step in to expose the deceptive nature of claims made by supplement manufacturers. In a well-publicized case a few years ago the New York State Attorney General’s office tested the contents of several popular herbal supplements and found either none of the advertised active ingredients in the product or levels too low to be effective. This past winter, the New York State Attorney General and the Federal Trade Commission (“FTC”) charged a company that claimed its product was shown in clinical trials to improve memory and cognition with making, “false and unsubstantiated claims” because the study cited by the company actually showed the product not working any better than a placebo. Yet the advertisements, seen frequently on television, were so compelling that the sales topped $165 million.

The most common claims seen on the labels of such dubious products are for weight loss, sexual performance (erectile dysfunction), memory loss, and mood.  Some claims are almost magical in the sweep of their promises: A New York firm claimed its dietary supplement treated senile dementia, brain atrophy, atherosclerosis, kidney dysfunction, gangrene, depression and osteoarthritis along with lung, cervical and prostate cancer. Alas, for anyone now wanting to buy a product that will cure all that is wrong with you, it is no longer available. U.S Marshalls seized it after a request by the FDA in 2012.

Personal testimonials are often so compelling that they sell a product. Who hasn’t looked at the before and after pictures of someone who used a weight-loss product and marveled at the change? Statements like, “I am no longer hungry, depressed, diabetic, or bald!“ beckon to us from the Internet, tabloid magazines, newspaper advertisements and television spots. These people must be real, one thinks…and if he grows hair, maybe I will also.

Health products claiming a quick fix such as, “Cover your bald spot by next Tuesday!” or, “Lose your double chin by this afternoon!” are also hard to resist, but should be regarded with as much suspicion as someone trying to sell you a bridge. Glue is a quick fix; health products rarely are. The FDA tells us to beware of health products attempting to gain a marketing edge by claiming that they are all natural. By the way, snake venom is also natural.

One easy way to detect whether a claim is legitimate or not is whether the term, “Miracle” is used on the label. Look at it this way, if the words “miracle cure” are attached to the ad, consider it a miracle that anyone is foolish enough to buy the product.

But of course there are many over-the-counter (non-prescription) supplements that work, are safe, contain the dose of active ingredients printed on the label, and don’t hide drugs deemed illegal by the FDA. If a combination of vitamin D and calcium promises bone health in the amounts recommended by physicians, such a supplement will help to restore bone cell growth and decrease bone fragility.  Supplemental vitamins, minerals and protein will help restore depleted levels of these nutrients due to prolonged illness, chemotherapy, or gastrointestinal impairment. Again, it is imperative to check with a healthcare giver about quantities; more is not always better.

But what if you are not sure whether the claims are to be believed. What should you do?

Ask your health care provider. Take a picture of the ingredient label on a product you are thinking of buying, and ask whether any of the ingredients actually do what they are supposed to. Use the Internet to look up the ingredients to see what studies support the claims of the product. Write to the FDA.

Example:  A product relieving anxiety and stress claims that the ingredients, “…promote serotonin synthesis.” But the main ingredients are chamomile and valerian, herbal products that may cause drowsiness; these do not promote serotonin. A physician will know that the product is incapable of increasing serotonin synthesis.

Here’s another: A product containing saffron extract as its main ingredient claims, ”…Reduces cravings, boosts metabolism, blocks appetite, lowers blood pressure and increases energy.”  Investigating whether there are any studies linking saffron extract to all these wondrous health effects may seem like a nuisance, but will save money and possibly, ill side effects.

Signing up for the FDA Consumer Updates page is essential for anyone routinely buying supplements because of their weekly descriptions of products containing hidden drugs, fillers, or bits and pieces of insects or twigs. Recently, the agency has warned consumers about more than 100 products containing illegal drugs; most of these products are sold for sexual enhancement, weight loss and bodybuilding.

Avoiding supplements that may not work, may not contain the ingredients listed, or contain ingredients that are harmful cannot be ensured. But a little homework and help from the FDA make the odds better that what you buy is safe and effective.

Social Loneliness May Make the Depressed Even More So

Loneliness is a state that may affect everyone at some point in his or her life. It is not necessary to go on a trek across the continent, or row alone across the Atlantic to feel lonely. Sitting by oneself in a crowded movie theater or restaurant, or walking on your own on a lovely spring afternoon in a park filled with couples, families and friends can feel just as isolating.

Sometimes social isolation is a matter of choice or temporary circumstance. A relative of mine, who had to rewrite a 500-page thesis in order to turn it into a book, willingly isolated herself for months in order to accomplish this task. A parent unable to leave the house because of weather and sick children may not speak to anyone over the age of six for a few days, but knows that eventually this will change. A computer coder may shun company for days in order to finish a time dependent task; so too may anyone involved in a creative act.

Others are alone too much, but not by choice or a temporary situation. It is a fact of their lives. The groups one thinks about first are the elderly, and those we call “shut-ins.” They weren’t always so alone but sickness, frailty, lack of easy transportation, death of spouses, friends, and even adult children…potentially their declining eye sight and hearing, limited financial resources, and fear of crime may result in an extremely limited interaction with the social world.

“My friends are all dead,” my husband’s uncle used to tell us as he reached the late nineties. “All the guys I would play cards with and have a meal with, they are all gone.”

Residence in an assisted-living facility may surround an elderly individual with people, but social interactions and friendships do not necessarily follow. A sad scene familiar to those of us who have visited relatives in facilities is a row of residents, lined up in wheelchairs, who are not talking to each other, and indeed seem to be totally isolated despite the other people around.

But one does not have to live into old age to feel this social loneliness. People of all ages who are suffering from mental illness can experience it at any age. In a recent report put out by an Australian mental health support organization, about 66% of people with mental illness report feeling socially isolated compared with about 10% of the general population. The reasons for this vary from lack of money and/or transportation, misunderstanding among others as to the nature of the illness, and even fear of others prevent forming a close relationship. Those with mental illness often claim that they are stigmatized, or at the very least, treated differently.

“Maybe people believe we are going to behave in unpredictable, embarrassing, or violent ways,” said a friend who has suffered from bipolar disease for years. “There is reluctance for a casual interaction to go much further.”nability to become involved in activities that may decrease loneliness is sometimes generated by mental illness itself. Social phobia, fears about public spaces (although these days, this may just be commonsense), inability to leave the house, hold a job or even communicate without difficulty; all reduce the possibility of interacting with others. A weight-loss client of mine was very specific about the days she could come to my office, as they were dependent on her cycles of mania and depression. Another client who was depressed would stay up very late at night and sleep most of the day, thereby avoiding the necessity to interact with anyone.

Regardless of the causes of social isolation and the groups who are affected by it, being alone is not good for one’s mental and physical health. Being alone most of the time is associated with increased weight, poorer diet, decreased exercise, alcohol abuse, greater risk of sickness, and even a shorter life span. Cognitive functions decline, possibly as a result of few verbal interactions. Added to this is the emotional pain of being lonely. People whose circumstances prevent them from interacting with others for short periods of time report feeling depressed and out of touch with what is going on around them. Imagine the effect if social isolation is a way of life.

Fortunately, there are social spaces where people with mental illness can go and feel comfortable and accepted, as well as receive advice, support, and/or information about relevant services, are available in many communities. Volunteers in organizations like the National Alliance usually run these drop-in centers or peer support groups on mental illness. They provide a critical service, especially for those patients and their families who are seeking to interact with others experiencing the same problems.

Going to meetings is one way of decreasing time spent alone, and it is possible that a network of acquaintances with whom to spend time can develop from this. Several years ago, I led a weight-loss group made up of mentally ill individuals who had gained weight on their psychotropic medications. After a few meetings, the participants organized Sunday walks or, if the weather was bad, a meal and a movie.

Unfortunately, making available accessible and socially safe places for people with mental illness to meet is dependent on volunteer resources, and these may be limited to family and friends of the mentally ill. The sad fact is that many potential volunteers would probably prefer giving their time (and maybe money) to an animal adoption center than spend time socializing with mentally ill individuals.  An acquaintance in a mid-size southern city found that despite city resources to fund a drop-in center associated with a neighborhood health clinic, there were no volunteers available to staff the facility.

According to the previously mentioned SANE report, almost all people with mental illness consider social relationships important in helping them manage their symptoms and improve the quality of their life. They said that simply having someone to talk to about how they feel is critical to their feeling better. It doesn’t take many people to diminish the loneliness of an individual.

Just one will do.

We all should try to be that one.

With Whom You Eat May Affect How Much You Weigh

Two weeks ago we were dinner guests at an expensive steak restaurant. Our hosts, who were celebrating their anniversary, urged their guests to order the restaurant’s specialty steak: twenty-four ounces of aged beef.  Everyone, except for another guest and I, complied (we both ordered fish.) Many side dishes were ordered by the hosts to be passed around family style: a dish of fried potatoes oozing butter, asparagus coated with a creamy sauce, and broccoli covered with melted cheese. Despite protests of feeling stuffed, we were told to indulge in dessert: soup bowls of creampuffs filled with ice cream and drenched in hot fudge sauce.

As we waddled home I remarked that it was a good thing we didn’t eat like this more than once a year, if that. Working off all those calories would take hours at the gym, and a frugal meal plan for a few days.  My husband agreed. “I really didn’t want to order such a large piece of meat but since our hosts were so insistent, and everyone else was ordering it, I felt that I should, too. And I wasn’t hungry for dessert, but it was hard to refuse. “

Last week we experienced an opposite social pressure on how we should eat.  Invited to a buffet dinner following a lecture at a local museum, we were offered poached salmon, baked chicken, marble-size boiled potatoes, salad and rolls. No butter was served. The plates tiny, somewhat smaller than salad plates, and once a lettuce leaf, tomato slice, and a minute piece of fish or chicken was placed on it, there was barely room for one potato.  No dessert was available or, if it was, it was hidden in a remote part of the dining area. As one of the guests with whom we sat remarked, “I guess I don’t have to worry about eating too much at this meal!“

These two eating experiences confirm anecdotally what many studies have shown. Social eating can influence the amount and type of food we consume.

Indeed, web sites focused on helping dieters stay motivated suggest choosing eating companions who reinforce healthy, calorie-conscious food choices.  Eating with friends at a restaurant that offers low-fat, non-fried foods, including a variety of whole-grain and vegetable options, makes it so much easier to stay on a diet than eating at a place where the food is batter-coated, or sauced with cheese.  Conversely, going with others to a massive brunch buffet, or a clam shack known for its tower of fried clams, coleslaw drowning in mayonnaise, and unlimited French fries makes it extremely hard for the dieter to say no to these temptations or, in some cases, such as the clam shack, even find something diet-worthy to order.

However, it is not necessary to become an “eating hermit” in order to lose weight. Many restaurants post their menus on their web sites so it is possible for the weight or health conscious to see ahead of time whether there are calorically appropriate meal options. Admittedly, it is difficult to tell friends or co-workers that you prefer not eating at a particular place because you won’t find anything to eat (like at a fried clam shack) that is appropriate for your diet. But these days it may be easier to do so as now that so many have specific food restrictions.  Friends or family, one hopes, would not invite a Moslem or kosher Jewish guest to a barbecue place featuring pork, or suggest going out for pizza with someone who has gluten sensitivity. Since it would be fitting to suggest an alternative restaurant for someone who can’t eat gluten or pork, it is appropriate to identify a restaurant with choices compatible with the caloric needs of someone on a diet or trying not to gain weight.

A little discussed but annoying problem of social eating is the nosy invasiveness of eating companions who feel they have the right to make remarks about the type and amount of food you are eating. Too often comments will be made about portion size: “Is that all you are eating?” or lack of fattening ingredients: “That salad looks inedible without any salad dressing!” or a rejection of dessert: “You never eat it, do you?”  People who would never urge someone in alcohol recovery to “just have one drink” will cajole a fellow dinner who is attempting not to gain weight to “C’mon! Enjoy some of that chocolate cake; it won’t kill you!” It is rarely possible to respond by pointing out the rudeness of the remarks or offering unflattering comments about the speaker’s size or eating habits. Avoidance and seeking out like-minded eaters is probably the only solution.

And that may not be so easy anymore, because the world is getting fatter. A recent report found that 10% of the world’s population is now obese. One consequence is a global eating environment where dishes containing excessively fattening ingredients or mega-sized portions are becoming normative. The gigantic, but apparently typical portions of steak we encountered at the anniversary party are likely to become more common than the meager portions of the museum dinner.  If we succumb to accepting that we are expected to eat portion sizes inappropriate for healthy calorie intake, then we risk increasing our own size a few pounds every year until we are overweight, or even obese. And even worse, if everyone around us is larger than they should be and consuming portions much larger than they should be eating, who will notice?

Obviously, it is rarely possible to restrict the people with whom you eat to those who will reinforce your weight and heath goals. But it is important to resist the pressure of fellow diners to eat promiscuously, to choose food without heed for calories or saturated fat or sugar that have negative effects on health. It is important to realize that after the meal is over, only you will be standing on the scale.

Can E-Cigarettes Reduce Smoking Among the Mentally Ill?

Two young men were walking toward me, their faces obscured by clouds of vapor coming from tubes stuck in their mouths. They appeared to be in a fog bank of their own making.  As they walked past, I realized that they were smoking, or rather vaping, e-cigarettes.

This relatively new form of sending nicotine into the blood differs considerably from conventional cigarettes that depend on the combustion of tobacco, paper, and miscellaneous substances.

E-cigarettes are powered by a battery and look like a real cigarette (or a pacifier for grown-ups.)  Inside the device is a cartridge filled with a liquid containing nicotine, flavorings like candy, and other chemicals. The liquid is heated to a vapor, which is inhaled like a cigarette, and called vaping.

The smoker of e-cigarettes can determine the amount of nicotine he or she will be inhaling by purchasing a specific amount to be added to the heated liquid. Traditional cigarettes contain about 4mg-14mg of nicotine, depending on the brand.  According to the CDC, the average smoker absorbs about 1mg of nicotine from smoking one cigarette, but of course this varies depending on the amount of nicotine in the brand and how deeply the smoke is inhaled. People switching to an e-cigarette can turn to charts that show the amount of nicotine to use to equal the amount they used to get from a traditional cigarette. Hopefully, they will use the e-cigarettes to consume less nicotine.

Many people still smoke because nicotine seems to improve their mood and cognition.  Indeed, smoking has been described as a means of self-medication used to diminish depression, anxiety and even distractibility.  Perhaps because of this, those suffering from mental disorders comprise one of the largest subgroups of people who are still smoking.  According to the Substance Abuse and Mental Health Services Administration,about 18 percent of the U.S. population as a whole smoke.

However, the rate is much higher among those who are mentally ill.  NAMI, The National Alliance on Mental Illness, reported that 60 percent of those with depression smoke, and the number increases to 90 percent among those with schizophrenia.

Nicotine’s positive effect on mood is measurable, although not everyone may benefit. Brain cells containing neurotransmitters involved in our behavior and emotional state contain sites or receptors sensitive to the presence of nicotine. These nicotine receptors may strengthen the effect of dopamine, serotonin and other neurotransmitters on mood, thus making the smoker feel less anxious and depressed. People who suffer from ADHD also may use nicotine to enhance attentiveness and concentration, as it is thought to have an effect on the brain similar to that of drugs used for this disorder.

Regardless of the benefits on mood and cognition, one cannot minimize or ignore the negative consequences of bringing nicotine into the body. In a conventional cigarette, the tar, and a multitude of other substances involved in its combustion, may be the villains in the cancer-producing effects of smoking on the individual, alongside the respiratory and other problems suffered by those exposed to second-hand smoke. E-cigarettes have not been used for long enough to detect the health consequences of habitual use, but nicotine is a drug and thus has the potential for harm, regardless of how it is administered.  And the sad fact is that someone who begins to smoke as a way of lessening the pain of depression and anxiety, may remain addicted to cigarettes long after the mental illness has been helped by medication and therapy.

Might “vaping” e-cigarettes be the solution to breaking the addiction, or at the very least decreasing the health risk? The nicotine delivered in the heated liquid inhaled and puffed out by the smoker is not in a matrix of cancer-causing substances, but added in a measured form to a liquid in the cigarette’s receptacle. The amount of nicotine in the e-cigarette can be slowly reduced to wean the smoker gradually from dependence, and ultimately be removed altogether so that all that is left is the oral gratification of sucking on a tube and emitting vapor.

In a May 13, 2014 issue of Tobacco Control, Sharon Cummings, PhD, reported that smokers with mental health problems are more likely to use e-cigarettes to reduce the hazards of smoking than the general population. She found that 60 percent of smokers with mental illness indicated that they were somewhat likely or very likely to try e-cigarettes in the future for this reason, compared with 45.3 percent of smokers without mental health conditions.

But should people who dose themselves with nicotine to help their mental health withdraw from this drug without medical supervision? Anyone who has tried to stop smoking knows that the craving for nicotine takes a long time (or never) to disappear, and the early weeks of abstinence are accompanied by side effects such as disruptive sleep, distractibility, excessive eating, depression, anxiety and anger.  How much more vulnerable must people be who are already suffering from some of these symptoms before nicotine withdrawal? What if the smoker who suddenly decreases the nicotine in the e-cigarette experiences a flare up of anxiety, panic attacks or depression?

The use of vaping, which allows the smoker to inhale smaller and smaller doses of nicotine, may be an effective way of eradicating the addiction.  But if this is done by those who have used nicotine as an adjunct to their medication, or as a way of preventing themselves from needing medication, the medical community should supervise and support them as they would with any other type of drug withdrawal.