Medication-Linked Weight Gain & Clothing Discrimination

Until someone joins the ranks of the size 16 and over, she probably has no idea of the discrimination from the fashion industry and department stores that awaits her when she needs to buy clothes. For you who were wearing “chubby“ sizes as children, and forced into wearing clothes designed for a woman when you were still an adolescent girl, shopping as an overweight or obese adult is an indignity and discomfort that you know all too well.

However, if you are someone whose size has migrated upward as a result of weight gain from antidepressants, mood stabilizers, low dose steroids, or other medications, you will probably be shocked at what awaits you on the racks of the larger size clothes in department stores. And if you loved fashion, or at least wanted to wear something other than oversized tops and stretch bottoms, you will be dismayed at the paucity of designers and designs for someone who does not fit into what the industry calls “normal“ size.

Once, while talking with a weight-loss client whose obesity was a result of her antidepressant treatment, I asked her how she shopped for clothes. She had been a competitive athlete during her young adulthood, and her body could have been on the cover of Shape or Self magazine. Now she was struggling to lose the fifty or so pounds she had gained on her medication.

“I don’t shop unless I absolutely have to, and then I go to stores like Old Navy where the sizes are more generous. A size large in a store like Banana Republic or Madewell would be a medium in a store like Old Navy, so I didn’t feel so bad about my body when I shopped there. And there were enough shoppers who wear large sizes to support a pretty good selection. It isn’t like going to a regular department store and being sent to a plus-size department behind housewares or pet supplies, and where there were relatively few styles and none I would consider wearable,” she told me. She went on to say that, like many women (and some men), she had found clothes shopping to be a pleasurable distraction from training and her college studies. “It was fun going to the mall with my friends and trying on clothes. But after I gained weight, the selection was so limited, and in many cases so ghastly, I hated to shop. It is as if fashion stopped with size 12.”

She was right.

A few weeks ago my persistent channel surfing on the TV attached to the treadmill at my gym brought up an old episode of “Project Runway.” What made this episode different was that the models were the mothers and sisters of the fashion designer contestants. Thus, they were told to design clothes for models whose bodies looked much different than the industry’s norm. Indeed, several of the moms were in the larger than “normal” size category, a fact that made the designers not very happy. Several seemed incapable of making clothes that were not burka-like; others covered most of the upper body with a voluminous poncho or jackets. The objective, it seemed, was to pretend that the women did not have body parts with bumps and curves.

Tim Gunn, who had been the taskmaster of this show, now many seasons old, confirmed my impression in an article published in the Washington Post in September 2016. He said that even though the average American woman is a size 16 or 18, and is willing to outspend her thinner sisters on clothes, “many designers—dripping with disdain, lacking imagination or simply too cowardly to take a risk—still refuse to make clothes for them.”

This past June, Steve Dennis, writing for Forbes, confirmed what Gunn stated. Dennis described much of the fashion industry as being biased against any image of women that did not conform to an unrealistically thin body. Yet according to Plunkett Research, a market research firm, 68 percent of American women today wear size 14 or above.

Women’s sizes may be getting larger, but the amount of space in a department store selling clothes to fit their bodies is not expanding. And the clothes are certainly not front and center when the shopper exits the escalator onto the floor featuring women’s clothes. The “cute stuff,” size 2, is on the mannequins; the plus-size department is a hike away.

The answer proposed to the frustrated larger shopper is to shop online. Of course, buying clothes, along with everything we need or want online, is done by almost everyone regardless of size. Indeed, some manufacturers of plus-size clothes that only sell online promote the advantages of trying clothes on in the privacy of one’s home, and will accept returns of clothes that do not fit.

But according to an insightful article by Sara Tatyana Bernstein, not being able to try clothes on at a store is frustrating. Not everyone who is size 14 or 18 or 22 has the same shape, and not everyone carries the excess weight in the same areas of the body, she tells us. And the woman who has had a slimmer body prior to gaining weight on antidepressants might need the help of an experienced saleswoman to figure out what looks best on her new larger shape. However, Bernstein did report her own positive experience going into a couple of stores (Torrid and Lane Bryant) where, in her words, “the larger shopper feels comfortable and supported by other shoppers of the same size.”

She also has an interesting observation about the lack of quality in many clothes made for the larger woman. Even though market surveys show that often the larger woman is willing to spend more on clothes than her smaller counterpart, according to Bernstein, clothes of good quality, made to last, are very hard to find. She suggests that manufacturers make cheap (in regards to the items’ durability) plus-size clothes in the belief that no woman wants to remain a large size. Thus she doesn’t want to invest money in clothes worn only temporarily—i.e. until she loses weight. Why, the thinking goes, would a woman want to buy expensive “staples” that sooner or later will be too big to wear?

Since many who have gained weight on medication now find it impossible to lose weight months, and even years, after the drugs are discontinued, they don’t know whether they will ever lose that weight. And there are many others who for a variety of reasons may not be able to reduce to a “normal” size without great difficulty. Isn’t it time to manufacture larger-size clothes that flatter and endure? If Peter Paul Rubens could make the larger woman look desirable, cannot today’s fashion designers do the same?

References

“A Plus In The Sun: The Spatial Politics Of Selling Plus-Size Clothes To Women,” Body Politics, Fashion July 31, 2017.

Should a Personal Trainer Be Present at a Wellness Exam?

Several years ago, wellness examinations were introduced into medical practices as a way of detecting possible health risks, especially among an older population. It made and makes sense. Detecting high blood pressure, elevated cholesterol or blood glucose, and too low levels of essential nutrients meant that interventions could be started to prevent a worsening of the individual’s health and quality of life. But do these assessments really measure the wellness of the individual?

Consider falling. Falling is a common risk factor for older people, and now that the Baby Boomer population is in that category of older Americans the incidence of falling will predictably increase. The loss of bone and muscle mass and balance that accompany aging certainly increase the risk of tripping over obstacles that might not even register a slight stumble in a younger individual. And unfortunately 30 to 40 percent of people 65 and older may trip and fall. The effect of a fall is not a tumble and, “Don’t worry, I am not hurt.” About half of these falls cause injury that becomes more serious the older the individual.

Thus the wellness assessment should include detection of physical deficits that might make the patient vulnerable to falling. If a decline in balance or uneven gait is detected before injury from falling occurs, a “prescription” for therapeutic exercises can be offered so these conditions can be helped. This would be similar to a physician making sure a patient received nutritional advice if blood tests showed pre-diabetes or early signs of iron deficiency. But according to guidelines from American and British Geriatric societies, no assessment of risk from falling will be made unless the patient has already fallen or complains of feeling unsteady while walking. If one is lucky or unlucky enough to have fallen (excuse the pun) into this category, then he or she is sent to someone for evaluation of walking and balance.

But why wait until there is a problem? If a patient was pre-diabetic based on fasting blood sugar levels, should a doctor wait until the symptoms of diabetes appears before starting treatment?

Your physician does not have to be a physical therapist or certified personal trainer to assess whether you have poor balance or impaired walking and need help to improve these functions.

The test to measure balance is simple. For example:

  • Can you stand on one leg and bend the other 45 degrees or place it against the calf of the standing leg? Can you do this on each leg for 30 seconds?
  • Can you walk ten steps with the heel of your front foot touching the toe of your back foot? (This is harder than it seems…)
  • Step to the right with your weight on your right foot. Bring your left foot next to your right foot. Then do the same with the opposite feet. Slowly.

There are other similar balance tests that are also used as exercises to improve balance.

The results of a balance test can be surprising. A friend who had an ankle operation found that even though her ankle had healed and the muscle mass of her leg restored, she had much more trouble balancing on the operated leg than the other years after the operation. Another who had stopped going to yoga classes because of scheduling conflicts and who could stand on one foot seemingly forever was horrified to find that after a couple of years not doing balance exercises she had trouble standing on one foot for less than a minute.

Gait is a fancy term for moving your feet while walking. Gait speed is a measure of how quickly someone can walk from a specific point to another specific point. Measurements of gait needs a bit more space than a balance test, and if problems are detected, a thorough evaluation, including walking on a treadmill and the walking videoed for later analysis by a physical therapist. In the initial test, a distance is measured out and the individual asked to walk at a normal gait /speed to the end point. This is timed and often repeated to get an accurate result. Gait speed is then calculated by dividing the distance by the time it takes to cover it.

So, if you walked 12 meters (one meter equals three feet) in 12 seconds, than you would walk one meter (or three feet) per second. Although gait certainly can slow down simply with aging—a 90 year-old probably walks more slowly than a 50 year-old—other factors such as being unable to pick up one’s feet (shuffling), perceptual problems, poor balance and muscle weakness can slow down the pace of walking in an otherwise healthy person.

These measurements of balance and gait do not require the services of a personal trainer or physical therapist. They can even be made at home. They don’t take time. Indeed, they probably require less time than one typically spends in the waiting room when the doctor is behind in his or her appointments.  But they should be made under medical supervision because they can reveal problems that are more medically complex than aging or lack of exercise.  Loss of balance and abnormally slow gait can be due to inflammation or other inner ear problems, nerve damage to the legs, vision problems, muscle weakness, side effects of some medications and neurological diseases like Parkinson’s. The underlying causes must be addressed.

Balance is something we don’t notice we have lost until we do. All of us must find out how vulnerable we are before that first fall.

References

“Assessment and Management of Fall Risk in Primary Care Settings,” Phelan, E., Mahoney, J., Voit, P., and Stevens, J., Med Clin North Am. 2015 Mar; 99(2): 281–293.

“Gait Speed as a Measure in Geriatric Assessment in Clinical Settings: A Systematic Review,” Peel, N., Kuys, S., Klein, K., The Journals of Gerontology: 68; 2013: 39-46.

Should Unhealthy Foods Become a New Food Allergy?

After we made our reservations at the bed and breakfast in a charming New England town, we received, along with our confirmation email, a form asking us to list any food allergies or food restrictions. The inn served a full breakfast, indeed, the gourmet quality of the breakfast was mentioned in several reviews and the couple running the inn obviously wanted to make sure that the culinary needs of their guests were noted.  We couldn’t think of any except the unthinkable, i.e. a breakfast without caffeine, and assumed that we would be able to eat the foods traditionally served at inn breakfasts: an assortment of bread, pastries, yogurt, fruit, cereals, and a hot egg-cheese casserole. We made a mistake. We should have said something about our food needs.

Her breakfast menu, the morning we were there, offered foods incompatible with what we normally eat for breakfast (or indeed ever.) The first course was a nectarine poached in syrup, coated with chopped nuts and seated on a bed of sour cream. The main course was a large slice of cheese quiche and a sour cream biscuit. The quiche was mainly egg, cream, butter and a great deal of cheese. The biscuit seemed to be mostly butter, sour cream and flour. To someone accustomed to eating a high-fiber cereal, fat-free milk and fruit, or yogurt and whole grain toast early in the morning, the inn’s breakfast was too high in fat to eat. But it was embarrassing. Other guests at the long table at which we all sat cleaned their plates. How to explain our nearly full ones? The face-saving one was that we usually were not very hungry in the morning.

Perhaps it was our fault. Perhaps we should have mentioned that for a variety of reasons, including a history of serious heart disease in our families, we tried to limit our saturated fat consumption. Or that we were going to be spending many hours that day driving home and would feel more comfortable eating lightly rather than digesting several ounces of almost pure fat. But we said nothing. We overheard the innkeeper explain to another guest that she liked to serve everyone the same food because it enabled her to control her food supplies and decreased waste. “If I put out a variety of foods like yogurt or fruit,” she said, “then I may have to throw some food away and I hate doing that.”  So we did not even ask if there was anything else to eat. We assumed that she was not prepared to offer anything but her own menu to her guests. Sadly, our food was wasted along with the labor she put into making it.

Could we have prevented this? She did ask us to list our food allergies and restrictions, but where would we have mentioned our desire to eat a low-fat, high-fiber, and vitamin-containing meal for breakfast?  Obviously we were not allergic to cheese, butter, eggs, and sugar, and it would have been dishonest to state that we suffered from diseases that prohibited eating these foods. (We simply did not want to develop these conditions.)

However, given the prevalence of medical conditions such as obesity, diabetes, heart disease, and gastrointestinal disorders that would benefit from a healthy diet, shouldn’t the potential guest be asked whether he or she preferred to limit consumption of high-salt, high-fat, and high-sugar foods? Shouldn’t the desire to serve a gourmet breakfast that featured high-fat ingredients be balanced against offering healthier options to the guests?  Or at the very least, offer them alternatives?

Our experience was not unique. Even with the greater sensitivity of the country as a whole to the restrictive food needs such as gluten, lactose, saturated fats, peanuts and other nuts, and all animal products of many people, it is still possible to be unable to find something to eat while traveling. A friend from India told us that when he arrived as a student in this country about 30 years ago and told people he was a vegetarian, they thought he was talking about what political party he belong to rather than his food restrictions. Fortunately, everyone now knows what a vegetarian is, although some still are not sure whether that is the same as being vegan (it is not).

Could the situation have had a different resolution? Should the website featuring the inn mention that gourmet breakfasts will be served, but those who need to restrict calories or fat or both should bring their own food?  Should we have mentioned before we arrived that we would be driving for hours that day and would have preferred eating lightly?  Was it her responsibility to make sure that her guests ate healthily or consumed calories in keeping with their day’s activities or their weight?  There are laws requiring inns to have sprinklers and well- marked fire exits in order to protect guests from fire, but so far no rules exist to protect guests from weight gain.

The answer in part is that we were guests, albeit paying ones, in her home.  The inn was not near any stores or restaurants so we were dependent on what came out of her kitchen for breakfast unless we wanted to travel for many miles to find a restaurant open in the morning.  If we had stated before we arrived that we wished to avoid unhealthy foods, this might have led to some confusion because there is so much disagreement among the public about what is healthy: bacon fat or olive oil, milk from cows, soybeans or almonds, egg yolks or tofu? So the solution (which other inns use) is to offer a variety of breakfast foods to which the guests could help themselves—at least to a couple of protein bars—even if it means throwing away an uneaten container of yogurt or an overly ripe banana.

When Competing Athletically Ends, Does Weight Gain Begin?

“I used to be able to eat anything and in any amount,” a young graduate student who had come to me for weight-loss consultation told me. Since I began competitive swimming in high school, I would burn off so many calories that keeping my weight on was a problem. And I swam all through college as well.  But I stopped now that I am getting my Ph.D., and after a couple of years sitting in class or in the library, I have gained 40 pounds. My anxiety as well as my weight has increased.”

Donna (not her real name) was in the enviable position of eating everything and never worrying about portion size. Even on school days, she would spend at least five hours training and when preparing for competition, more hours. And when she felt anxious over college applications and then later about getting into graduate school, for example, several minutes of doing laps decreased her anxiety and left her feeling calm and in control. But all that changed and she now had to learn how to eat like the rest of us who can never approach the level and intensity of a training regimen for a competitive athlete.

Donna’s predicament was not unique. Indeed, she joined the ranks of young athletes whose participation in sports, even at an Olympic level, stopped when they did not transition to professional status. And this group is folded into the company of professional athletes who at some point in their lives (Tom Brady notwithstanding) decide that age, injury, and competition from younger players are good reasons to hang up their bathing suits or shoulder pads. And many experience changes in their body, food intake, mood and general satisfaction. As a trainer in a gym told me, “How can they not feel depressed when no one is cheering for them or they are no longer feeling that adrenaline rush from a perfect gymnastic performance or another home run?”

Gymnasts are only one category of athlete who must deal with body image, weight, eating issues and mood changes after withdrawing from competition. In a small study,  the authors found the excessive concern over body image, weight gain and the use of laxatives and excessive exercise to restrict weight gain. (1)

Heightened concern over body weight extends to other sports as well. In the article “The Inextricable Tie Between Eating Disorders and Endurance Athletes” (Outside Magazine June 2017) Nora Caplan-Bricke describes the pressure on Tyler Hamilton, a Tour de France cyclist to lose a considerable amount of weigh in order to compete more successfully. Even though he was 5’8”, his racing weight of 130 pounds was achieved by hours of training followed by little or no food. Hamilton, like other athletes she describes, felt that a low weight gave him a competitive advantage for a while. Women athletes from marathon runners to professional climbers have also spoken out about an obsession with achieving a pathologically low weight in order to perform better and the eating disorders that inevitably accompany such goals.

But skinny athletes aren’t the only ones facing problems in controlling their eating after retiring from competition. Consider the massively large football players whose weight is an advantage while on the playing field but once they retire can lead to a variety of obesity-related disorders. According to an article “Obesity Could Be the True Killer for Football Players” by Rose Eveleth in Smithsonian.com (January 31, 2013), football players are becoming supersized.  She quotes research showing that since l942, the weight of linemen has increased by almost l00 pounds. To be sure massive muscles contribute to the weight and, under the supervision of coaches, the players’ food intake is monitored and exercising regularly is hardly a problem. But when they retire, the players do not automatically (or ever) drastically reduce their calorie intake because they are no longer in training and no longer need to maintain a massive size to be competitive on the football field.

Moreover (and this is not limited to ex- football players), anecdotal reports indicate that it is very hard for players to continue their intense workouts when they are no longer playing /competing professionally. Thus they lose their edge, their stamina, and their ability to endure pain and find it very hard to resume their workouts at a lower level of intensity and skill. Donna reported the same thing. Once she stopped her very long swims, it was hard for her to be content with doing only 30-45 minutes of laps rather than the hours she used to spend in the pool. She told me she mourned her decreasing endurance and speed.

When an individual entering a new sport exhibits the potential to become competitive he or she is coached to attain higher and higher levels of competence and success. Specific training programs often based on scientific analyses of how best to enhance performance are offered, along with nutritional and even psychological counseling. But when the same athlete withdraws from the sport, for whatever reason, there is no compatible oversight to help transition back into a normal life. Although there are nutritionists who specialize in sports nutrition, they by and large do not specialize in “leaving the sport” nutrition. Nor are there personal trainers with similar “retiring from competitive training” specialties or many therapists who know how to deal with the loss of withdrawing from an activity that dominates much of the individual’s life.  Gaining weight may be a visible sign that the individual needs help in adapting to an ordinary life but doing so must be emotionally as well as physical difficult. The ex-athlete deserves well-informed support services to be successful at doing so.

1.) “Influence of Retirement on Body Satisfaction and Weight Control Behaviors: Perceptions of Elite Rhythmic Gymnasts,” J of Applied Sports Psychology, Stirling, A., Cruz, L., and Kerr, G., 2012: l24; 129-143

 

 

 

 

Can You Laugh Off a Few Pounds?

Most of us have a friend who, if invited to dinner, will make us laugh so much with an unending stream of funny stories that the food will get cold and neglected. The jokes may start soon after hunger has been dulled sufficiently to slow down eating and, if the jokes are well presented, laughter will prevent many from continuing to eat.  And indeed, what one remembers after this type of dining experience is not the food (regardless of how good it is) but the shared experiences of laughter.

Many people have tried to define the effects of laughing on the brain, attempted to analyze how structure of jokes activates laughter (there is a linguistic basis for this) and even have measured physiological responses to laughter. But it is not necessary to know what neurotransmitters in the brain are involved in the laughing response to know that it makes you feel better. The feeling may not last any longer than it takes to forget the punch line, but there is a sense of contentment after a good laugh, a feeling of relief because even if it is only for a few minutes, any negative emotions we are harboring seem silenced by the sounds of laughter we are making.

The idea that laughing releases tension is well understood by therapists who study the effect of laughter on behavior and mood. Moreover, even though we can laugh privately at something funny in a book or in a New Yorker cartoon, laughing is acknowledged as a way we communicate with others in the few minutes we all perceive the world of the funny story the same way. Indeed, if someone in a group mutters, “Why is that funny?” others view him or her temporarily as an outsider to a shared understanding of the story.

Laugh therapy has been used to reduce anxiety and depression among patients confronting illnesses like cancer and chronic diseases that have no apparent cure. Laughter is used as a tool to help people with social anxiety, according to Aaron O’Banion and Justin Bashore, who write about this on their website, Social Anxiety Institute.

Doctors rarely, if ever, prescribe laughter as a remedy for disease but one man, Norman Cousins, proved that it could be a powerful tool. Cousins, the editor-in-chief of the Saturday Review, developed a painful connective tissue disease with a very small chance of recovery.  His own treatment plan included watching reruns of humorous television programs and movies. His book, The Anatomy of an Illness, published in l979 after he recovered from his disease, described how, “…ten minutes of belly laughter allowed him two hours of pain-free sleep.” Of course, as some critics pointed out, he may have been misdiagnosed and whatever he had could have gotten better without the laughter, but the effect of laughing was immediate and the results, no pain, easily noticed.

Inducing laughter for therapeutic reasons, such as decreasing anxiety, is not left to the telling of jokes or watching a stand-up comedian. There are therapeutic laughter meet-up groups, laughter yoga (known as Hasya yoga) and laughter clubs. The objective is put an individual through a series of breathing and moving exercises that mimic, to some extent, the body movements when one is laughing. And sometimes laughing is induced just by having two people sit, stare at one another, and then force a laugh. It works as anyone who has giggled in response to someone else giggling knows.

It seems obvious that laughing should somehow find its way into a weight-loss program, especially for those whose excessive food intake is the primary, indeed only, pleasure they have. Eating is commonly done to reduce tension and anxiety, as a pleasurable way of reducing boredom, loneliness, the tedium of work or household tasks, and as a source of comfort that never fails. If laughter can decrease the negative moods often associated with overeating, the effect may be a painless, and indeed enjoyable, way of losing weight.

Laugh It Off! Weight Loss for the Fun of It by Katie Namrevo was published 14 years ago and describes the effect of laughing on the weight loss of the author. Unfortunately, her book has not spawned the equivalent of national weight-loss laughing groups that, unlike Weight Watchers, would allow clients to tell jokes rather than sad stories about how they overate the previous week. Moreover, might laughter therapy be used to relieve the intense loneliness of a morbidly obese shut-in individual who finds pleasure only when eating? If Norman Cousins could experience a few hours of reduced physical pain, might laughing also bring about a few hours of relief from emotional pain? Consider what might happen if someone attempting to lose weight was told that a meal could be consumed only after the individual watched 10 or 15 minutes of a funny movie or video or listened to a recording of a very funny writer like David Sedaris. What if an exercise-averse individual were told that a yoga group was focusing on movements related to laughter? A weight-loss group might be more fun if the attendees laughed together instead of describing events in which they overate, or the reasons they were provoked into doing so.

All of us, regardless of our weight, probably don’t spend enough time laughing. And yet, all of us have had the experience of repeating to ourselves a joke or funny observation we may have heard recently, just because it brings a smile to our face. Doing so makes us feel good. And feeling good is an effective way to support weight loss.

References

“Effects of laughter therapy on anxiety, stress, depression and quality of life in cancer patients,” Demir, M. J., Cancer Sci Ther 2015 7: 272-273.

An Afternoon Starbucks’ Drink May Be Great for Your Mood, but a Disaster for Your Weight

A full-page advertisement for an Ultra Caramel Frappuccino stopped me from turning the page in a magazine I was reading. The picture of this drink caused my mouth to water, and was one of several Starbucks drinks they are featuring to entice morning customers back into their stores for afternoon refreshment.  Hidden in small letters at the bottom of the page is the phrase “Find Your Happy.” Perhaps it refers to happy taste buds after drinking one of the Frappuccinos.  And for many, this may be the result. Moreover, I suspect that the marketing people at Starbucks who came up with the campaign did not know that an afternoon drink combining caffeine and carbohydrate are satisfying a need rooted in our brains, not our taste buds.

Collette Reitz describes how many of us feel around 3 or 4 pm when she writes on Elite Daily’s May 2018 web site”…you can’t decide what to order at Starbucks because you are craving both a giant piece of cake and a caffeine boost.“ What Ms. Reitz is describing is the phenomenon of a, “…universal afternoon carbohydrate craving and afternoon lack of caffeine fatigue.”

The flagging energy and blah feelings experienced around 3 or 4 pm is largely due in part to caffeine levels that have been declining since morning, when many of us drink our coffee or other caffeinated drinks. They can be quite low by mid-afternoon unless a caffeinated beverage was consumed with lunch.  But most of the mood changes in the afternoon seem to be associated with decreasing brain levels of serotonin. We don’t know why there should be a change in the level of this neurotransmitter, but its effects can be seen in the craving for carbohydrates along with the distractibility, grumpiness, irritability and restlessness many experience between 3 and 5 pm.

We discovered this in studies carried out at MIT almost thirty years ago with people who self-identified as carbohydrate cravers. At first we believed people were eating carbohydrates in the afternoon because they wanted something pleasurable to munch on when they took a break from work. But it turned that eating the carbohydrates was a kind of self-medication. Our subjects told us how they couldn’t concentrate or became irritable with their kids, or felt depressed or angry late in the afternoon. They said they needed to eat carbs at that time. They weren’t hungry, but they found it impossible not to eat a sweet or starchy snack and when they did so they felt better.

We tested their claim that eating a carbohydrate in the afternoon positively affected their moods by giving them a drinks containing carbohydrate or protein, and measuring their moods before and after the drinks. They didn’t know what was in the drinks. It turned out that the carbohydrate drink reversed their bad moods but the protein drink had no effect.   (“Changes in Mood after Carbohydrate Consumption may influence Snack Choices of Obese Individuals,” Leiberman, H.J., Wurtman, J., and Chew, B., Am. J. Clin. Nutr. 45:772-778, 1986)

Further tests in which they received either a drug that increased serotonin activity, or a placebo showed that when serotonin was more active, their carbohydrate craving disappeared.( D-fenfluramine selectively suppresses carbohydrate snacking by obese subjects.Wurtman, J.J., Wurtman, R.J., Mark, S., Tsay, R., Gilbert, W., Growdon, J. Int. J. Eating Disorders, 4(1):89-99, 1985.)

So it appeared that somehow serotonin was signaling them to eat carbohydrates. Why? The reason was actually discovered years earlier, also at MIT. Serotonin is made after insulin is released and changes the pattern of amino acids in the blood. When insulin does this, a particular amino acid, tryptophan, gets into the brain and instantly is converted to serotonin. Insulin is secreted only after sweet or starchy carbohydrates (with the exception of fructose) are eaten.  (“Brain serotonin content: physiological dependence on plasma tryptophan levels,” Fernstrom, J., and Wurtman, R., Science, 173:149-152, 1971) Perhaps the lack of serotonin sent a signal in the form of carbohydrate craving just as thirst is a signal that the body needs water.

Starbucks’ “afternoon made” drinks may be the solution to this serotonin-generated afternoon mood and energy slump. But it is also a problem. The heavily advertised Frappuccino contains so many calories that the elevation in energy and mood may be costly in added pounds.  A grande size of the Ultra Caramel Frappuccino contains 420 calories, 19 grams of fat, 59 grams of carbs and 5 grams of protein. The grande size Triple Mocha Frappuccino has 400 calories, 18 grams of fat, 55 grams of carbs and 5 grams of protein. One does not need to consume 55 grams of carbohydrate and 400 calories to increase serotonin levels. Twenty-five to thirty grams is sufficient and if the snack is very low in fat or fat-free like some breakfast cereals the calories rarely exceed 130. Moreover, the fat content of the drinks may actually have a negative impact on mood. Feeling logy or foggy or just tired after eating a load of fat is not uncommon. Drinking 18 or 19 grams of fat puts a “ball of fat” in your stomach, and when digested rarely leads to increased mental or physical energy. I would not want to have a surgical procedure if my doctor just finished drinking a Frappuccino. To add fat to the fire, as it were, the fat drastically slows down digestion so the beneficial effects of caffeine and carbohydrate on energy and mood take longer to be experienced.

Starbucks offers other options that refresh and rejuvenate with many fewer calories. Mango Dragon Fruit Lemonade has 110 calories and 26 grams of carbohydrate. Strawberry acai lemonade has a similar nutrient profile. Other low-calorie drinks such as lemonade do not have quite enough carbohydrate to activate serotonin synthesis in the tall size, but would if ordered in the next larger size.

Will you find your “happy” in these afternoon drinks? Yes—but only if your mood goes up without your weight doing the same.

Salting Your Way to Health Problems

A few months ago we dined with friends in a restaurant featuring small plates of ‘interesting food’ that were meant to be shared by everyone at the table. For the first time ever in a restaurant, we sent back a few of the meal items. They were so salty we had to spit them out (discreetly). A review of the restaurant read after our visit confirmed our impression that the dominant seasoning came from the salt shaker.

The excessive salt content of this restaurant’s food was apparent to anyone with taste buds, but could not be avoided unless we left the restaurant hungry. However it was not alone in supplying more salt than our body needed or should  be given. Restaurant food in general is a major source of excessive salt content; so much so that the Center for Science in the Public Interest (“CSPI”) gives unwelcome prizes to the fast food chains whose dishes contain the most egregious amounts of NaCl. Two of the prize winners this year were Chili’s Crispy Fiery Pepper Crispers (6,240 mg of sodium ), and Applebee’s New England Fish & Chips/Hand Battered Fish Fry (4,500 mg of sodium). To put the salt content of these meals in perspective, the American Heart Association  says that we should consume no  2,300 milligrams a day, and ideally less.  And for those with high blood pressure, salt intake should not exceed 1,500 milligrams per day.

But you don’t have to be a patron of these notable restaurants to have your cells swim in salt. According to the Center for Disease Control, the average American, regardless of where he is eating, eats too much salt. We eat on average  according to their 2014 report, 3,400 mg of salt each day; about a thousand milligrams above the ‘highest’ amount we should be eating.

About 61 percent of the salt we consumed each day comes from processed foods and restaurant meals, according to Zerleen Quader, an analyst from the CDC. However the top five saltiest foods may not be the ones we would think of: they are soups, pizza, bread, luncheon meats, and sandwiches ( presumably because of the bread and the meat filling). Potato chips and other salty crunchy are close contenders .

While we are managing to eat too much of the mineral sodium (half of the salt molecule) we don’t eat enough potassium, a mineral  that we should be eating in much greater amounts than sodium. The consequences can be serious: the results of a major study published in the Archives of Internal Medicine showed  “…a significant increase in the risk of cardiovascular disease with higher ratios of sodium to potassium…”  We should be eating about 4700 mg of potassium and of course only 2300 g or less of sodium.  Most of us fail miserably in reaching this balance. According to their survey, of almost 3000 participants, less than 5% reached their potassium goals and only 13%  did not eat too much  sodium.

This study was based on information gathered more than ten years ago. Might our current emphasis on low carbohydrate, high protein diets make us even more vulnerable? Bananas for example, which are very high in potassium , would be eliminated on a Paleo or Keto diet, along with many other fruits and vegetables.

Changing sodium consumption behavior is difficult because unless we read food labels carefully, avoid most processed foods and restaurants, and rein in our tendency to use spices that have high sodium content, e.g. garlic or onion powder, soy sauce and condiments in general. Many contain MSG, which of course has sodium.

New York City is making it easier to identify high sodium foods by requiring a restaurant chain with 15 or more locations nationally to list sodium contents of their menu selections. And just a few months ago, Philadelphia passed a law that requires restaurants to mark menu items that contain 2300 mg of sodium or more.

High salt intake has been linked to hypertension (high blood pressure) for decades. A recently published study of nutrient intake among more than 46,000 men and women in Japan has shown that both sodium intake alone and the sodium to potassium ratio are linked to hypertension and the diseases that can result such as strokes.

But just as it is with those television infomercials always say, “Wait! There is more!” A press release from the Alzheimer’s Association International Conference this week announced a significant relationship between blood pressure, impaired cognition, and dementia.  Professor Jeff Williamson and his colleagues at Wake Forest School of Medicine found a decrease in the number of new cases of mild cognitive impairment and dementia among individuals with normal systolic blood pressure (systolic is the higher amount and normal readings are 120 and below). Many medications are available, the anti-hypertensives, to reduce  blood pressure to normal levels. However life style changes, most obviously cutting back on salt intake, would support the effect of the drugs on returning blood pressure to normal readings.

As a friend who loves salt told me, “ It is worth giving up salty foods so I can remember what I just ate.”

References

Joint effects of sodium and potassium intake on subsequent cardiovascular disease: the trials of hypertension follow-up study Cook N, Obarzanek E, Cutler J et al    Arch Intern Med. 2009;169(1):32-40.

Relation of Dietary Sodium (Salt) to Blood Pressure and Its Possible Modulation by Other Dietary Factors The INTERMAP Study   Stamler J, Chan  Q, Daviglus M,  Dyer A, et al Hypertension. 2018;71:631-637.

Is the Gym the Place for Psychotherapy?

I was on the treadmill when the battery for my noise-canceling headphones died. As I took them off and hung them on the railing of the machine, I heard a personal trainer talking with some urgency to the woman walking on the machine next to me. She was in her late forties, more or less, and about forty pounds overweight. He questioned whether she had planned to cancel the training session because she had not lost any weight, and when she nodded in the affirmative, he went on for some minutes, describing her emotional problems and what she should do about them. The noise of the treadmills was not loud enough to block his voice. The trainee, a woman, was a little out of breath which may be why she did not respond to his lecture.

What to do?  “I really should not be hearing this,” I told myself.  As someone who has done weight counseling and clinical research, I know how important it is to protect the privacy of everyone with whom I have contact.  Having a therapeutic conversation with a client would be done in an office, and the information in my notes was protected against an invasion of privacy. And yet, this trainer was conversing in a sufficiently loud voice so that I, and perhaps someone on a nearby machine, could hear what he was saying. Should I have been hearing about her problems with her mother? Did I want to know what she eats when she is upset? I suppose we all would benefit from his advice to take better care of ourselves, but it was not necessary for me to hear that as a bystander.

Combining exercise and talk therapy is certainly a good idea, as it may amplify the benefits of both. Presumably both therapist and client are better off engaging in physical activity; we all sit more than we should.  And as a friend told me, you, the patient, know that your therapist isn’t sleeping while you are talking if you are walking together. Sometimes simply walking side by side with someone who is an empathetic listener makes it easier to talk about problems than sitting face to face. How many of us have taken a walk with a friend or family member to discuss a problem?

But the personal trainer is neither a friend nor a family member, much less a licensed therapist. Yet because his advice was being given in a professional capacity as a paid trainer, it is reasonable to assume it would be taken more seriously than if the advice came from a friend or another gym member on an adjacent treadmill.

It is very tempting to give advice even when it is outside the area of one’s expertise. I go to the gym; shouldn’t I be able to help a weight loss client plan a program of physical activity?  For example, when I see a client for a weight-loss consultation, I ask about the level of physical activity and usually suggest exercise as part of a weight-loss plan. Certainly I should be able to suggest even more: how much weight lifting should be done along with cardiovascular activity.  But I am not a certified personnel trainer and I would never give advice as to the kind of exercise that should be followed, beyond the obvious recommendation to walk. Instead, I recommend a consultation with a personal trainer or physical therapist to make sure that the physical activity is compatible with the client’s health, stamina and age.  Would I take the client to a gym to show her how to use the machines? Of course not.  I do spend time with clients helping them figure out when their schedules will permit them to exercise.  And once I discussed with a client what she could wear in the gym that would flatter her shape. (It is hard to find workout clothes in large sizes.)

However, I have overheard many trainers who have relatively little nutritional expertise giving advice about diets or nutritional supplements; sometimes their information is erroneous or based on little evidence that a particular supplement, for example, is safe and effective.  Too many times, I have been told that a friend is following the latest diet fad because his or her trainer recommended it.

Would we be taking financial advice from our trainer or listening to her about how to decorate our living room, buy a car, or deal with a troublesome teenager? Unlikely.  Would we take marital advice or suggestions on how to deal with an aging parent from the person who helps prepare our income tax?  Probably not. But as I kept glancing at the woman on the treadmill beside me, I wondered why she was allowing her trainer (and not a therapist) tell her how to handle the demands of her mother, or problems with her marriage. (I obviously heard too much.) Was it because she was a captive on the treadmill? Or maybe she believed that someone who is overseeing how your muscles are working is competent to advise her on her emotional state.

The trainer’s advice to exercise faithfully, eat frugally, and give her some time for herself are within the bounds of common sense; they are suggestions that any of us could give and receive.  But if he plans on continuing his gym psychotherapy, let him go through professional training and receive the credentials to do so. And then he should he want provide therapeutic consultations in the gym, go to a place where only the client is listening.

Too Little of a Good Thing: Carbohydrates

I was in charge of refreshments at a reception held for a guest lecturer and, aware of some of the attendees’ dietary limitations, selected gluten-free, sugar-free, dairy-free, and vegan cookies, as well as a large bowl of seasonal fruits.

“I am on the keto diet,” several of the guests told me as they avoided the cookies and fruit.

Where had I been?

I did not realize that the ketogenic diet had reappeared with such popularity, although I knew it never had really gone away since the days of Dr. Atkins. A few minutes on the internet made apparent the ubiquity of a diet that forces the body to switch from using glucose to fatty acids for energy. The diet seems to appeal to those who believe that total abstinence from sweet and starchy foods is the only way to control calorie intake. It also appeals to those who feel that carbohydrates are the source of physical and cognitive distress.

That adherence to such a diet has side effects ranging from unpleasant to worrisome is a small price to pay for those who follow a carbohydrate-free eating plan. Who cares about bad breath, constipation, “keto brain” (inability to concentrate and remember), difficulty sustaining strenuous exercise, and dangerously low electrolyte levels? As long as the weight comes off, it is worth it. Or so the thinking goes.

What happens after the diet ends can be dealt with after the diet ends, and if it seems impossible to maintain weight loss, well, why not go right back on the carbohydrate-free diet? Long-term effects? No one knows, so it could be good (or bad).

When someone is in ketosis, the body uses fat as a back-up energy system. Normally and naturally the body depends on glucose for all its energy needs. The glucose comes into the body as the end product of digestion of all carbohydrates, whether sucrose or brown rice, and is converted through a series of biochemical reactions into energy. In ketosis, the body uses fatty acids as its energy source. Once the body adapts to this alternate source of energy, it seems to run more or less the same (except for muscles which work longer and harder when using glucoose, the natural source of energy.) Exercise physiologists tell us that there is so little stored glucose in muscle on a carbohydrate-free diet, that muscles may fail to sustain strenuous movement after a few minutes of intense exercise. This means muscles used to sprint after a dog darting into the street, or a toddler about to climb up the rungs of a bookcase, will run out of energy reserves very quickly.

However, the body has a way of getting around the lack of carbohydrates for its glucose source by making its own. Certain amino acids in the protein we eat are converted to glucose in a process call gluconeogenesis. This occurs in the liver and kidneys and, according to advice given to wannabe ketotics, must be prevented. According to one Internet site, “Perfect Keto,” one should eat a specific ratio of fat to protein, because if too much protein and too little fat are consumed, the body will use the amino acids in protein as a source of self-made glucose. To prevent this, one should eat a very high fat diet, and only moderate amounts of protein, namely 75% fat, 20% protein, and a tiny amount of carbohydrate, 5%.

You will know whether or not you have achieved your goal of ketosis by testing levels of ketone bodies in your urine, blood or breath. Ketone bodies are three substances (acetoacetate, beta-hydroxybutyrate, and acetone) that the liver produces from fatty acids during periods of fasting, starvation, and very low or zero carbohydrate diets.

Although we tend to associate a carbohydrate-free or extremely low carbohydrate diet with dieting, it has long been seen as an effective treatment for controlling intractable pediatric epilepsy. Indeed, it is so important that the epileptic child not deviate from this diet that nutritional products have been developed containing flavored protein/fat liquid supplements that function as meal substitutes.

Moreover, avoiding carbohydrates used to be, prior to the availability of insulin, the only way someone with diabetes could handle this disease. And minimizing carbohydrate intake not only from sugary foods, but vegetables such as winter squash, corn on the cob, and carrots may help maintain a normal fasting blood sugar level.

Is it worth putting the body through a major physiological readjustment in order to lose weight?  What about the effect of carbohydrate deprivation on mood? Will there be any rebound eating of carbohydrates once the diet is switched back to including some carbohydrates? A definitive study comparing weight loss among 609 participants who were on a low carbohydrate or low-fat diet over a 12 month period was published this past winter in the Journal of the American Medical Association. The study did not support claims that avoiding carbohydrate produces a better weight-loss outcome. The difference in weight loss between the two groups was about l ½ pounds.

But perhaps the low carbohydrate diet is better for mood. Certainly anecdotal reports of the benefits of eliminating or drastically reducing carbohydrate intake would have you believe that clearer, sharper, focused, energetic minds result.  Here, also, the claim was not borne out by results of another twelve month study comparing  a low-fat and low-carbohydrate diet.

That moods improve among those in the study not denied carbohydrate is not surprising, assuming that some of the mood effects such as energy, focus, calmness and a sense of well-being are associated with normal serotonin activity. The absence of carbohydrate over prolonged periods of time prevents the amino acid tryptophan from entering the brain where it is converted to serotonin. The result: a decrease in serotonin levels and the risk of mood changes associated with too little of this neurotransmitter.

What happens if and when carbohydrates are added back into the diet? Diminished serotonin levels may make the dieter vulnerable to overeating this food group.

Next time I am asked to bring refreshments, I will be sure to include some pork rinds.

References

“Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion,”  The DIETFITS Randomized Clinical Trial,  Gardner, C., Trepanowski, J., DelGobbo, L., et al,  JAMA 2018; 319:667-679

Long-term effects of a Very Low-Carbohydrate Diet and a Low-Fat Diet on Mood and Cognitive  Function .Brinkeworth, G, Buckley J, Noakes, M,  Arch Intern Med 2009 :169; 1880-1873

“Influence of tryptophan and serotonin on mood and cognition with a possible role of the gut-brain axis,” Jenkins. T., Nguyen, J., Polglaze, K.,, et al, Nutrients 2016 8(1): 56.

The Most Overlooked Benefit of Exercise: The Ability to Get from Point A to Point B

A friend who just returned from Seattle was recounting the unexpected steepness of the city streets. ”Nothing is flat,” she told me. “You are either going up or down.” She was not young and had been worried about spending time exploring the city with a relative at least 10 years her junior. The younger woman was athletic and her favorite leisure activity was going on very long walks.“One day we walked up hills so steep I wondered how cars could drive up them! She took me up flight after flight of outdoor steps to get into certain neighborhoods. But I kept up with her and I don’t think I was puffing anymore than she was…“

My friend ascribed her stamina to her favorite gym activities: either walking on an elevated treadmill that mimicked walking uphill, or the elliptical climber which required a motion similar to climbing a shallow set of steps.

“I exercise because it is a habit,” she said as we discussed her unexpected physical prowess. “If I skip more than a day or two, I don’t feel right and have trouble sleeping. And of course it is good for my bones, especially since my mother suffered from osteoporosis and fractured her hip. But it never occurred to me that it would improve my, I guess I would call it, functionality.”

“You mean your ability to move better, longer, more efficiently and with less fatigue?” I asked.

“Yes, all of the above,” she laughed, “almost like a real athlete.”

Her experience of finding herself able to handle the demands on her body of trudging up hills because she exercised regularly should not have been a surprise. This, after all, is the point of training for competitive athletes or people setting off to climb mountains in the Himalayas or bike ride across the continental U.S. But those of us who are not planning on competing in athletic events and prefer to watch mountain climbing on a National Geographic special forget the most basic benefit of exercise: It prepares our body to engage in physical activity that may at times become demanding and strenuous.

The converse is painfully obvious. Someone who is unfit because of a voluntary disregard for any type of regular physical activity will have trouble climbing the steps out of a subway station or walking down a seemingly endless airport terminal corridor on the way to a gate or exit. Breathing becomes labored, muscles begin to ache and there may even be the feeling that unless help in the form of an escalator or one of the airport moving people carriers comes along, the goal of getting out of the subway or to the departure gate will not be achievable.

Of course, there are many who would, but cannot, exercise because of physical limitations. For example, a painfully bad back or severe asthma are obstacles to physical activity that may be difficult to overcome. And there are many whose lifestyle severely limits time to go on a long walk, work out at a gym or have time on a day off to engage in recreational sports. Convincing those who could, but don’t exercise, usually relies on listing the benefits to one’s weight, skeletal infrastructure, digestive system, sleep, cognition, mood, vulnerability to diseases like diabetes or high blood pressure, and life span. For example, there are some studies claiming that weight loss can be achieved through exercise alone without dieting, and that exercise is important in decreasing stress and depression.

But why do we ignore the obvious? If we rely only on vehicular transportation, we will diminish our stamina, endurance, the ability to oxygenate muscle cells sufficiently for prolonged contractions, and our muscle mass.

In short, we will find it more and more difficult to go from point A to point B.

It is possible to go through adult life with minimal need to engage in physical activity to arrive at a destination. Cars that sit in a garage next to the kitchen, or in a parking space a few steps from the elevator in the office building, reduce the need to walk. Malls that allow parking in front of a store or restaurant, or valet services that bring the car back to where you are standing on a sidewalk, also eliminate the need to move very much. One can even find scooters in supermarkets so walking can be avoided, and ordering groceries on line eliminates the need to even go to the market.

However, there are consequences to a lifetime of little voluntary physical activity beyond the obvious ones of physical well-being. It means not being able to explore a new city or museum or zoo on foot. It means not being able to walk through the woods, around a lake, or a botanical garden. It means a casual stroll with a child or friend or spouse is not pleasurable because fatigue and muscle pain quickly limit distance and enjoyment.

My friend concluded her description of her tramp through the city with an ecstatic description of the flagship Starbucks restaurant that sits on top of a steep hill. The restaurant, part museum, part coffee grinding factory and mostly a place where the city folk gather to drink coffee and eat incredible pastries from Italy was the treat her relative had planned for her. “She told me parking is impossible around that neighborhood, and she hoped I was going to be able to get there on foot. My days of exercising really paid off.”