PMS Carbohydrate Craving and Personalized Weight Loss Plans

There is much talk these days about developing a personalized diet based on DNA analysis, lifestyle, food sensitivities, and the use of apps alerting a dieter to situations that might derail a diet. However, in developing an overeating profile, is enough attention being given to a condition that causes some women to eat foods that are expressively forbidden on their diets? Does the eating profile include the information that this condition occurs every month, often for five days or longer? Does the eating control app have in its database knowledge that if the dieter does not get the food she craves during that time she may become very angry, may even delete the app from her phone, or that cognitive changes may make her misplace the cell phone? This monthly change is premenstrual syndrome (“PMS”), and unfortunately, it may be overlooked or marginalized when planning an individualized food plan. Indeed, if the wrong foods are on the food plan, the dieter may find her symptoms worsening and her ability to stay on a diet eroded.

PMS is associated with a change in hormones that occurs in the luteal, or second half, of the menstrual cycle. Estrogen levels begin to decrease and progesterone to increase soon after day 14 or so of the cycle. PMS typically appears a few days before menstruation and can suddenly alter mood, sleep, energy, concentration, and food cravings. Not all women experience PMS; the severity of the symptoms vary from barely noticeable to hampering daily life. Women who experience PMS may not experience it every month and with the same degree of severity. The most severe form is called premenstrual dysphoric disorder and is similar to clinical depression except, unlike a typical depression, it goes away by the beginning of the next menstrual cycle. PMDD, as it is called, is often treated with anti-depressants.

Craving chocolate is commonly associated with PMS and is not to be taken lightly as anecdotes describe women braving blizzards to get a chocolate bar. However, the cravings encompass both sweet and salty crunchy carbohydrates. A weight-loss client told me, “I did not know I was premenstrual until I returned home from my weekly grocery shopping with bags of cookies, ice cream, chips, hot fudge sauce, and packaged cupcakes. My husband asked me why I hadn’t bought any real food, and I told him this was what I wanted to eat. I got my period the next day.”

Several years ago, we were able to admit normal weight women with PMS to our MIT clinical research center to evaluate their mood and directly measure what they were eating when they were at the beginning of their menstrual cycle. We then would evaluate three weeks later when they had PMS. Food was provided in pre-measured servings at meals, and a computerized vending machine allowed the women to obtain protein-rich snacks such as cold cuts and cheese, as well as sweet and starchy snacks such as cookies and potato chips between meals and in the evening. When these normal-weight women were premenstrual, their calorie intake increased by more than 1100 calories a day, compared to the first half of their menstrual cycle — and the calories came from carbohydrate meals and snack foods.

Because all of these women were active and did not overeat when they were not premenstrual, their weight remained stable. However, if they had been trying to lose weight, the obvious response in developing a personalized weight-loss plan would be to insist on cutting out carbohydrates. Indeed, it seems obvious that if they had been on a low-carbohydrate diet, PMS would not have affected their food intake, because carbs would not have been allowed.

Perhaps. But eliminating carbohydrates would have affected their mood, and done so negatively.

Our research team discovered that the deterioration in mood, energy, focus and control over carbohydrate intake was due to alternation in serotonin activity, probably caused by the shift in hormones at the end of the menstrual cycle. Our research was involved in the first use of an antidepressant (Sarafem) that increased serotonin activity to relieve the symptoms of severe PMS.

Women with PMS apparently crave both sweet and starchy carbohydrates because their consumption will increase the level of serotonin. Eating carbohydrates is a natural solution to easing the deterioration of mood, energy, and concentration. A two-year study on the effects of a carbohydrate-rich drink on these symptoms of PMS showed this to be the case. The small amount of carbohydrate in the drink decreased cravings for carbohydrate snack foods significantly. When the women were given a drink containing protein, the PMS symptoms were intense including alterations in cognitive function.

The test carbohydrate beverage used in our study was fat and protein-free, and thus its calories came only from a combination of a simple sugar, glucose, and a mixture of starchy carbohydrates. Some breakfast cereals could easily be substitutes for our drink with their sprinkling of sugar on a high-fiber, starchy crunchy square or flake.

Eliminating carbohydrates, as is still the fashion in many weight-loss plans, overlooks a significant connection between this nutrient and brain function. The brain needs carbohydrates to be consumed to maintain serotonin levels and activities, especially when hormonal changes decrease such activity. In short, to remove carbohydrates in the interest of weight loss may be akin to tampering with nature.

References

Wurtman J, Brzezinski A, Wurtman R, and LaFerrerre B, , “Effect of nutrient intake on premenstrual depression,” Am J of Obstetrics and Gynecology l989; 161(5): 1228-1234

Brzezinski, A, Wurtman J, Wurtman R, Gleason R, Greenfield J, and Nader T D, “Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression,” Obstetrics and Gynecology l990; 76: (2) 296-391

Sayegh R, Schiff I, Wurtman J, Spiers P, McDermott J, and Wurtman R, “The effect of a carbohydrate-rich beverage on mood, appetite and cognitive function in women with premenstrual syndrome,” Obstetrics and Gynecology 1995; 86: 520-528.

When Food is Used to Push Away Anxiety, What Happens When a Weight Loss Program Takes Away the Food?

This past week, severe bronchitis and a high fever confined me to bed for a few days, and television reruns. The series, “My 600 Pound Life,” filled several hours but left me alternately feeling sorry for and annoyed with the people who were attempting to lose enough weight to qualify for bariatric surgery. Some did, others didn’t, and one died.   The program followed a fixed sequence of events: the excessive overeating of a potential patient, consultation with the bariatric surgeon, the requirement to lose some weight before being eligible for the surgery, and the surgery for some and its aftermath.  The viewer is rarely given any information about the social-psychological background generating the enormous weight, although in some cases, horrific childhood experiences are revealed.  And a fair amount of time is spent on the struggles the patient has in following the surgeon’s diet, which of course eliminates all the foods the patient was eating, and eliminates much food in general. Patients often fail to lose weight and are told they are not trying hard enough. Rarely is an explanation given as to why they fail.

But in one episode, the young male being featured did say something that dramatically underscored why he was eating constantly. His mother had come to visit for a few weeks, and we see her cooking and then serving him breakfast. She puts a large serving of scrambled eggs and bacon on a plate, covers it with a ladle of cream sauce, adds two large waffles, and ladles more cream sauce until everything is saturated. As her son begins to eat this dish with obvious enjoyment, he tells the camera and us that he is anxious about his mother’s departure because he will be alone again. He says he wants to eat slowly but his anxiety is making him eat very quickly. As long as he is able to put food in his mouth, he doesn’t feel that anxious.  But as he cleans his plate, he says the anxiety of being alone is coming back. He says that he must keep on eating; he must keep on putting food in his mouth in order to deal with his unbearable anxiety.  He takes a pizza out of the freezer, microwaves it and starts eating, again.

Having fallen asleep before program ended, I don’t know how his problems were resolved. I wondered if the son’s obvious compulsive eating would be addressed, but I doubted it.  I knew from watching other episodes, that if he were suffering from a mental disorder like Obsessive-Compulsive Disorder, it would not be discussed, at least on air. If the young man repeatedly failed to lose the requisite amount of weight, he might be seen by a therapist.   But the focus would be on his incessant overeating, not the psychopathology behind such behavior.  This was a show about bariatric surgery, not psychiatric disorders.

“That poor kid”, I thought. Would he ever be worked up for generalized anxiety disorder? Obsessive compulsive disorder? Depression?  If he went on the surgeon’s restrictive diet and was no longer able to engage in the kind of eating that made his anxiety bearable, did he get worse?  If he had the surgery and now could eat only tiny amounts of food, did he try to eat more than he should because he still had no other way of decreasing his anxiety?

But what if he weren’t on this reality television program. What if he presented himself as a compulsive eater at an eating disorder clinic?  Or joined Overeaters Anonymous or checked into a residential eating disorder program?  Would he be treated differently?

Obviously he would not be allowed to continue his eating behavior, because unchecked it may kill him. But what would be the primary focus of these programs? The mental disorder causing the compulsive eating? Or the eating itself? There is of course an urgency in controlling the eating.  But once the unhealthy foods have been replaced with large salads, fresh vegetables, lean protein in small controlled quantities, what then?  Will the reasons, psychosocial or neurochemical, be probed to understand the roots of his compulsive behavior? Will cognitive-behavioral therapy be used to develop behavioral patterns to replace his compulsive eating when the anxiety strikes? Will medications be used if these interventions do not work?

If this young man had compulsively washed his hands hundreds of times a day so that the skin was peeling from his finger and he was in pain, then the treatment for this compulsive behavior would have gone far beyond halting the handwashing per se.  His treatment would not have started and stopped by making it impossible for him to engage in the compulsive behavior by making him wear a pair of thick gloves and limiting access to water.  But if the therapy for helping compulsive eating focuses exclusively on removing excess food, isn’t this like  focusing only on the water used by the compulsive hand washer?

Bariatric surgery has been successful in producing significant, and in many cases, permanent weight loss. Some of these successes have been shown on the 600 pound weight loss series. But this program is not designed to disclose the psychological reasons for the weight gain and/or failure to lose weight of its patients, except in very superficial ways. The viewer becomes annoyed, as I did in my somewhat fevered state, with those who can’t lose the weight. “Stop eating”, one wants to say, “You are going to commit suicide with food. “ What we don’t know, and are not told, is that for some their emotional pain, their distress, their depression is made bearable only by constantly eating, and unless and until these are helped they are not giving up the only remedy they have. Taking away the food is only the beginning of the solution.

Monosodium Glutamate: Will It Make Us Eat More or Less?

In a recent study, female subjects consumed chicken broth with or without monosodium glutamine (“MSG”) to see if this flavoring ingredient might alter their appetite. State of the art electronic devices that could detect their interest in eating certain foods monitored their intake during a subsequent meal. For those of you who order wonton soup, a chicken soup that usually contains MSG, in a Chinese restaurant, you might be interested in the results. Subjects exhibited more control over their food intake and ate less saturated fat after ingesting the broth with the MSG than after consuming the non-MSG soup.

In practical terms, this may mean you will eat more steamed broccoli and less battered shrimp or chicken after a cup of Chinese chicken soup. The authors suggest that the glutamine, an amino acid that functions as a neurotransmitter in the brain, in monosodium glutamate may be responsible in part for the eating behavior seen in the study. But before going on an MSG diet to lose a few pounds, it might be worthwhile considering that opposite effects have been described as well.

In 1990, a paper published by Rogers and Blundell recounted that subjects consumed broth (it was beef in this experiment) containing different amounts of MSG, and their food intake was measured about thirty minutes later. Initially after consuming the soup, subjects reported feeling full and not interested in eating. However, thirty minutes later their motivation to eat was higher after they consumed the MSG-containing soup than after soup without the ingredient. But this was not reflected in what they actually ate. They ate the same amount after each soup.

Scientist Takashi Sasano and his colleagues at Tohoku University in Sendai, Japan, concerned about the inadequate food intake of the elderly, found that giving them kelp-enriched tea could enhance their appetite. As reported in an article in New Scientist by Jessica Hamzelou in January 2015, the kelp, which is exceedingly rich in monosodium glutamate (MSG), stimulated food intake. The scientists speculated that an increase in saliva secretion was the reason.

So does MSG change your food intake? This is still in dispute. What is not in dispute is that the glutamate in monosodium glutamate is the source of a taste called “umami” by the Japanese. Kikunae Ikeda, who coined the term, discovered umami in 1908. There is no English word synonymous with umami; the closest related terms are savory, meaty, and broth-like. Because umami was originally a Japanese term, it was thought to be a taste associated only with Asian foods, and not one detected by Western taste buds.  However, it has been now established as a fifth basic taste along with sweet, sour, bitter, and salty.

Although most of us would immediately associate the umami taste with soy sauce, other Asian sauces such as oyster sauce, and the flavor imparted by MSG to soup powders and other processed foods, the umami taste is naturally present in foods we commonly eat.  Tomatoes, mushrooms, hard cheeses such as Parmesan and Roquefort, and also green tea contain high quantities of monosodium glutamate. Anchovies, an often disdained fish (except by the few who love them), contain substantial amounts of monosodium glutamate and have been used for thousands of years to impart the savory umami flavor to food. Garum, a condiment used in the Roman Empire, was as costly as perfume according to an NPR report by Howard Yoon in August 2009, and was prized for its ability to make foods taste, in his words, irresistible.  Anchovies have imparted this fifth taste in Indonesian, Korean, Filipino, Vietnamese, and Thai cooking over many centuries, although presumably adding purified MSG these days would keep the anchovies in the ocean.

And, according to Mr. Yoon, we fall prey to this savory taste when we find it hard to stop eating Doritos or instant ramen noodles.

MSG is both good and bad for us. It has received decades of bad press because of the so-called Chinese restaurant syndrome, a cluster of symptoms such as headache, flushing, tingling, rapid heartbeat, sweating, nausea and burning sensations in the face. After years of extensive research, it has been found that a small percentage of people experience an acute short-lived reaction to MSG. But this is not why MSG is bad. It is bad because, as an additive to many highly processed foods as well as snacks, its umami taste causes us to fill up on foods that, at the very least, don’t really nourish us, and at worst, cause us to eat too many calories in the form of junk food.

But monosodium glutamate could also induce us to eat foods that are healthy, but are avoided because their taste is so boring. Think of how many people do not eat vegetables. They have made up their minds, perhaps as children being forced to eat them, that when they grow up, they will never eat a carrot or a serving of spinach again. What if they were presented with vegetables that have the savory taste of umami? What if the salads and vegetables they disdain had the “lip-smacking flavor“ of a Dorito or ramen noodles and were suddenly craved? An increase in vegetable consumption would certainly improve the quality of our nutrient intake and might even reduce calories.

The article by Yamaguchi and Ninomiya points out that Western foods traditionally rely on high-fat ingredients like butter, oil, and cream to deliver taste and carry the taste of other ingredients. This is why bacon fat or melted cheese or heavy cream bring a deliciousness to dishes that can’t be mimicked by skim milk and canola oil. But, as they point out, much pleasure in the taste of foods is also found in foods delivering that fifth taste—and without the caloric cost.

Regardless of whether MSG makes us eat more or less, what it can do through the fifth taste sense, umami, is to bring more nutritional sense to our diet.

References

“Neurocognitive effects of Umami: Association with eating behavior and food choice,” Magerowsski G Giacona G, Patriarca, et al Neuropsychopharmacology   2018; 43: 2009 -2016.

“Umami and appetite: Effects of monosodium glutamate on hunger and food intake in human subjects” Rogers P and Blundell J Physiol Behav. 1990 48:801-4.

“Umami and Food Palatability,” Yamaguchi S and Ninomiya K The Journal of Nutrition 2000; 130: 9212-9265s

Give Yourself the Gift of Energy

Fatigue seems to be as ubiquitous as complaints about the weather. But it is especially prevalent during the holidays for obvious and not so obvious reasons. The obvious:  buying, wrapping and sending presents, food shopping and preparation, decorating the house, travel or hosting guests, and so forth.  The not so obvious is the inescapable darkness of this time of year. When the sun is gone by 4pm in some parts of the country (and certainly by 5:30 in other parts) it is hard not to feel that bedtime is not so very far away. In addition, an all-encompassing fatigue is one of the symptoms of the winter blues that many experience during the late fall and winter.

Regardless of its cause, fatigue diminishes our productivity and takes away the pleasure we might have in what we have produced. If after shopping, cooking, decorating, buying and sending gifts, the holiday event you have worked so hard to bring about is just ‘… one more thing to do’, then fatigue has taken away your pleasure.

Recognizing that you will probably be more tired than usual is the first step in reducing the fatigue. Getting enough sleep is not only an obvious way of preventing exhaustion, doing so has been shown in countless studies to enhance both physical and mental performance. You would not want a neurosurgeon to perform an operation on you, or have your pilot fly you across the Atlantic with inadequate sleep. Staying up later or waking up earlier than your body’s normal sleep timetable may not allow you to accomplish as much as you want, or as well as you want, because of diminished cognition.

Planning rest intervals of only a few minutes throughout a day of endless tasks will also relieve tiredness. These rest periods are sort of like sitting on a rock or log during a long hike, drinking water and looking at the scenery.  Time-outs from the endless doing will give you energy to continue, just as sitting for a few minutes during the hike gives you the stamina to continue.

Avoid eating high fat foods, as these may cause you to feel sluggish. A double bacon cheeseburger with a fat filled sauce and French fries may seem just the food to restore your energy. Unfortunately they will leave you with just about enough energy to crawl onto a sofa for a nap. Stick to vegetables, fruits, lean proteins like fish, chicken, low fat yogurt, and fiber filled carbohydrates like whole grain breads. These low and no fat foods will nourish you, and not leaving you feeling like a zombie.

Drink plenty of water.  Indoor heat can be dehydrating, and even though you may not feel thirsty the way you did during the summer, your body still needs water.  Not getting enough liquids will only add to your fatigue.

Late afternoon is perhaps the most fatiguing time of all. Many people experience a deterioration in their energy levels and mood around 4 or 5 pm, regardless of how busy they are, and this is particularly true if the sun has already set. Decreases in serotonin may be one cause of the fatigue, along with a decrease in blood caffeine when that cup of coffee was consumed hours earlier.  Eating a small starchy, low or fat-free snack such as pretzels, bagel thins, rice cakes or breakfast cereal increases serotonin within 30 or so minutes, restores mental energy and improves mood. The snack should contain about 30 grams of carbohydrate (read food label) and have no more than 2-3 grams of protein, as protein prevents serotonin from being made. If drinking a caffeinated beverage will not delay your sleep onset later on, then a cup of tea or coffee, along with carbohydrate, will give you an energy boost that should last for a few more hours. Think of this as an English tea.

Exercise has an amazing restorative power. The common excuse about not doing any physical activity is that is since one is already tired, how can becoming more tired (through exercise) make one less tired? It does seem paradoxical, but it works. Moving the blood more quickly through the body, heating up the body through vigorous movement, oxygenating the blood with deeper breathing; these all may contribute to the clearing of the head and invigorating the muscles.

But taking the time to go to a gym, exercise class or indoor swimming pool may seem totally incompatible with an overcommitted schedule. There are two ways of dealing with this: One is to put the word exercise on the ‘to do’ list or day’s calendar, and give it the same prominence as a dentist appointment or a meeting with your child’s teacher.  Go to the exercise class or meet a friend for a walk or take your dog for a long walk at least a few times a week. The second option is to incorporate short bouts of exercise into the day. Avoid elevators. Take the stairs even if you are loaded down with packages. Walk, don’t drive to do an errand several blocks away. Use an exercise app that puts your body through a workout in 7-10 minutes. This is a good option for those days (weeks) when the weather makes outdoor exercise unendurable.

Find a place where you can be alone, where you can withdraw from the demands around you. You may have to put a “Do not Disturb “ sign on the door or a “Back in 10“ sign on the outside of the room where you retreated. Use the room when you feel that you must have a respite from everything going on around you. Sit or lie down, meditate if you can, do some stretching exercises, listen to music, or the radio or television, read a magazine or a few pages of an engrossing book. When you emerge, you will notice that your energy has returned. Perhaps not as much as you want, but you will be able to continue getting through the rest of your list.

If your fatigue is exacerbated by the decreasing hours of daylight, consider using a sun or light box. These devices contain lights that mimic the spectrum of the sun.  Studies over the last thirty years have shown that early more exposure to these lights seems to decrease the symptoms of winter depression, including intense tiredness.

Finally? Laugh. There is nothing so energizing as being with friends or family and hearing a funny story. Failing that, try watching some of the home videos on television. They will also drive away your fatigue.

 

Are Sugary Foods Less Unhealthy During the Holidays ?

The disconnect between 11 months of dire warnings about the evil of consuming sugar, and one month in which the ambitious baker produces prodigious numbers of sugar-sweetened cookies is glaring. The internet, print media, and holistic gurus on television tell us that sugar will, at the very least, cause diabetes, inflammation, cancer, cognitive deficits and, of course, obesity. If you want to live into the next calendar year, these experts tell us, stop eating sugar in this calendar year.

And yet, come the late days of November, baking supplies are prominently displayed on shelves in the front of the supermarket, many with sugar as a significant ingredient. Chocolate chips, sweetened coconut flakes, candied fruit, sugared pecans, and refined, brown, turbinado, and powdered sugar compete for shelf space. The shopper is motivated to buy and use these ingredients by the countless articles in newspapers featuring recipes for cookies and other holiday sweets. Television shows about food also are similarly focused, and show the viewer taught how to make mouth-watering cakes, pies, and, of course, cookies. Who wouldn’t run out to the supermarket and stock up on sugar, eggs, cream, butter, chocolate, and nuts?

But it is curious how those food components we are told to shun (because eating them will lead to a variety of health disasters…) are the dominant ones in these recipes. Sugar is present by the cupful, but generous amounts of butter, egg yolks, heavy cream, and even salt are also major players in the holiday bake-off. The recipes in the newspapers, magazines, and television programs promise taste-bud delight. Where are the nutrition experts now warning us that if we eat these potentially harmful ingredients, we may be giving the gift of future illness to our loved ones?

But wait. They will be around in January.

In the meanwhile, we are told that giving something homemade is to be prized above other gifts. It makes sense. There is much labor that goes into making and then packaging cookies, fudge, peanut brittle and homemade jams. Because they are not available with the click of a mouse, we are told that they represent some of the best gifts we can give. Obviously knitted, woven, or crocheted homemade items are also prized, except that they may not be in a color, size or shape the recipient likes.

For those without the time, talent, or motivation to make edible gifts, but who see such gifts as sufficiently impersonal to be given to people they don’t know very well, the alternative is to buy gift food baskets or boxes. Most will include a least one item that is made from sugar and fat, although some of the options include protein and high-fat foods like processed meats, or just mostly fat such as gourmet cheeses. To be fair, some gift package options are fatfree and feature fruit and nuts, gourmet honey and jams. But some of these items contain plenty of sugar.

Receiving such gifts may be awkward if the donor expects the food item to be open, tasted and shared. A friend who does not like chocolate says that she never knows what to do when presented with a box of gourmet chocolate. “I feel I am expected to open the box, take a piece and then share the rest. I don’t mind the sharing, in fact I would happily give away the entire box, but I don’t like having to eat something I don’t care for.

Returning homemade edible gifts is out of question, and regifting socially dangerous if the new recipient knows the person who made the food or perhaps received some herself. But what do we do if the food gift is incompatible with our dietary needs? What if we are pre-diabetic and told to reduce our sugar intake? What if our bad cholesterol and triglyceride levels are above normal, and we are told to reduce our consumption of saturated fat like butter and egg yolks? Or what if we know we will binge on that jar of buttery sugar cookies or tin of peanut brittle if these foods are in the house? Giving them away, rather than throwing them away, is one solution, but a recipient can’t always be found. And finally, how do we convey to the gift giver that we appreciate the labor and the thought that went into the homemade holiday food gift, but that we are unable to eat it so the person does not give us a similar gift next year?

Perhaps it is time to pay attention to the dire nutritional warnings coming at us the rest of the year about our rising rate of obesity and obesity-related disorders, and find acceptable gifts that do not war with our health needs. Indeed, gratitude at receiving a basket of buttery sugary cookies may turn to dismay when the scale reveals the aftermath of consuming the gift. It is very hard to resist tempting foods displayed on the coffee table. Better not to have them in the house at all.

But that leaves the challenge of finding gifts that are either impersonal (money is impersonal but that is another matter) and /or reflects who we are rather than a commercial enterprise. Making donations to causes that appeal to many people, like organizations which foster and adopt abandoned dogs and cats, or which support environmental protection, or help those less fortunate (such as victims of California’s fires), are alternatives that could be considered. Donating to these organizations in the name of the person to whom you want to give a gift makes everyone feel good. Donating money to organizations that feed those who do not get enough to eat, rather than spending it on baskets and boxes containing foods that no one really needs to eat, is an alternative that benefits everyone.

Do College Students Get Enough (Nutrients) to Eat?

Thanksgiving week is often the first time parents get to see their college-age children after they leave for the fall semester. They often come home not just with a knapsack filled with dirty laundry and a serious sleep deficit, but with the possible beginnings of nutrient deficiencies. It is unlikely that the student will have symptoms of scurvy (Vitamin C deficiency) or iron-deficiency anemia. But, at the very least, many will have been following a nutritionally questionable diet.

Worried about the eating habits of a young relative who is completing his first semester as a freshman, I queried him about the nutritional adequacy of the foods provided in his college’s dining room. The food was acceptable, I was told, although since he was a vegetarian, he couldn’t comment on the meat dishes. His problem, common to so many, was a schedule that included long afternoons in a physics or computer laboratory causing him to emerge for supper  after the dining room had closed. Then his only options were sandwiches and fries at the college-owned café that was open much later, or pizza from a place down the street.

But he mentioned that his friends teased him about his food choices because when he did eat in the dining room, he always had a salad and fruit (his mother would be proud). Asked what his friends usually ate, he quickly tossed out,  “Mac and cheese, pizza, hamburgers, onion rings, and soda. They eat terribly. They never eat vegetables or fruit.”  Knowing that he rarely drank milk and ate yogurt infrequently, I was happy to know that his calcium needs were being supplied by the chocolate milk he drank after long runs.

His perception about the  poor food choices of his friends has been confirmed by many studies of the food habits of college students. The reasons are pretty obvious. Breakfast is often skipped in favor of sleep, and often lunch and dinner may be obtained from food trucks, nearby pizza shops, fast-food restaurants, and snack shops rather than the college dining room. This is particularly true if meal tickets can be used at food trucks, coffee shops and other nearby restaurants.  One consequence, however, is a minimal consumption of fruits, vegetables, and often dairy products. Dieting, especially following  diets  that arbitrary eliminate various food groups (i.e. paleo, keto, cleanses), may also cause inadequate nutrient intake, although this is hardly confined to college campuses.

As the article by Abraham, Noriega and Shin point out (“College students eating habits and knowledge of nutritional requirements,” Survey of attitudes and eating habits  Abraham S, Noriega B, Shin J, J of Nutrition and Human Health 2018 ; 2:13-17), college students often know very little about their nutrient requirements, believe that food additives rather than high calorie content is the reason fast foods should be avoided, and either disregard or know very little about the relationship of nutrient intake to health.

Alerting this population to the consequences of inadequate nutrient intake is a mission that must wait its turn behind education on the perils of nicotine, excessive alcohol and unprotected sex. Not surprisingly, it is a subject rarely discussed, except perhaps by coaches who realize the importance of adequate nutrient intake for their players.  (“Web-based nutrition education for college students: Is it feasible?” Cousineau T, Franko D, Ciccazzo M, et al Eval Program Plann. 2006; 29: 23-33) Male college students, according to the article by Cousineau, Frano, Ciccazzo et al, are particularly uninformed about what they should or should not be eating. But all college students seem to know little about food labels, appropriate number of servings from various food groups, the relationship between calorie intake and energy metabolism, the need for fiber, vitamins and mineral rich foods, and indeed, what happens to food after it is ingested.

One wonders if the ready acceptance of misinformation about diets, effects of certain foods on cognition, inflammation, the intestinal tract, mood, and energy is not a consequence of college age and older adults knowing so little about basic physiology. Often the nutritional information is about as accurate as the belief that the world is flat. Yet where and when does the college student, and indeed anyone in the population, obtain some basic facts about how the body uses what is being consumed?

Weight gain is common in college, especially during the first year, due to a combination of lack of exercise, stress, too little sleep, and perhaps too much pizza and beer. Students are especially vulnerable to this when midterms and final exams approach. Somehow the message that good nutrition and adequate sleep might help cognition and mental performance, has not been able to offset the constant snacking and staying up all night that characterize these periods of intense study.

A simple solution to possible inadequate nutrient intake is a daily vitamin supplement or a vitamin supplement that also contains calcium and iron for those who avoid dairy products and foods rich in iron (such as red meat.) The vitamin supplement is, of course, no substitute for those fruits and vegetables, and dairy products the college attender should be eating. But until that happens, a chewable vitamin or a pill may be the best solution.

The Guest with the Surgically Shrunk Stomach & Thanksgiving Dinner

Surgical interventions to reduce the size of the stomach are increasing in popularity, predominantly because they have been successful in reversing years of dieting failures. Patients who have had these procedures, however, may find themselves struggling to deal with the excessive amounts of food commonly served on Thanksgiving.  Although Thanksgiving is still a day when we pause in our daily lives to be grateful for what we have, including food, health, family and friends, the holiday sometimes seems to be almost exclusively concerned with only the food. Judging by the number of media articles and television shows advising us on recipes and methods of cooking, sometimes it seems that the purpose of the holiday is to see how successful we are in preparing the meal.

The amount of food served on Thanksgiving Day must resemble a feast. If the host decides that the turkey, two vegetables and just one dessert are sufficient, he or she will be regarded as a food miser. “What are you making for Thanksgiving?” is the greeting of the week before turkey day, and guests often arrive with dishes to supplement the many made by the host. One young woman who is hosting Thanksgiving dinner for the family for the first time was gently reminded that her dinner plates were not sufficiently large to contain all the side dishes she thought she had to prepare.

The typical guest, confronted with all that food, manages to eat much more than the amount he or she would normally consume at a dinner meal.  Despite protestations of feeling too stuffed to eat another bite after the main course has been consumed, most will manage somehow to sample at least a couple of pies when dessert is served.

But what if the guest does not have considerable room in his or her stomach to eat the many dishes being offered? What if the guest has had bariatric surgery to reduce the size of the stomach, and now it can hold no more than a couple of ounces of food at one time? The point of the surgery is to make the stomach so small that the patient, eating only tiny amounts of food, will lose weight.

What makes an occasion like Thanksgiving so difficult for those who have had this surgery is that for years, they were able to eat whatever they wanted, and as much as they wanted. Even though they know it is physically impossible now for them to do so, emotionally this may be hard to accept.  I wonder if any one us who has not had such an operation can imagine how difficult it must be to watch others around the Thanksgiving table help themselves to large portions, take additional servings and eat as many desserts as are available. The guest with the surgically reduced stomach not only is unable to eat normal-size portions but must also restrict what is eaten to the foods that will nourish his body rather the foods that he may crave. Filling up on stuffing or marshmallow-topped sweet potato pie or onions in cream sauce is not an option when his body needs lean protein.  A normal size stomach can handle the turkey and all the side dishes; a surgically reduced stomach may accept only the turkey.

Moreover, those who have had this type of surgery may be reluctant to share this information with others at the table.  But then, how to explain the sudden significant decrease in food intake? Several years ago, I noted that a relative who was known for consuming large quantities of food was eating tiny portions, and refusing most of the dishes offered to him. When I asked him if he was not feeling well, he told me about this surgery to reduce the size of his stomach. Suddenly others, overhearing our conversation, threw questions at him so quickly he couldn’t answer them: What was the surgical procedure? Did it hurt? How much weight have you lost so far? What can you eat? Are you hungry? Even though it is no one’s business and the guest should not feel obliged to answer the questions, often, especially when relatives are present, people want their curiosity satisfied.

Fortunately for our guest with the surgically smaller stomach, there are probably others who are also limiting their food intake.  Many Thanksgiving dinners will have guests who are avoiding gluten, dairy, meat, all animal products, all carbohydrates, foods without probiotics, cooked foods, certain fruits and vegetables, fat, and salt. Thus several of the diners may be putting only one or two items on their plate, and in some cases guests may even bring their own food because they don’t want to risk eating foods which may make them ill.

But even if the limited food intake due to bariatric surgery is camouflaged by the presence of others who pick, choose, and reject the food being served, the psychological difficulty of not being able to eat freely remains. Portion control is essential as is eating slowly, limiting fluid intake including alcohol so the stomach has room for food, and knowing when to stop eating. This is not easy, and often is accompanied by a sense of loss as acute as that experienced by others…such as a diabetic or someone with certain types of gastrointestinal disorders who must accept that they can no longer eat everything they want.

Perhaps the presence of some guests who cannot indulge in unlimited eating might be a catalyst to decrease the excesses of the Thanksgiving meal. Certainly, one point of the meal is to be thankful that we can feed our families, friends, indeed, those in our community.  But feeding one’s guests and feeding them to excess are not the same thing.  If we simplify the menu, provide a realistic amount of food, and alter the emphasis from what is on the table to who is around the table, then even those who cannot eat much will not feel deprived.

Might Physical Activity Be as Effective as Antidepressants?

The well-known recommendation to exercise in order to relieve and/or improve a wide variety of health problems may sometimes seem exaggerated. One might ask whether going to the gym or chopping wood will truly improve sleep, cognition, fragile bones, cholesterol levels, high blood pressure, and obesity, as well as decrease vulnerability to diabetes, heart disease, and cancer. That is an awful lot to ask of a daily bout of physical activity.

However, many studies over the past several decades have confirmed the positive relationship between exercise and an array of health effects. Exercise is not going to prevent anyone from eventually exiting this world, but engaging in physical activity may make us more healthy while we are still in it.

Studies over the past decade on exercise and mental disorders have added another benefit to consistent physical activity: Depressed patients may benefit as much from routine exercise as they do by taking antidepressants. Craft and Perna published an extensive review of studies on whether or not exercise might have a therapeutic role in clinical depression. The ability of depressed patients to carry out physical work has been shown to be significantly impaired, and they are less fit than the general population, according to some studies cited in the article. It is not hard to find reasons for the diminished physical well-being. Depression is often accompanied by fatigue, social withdrawal, sleep disturbances, and the side effects of antidepressants include dizziness, nausea, and even weight gain. These factors may make engaging in routine physical activity difficult, unless there is outside support to do so.

In a typical study to see whether exercise might be beneficial not just in improving physical status but also in relieving the symptom of depression, the patients are enrolled in an exercise program, walking three or four times a week, for example, or doing resistance training. The severity of their depression is compared with a control group of patients who do not exercise but engage in some other type of intervention so they receive the same amount of care and attention from the research staff. The results have been consistent study after study: Exercise has a positive effect on depression.

In one particularly compelling study, the effect of exercise over 16 weeks was compared with the effect of an antidepressant (sertraline) alone and with sertraline and exercise. About two-thirds of the patients in each group went into remission after the four-month testing period. The results indicate that exercise alone was as effective as the medication alone or medication plus exercise in relieving the depression.

If exercise is treated like any other therapeutic intervention, it is important to determine the most effective dose, timing, and type, as one would with medication. Walking slowly on a treadmill versus jogging or resistance training once a week, or four times a week, are some of the variables that have to be examined. Should the exercise be mild or intense? Is it better to exercise outside in the fresh air and sunlight, or does this make any difference? Might yoga or other group exercise be more beneficial than solitary workouts, or a walk, because they diminish social isolation? Is there some way of identifying patients at the onset of their depression who might benefit from exercise rather than antidepressant therapy? How long should it take for an exercise program to produce a lessening of depressive symptoms? Many antidepressants take several weeks before they seem to have an effect; should the patient wait the same amount of time to see whether exercise relieves symptoms?

These questions can be answered fairly easily with additional studies. What is more difficult is how to translate these findings to the real world. To begin with, who is going to treat the patients? Therapists are rarely, if ever, also trained as exercise physiologists. And exercise physiologists may not have any training or experience working with depressed clients. Do these professionals even communicate with each other? A therapist may be able to refer a patient to a physical therapist for an initial consultation as to what kind of exercise the patient can do without injury or pain, but how should the patient follow up? Where will she exercise? Does he have to join a gym or a local Y to exercise? Who will determine the type of exercise program? What oversight is available to make sure the exercise program is carried out effectively and without injury or pain from overused muscles? Who will help/motivate the depressed patient to participate over several weeks rather than dropping out? And finally, even if exercise can be as effective as medication for depression, who will pay for it? Visits to a psychotherapist and medication may be paid for now in their entirety, or at least in part, by health insurance. Therapeutic visits with an exercise physiologist rather than a prescription for an antidepressant is probably not covered under billing codes for mental illness, and thus may be an out-of-pocket expense.

And yet, exercise should not be overlooked or discarded as an effective way of managing depression. Its value in increasing general health, sleep efficacy, and increased physical fitness, in addition to relieving the symptoms of depression without the side effects of drugs, cannot be overestimated. Now is the time to figure out how to apply this knowledge.

References

“The Benefits of Exercise for the Clinically Depressed,” Craft L and Perna F, Prim Care Companion J Clin Psychiatry. 2004; 6(3): 104–111.

“Effects of exercise training on older patients with major depression,” Blumenthal JA, Babyak MA, and Moore KA. et al. Arch Intern Med. 1999 159:2349–2356

The Social Isolation of a Painful Disease

We visited B for the first time in three years because of our infrequent trips to the country in which she lives, thousands of miles and several time zones away from us. Emails and phone calls had informed us of her worsening fibromyalgia, but we were not prepared for the almost total isolation imposed by her chronic pain. She has trouble walking because of pain in her legs, and simple movements, such as getting up from a chair or climbing a flight of stairs, are difficult or on some days impossible. Plans to socialize with friends or attend a lecture at the university where she used to be a professor are often canceled, she told us, due to overwhelming fatigue.

Fibromyalgia is a disease that seemed to defy diagnosis or categorization for decades, because no objective measurements, such as blood tests or scans, revealed the source of the symptoms. An advertisement for a drug to relieve the pain of fibromyalgia demonstrates the hidden nature of the disease: A woman tells us that we might assume she is perfectly healthy, because there are no outward signs of her symptoms, yet she is in constant pain.

Fortunately, the medical community has now accepted fibromyalgia as a real disease with multiple symptoms. The most common is pain that seems to migrate almost randomly around the body, affecting soft tissue, tendons, ligaments, and muscle. However, patients may experience severe migraines, sleep disturbances, mood and cognitive disorders, gastrointestinal disturbances, and fatigue.

It is not clear what causes the disease or why pain is felt when there is no visible injury, inflammation, infection, or sign of any other cause, such as cancer. Now researchers are investigating whether the pain is not due to some injury or other disorder within the body, but rather to inappropriate messages from centers in the brain that signal the presence of pain.

One therapeutic approach has been the use of drugs which activate neurotransmitters such as serotonin and norepinephrine to see if they can counteract the pain signals from the brain. But the drugs are not always effective and have their own side effects. Presently, a multifaceted therapeutic approach is advised, incorporating psychological counseling, cognitive-behavioral therapy, meditation, exercise, and reducing sleep disturbances.

However, these interventions are not always successful. Our friend swam and did exercises in the water for two years with no improvement. Now an exercise physiologist trained to work with fibromyalgia patients is available to help her exercise twice a week, but the sessions are often canceled because the intensity of her pain makes any type of exercise too difficult.

Physicians and other health professionals have not been able to find any effective intervention to allow this once-vibrant woman to return to her former active life. She taught university-level courses, turned her research into highly regarded books, and was active in an organization that worked with disadvantaged children. Now, most of her days are spent alone in her apartment with a part-time caretaker. Her friends have dropped away, not because they don’t want to be with her, but because her pain makes it difficult for her to be social. Her hands hurt too much to text or email or engage in social media, and she finds it hard to carry on phone conversations. We don’t know how much our visit cost her in pain. Because we had traveled so far to see her, she never revealed to us, honestly, how she was feeling.

And yet it was apparent that having visitors who made a point of not focusing the entire conversation on her disease had a positive effect. We amused her with some interesting gossip, engaged her in a political discussion that we knew would animate her, shared memories of a time when we lived in the same city, and talked about her research.

Did her pain recede as a result? We never asked, but the energy she summoned several minutes into our visit seemed to indicate that perhaps her pain was not taking over her life at that time.

Sadly, we had to leave her and return home, promising not to wait so long before we made the trip again. But our visit pointed out how a chronically painful disease reduces the quality of life and in particular the loss of human contact. And it is not obvious what can be done. It is hard to spend time with someone who is in constant pain; we don’t know what to say, how to help, or how to understand what they are feeling unless we have had similar experiences. We fear that we may be causing the patient more stress by forcing her to put on a cheerful face and chitchat with us as if nothing is wrong when we all know that she is deeply distressed. Sometimes it’s easier to stay away.

But we shouldn’t stay away. We should not allow the pain and other symptoms, such as sleep disturbances, limit our visits with the patient. If we allow this to happen, then we are allowing the disease to replace our relationships.

When we saw our friend, it was apparent that once we stopped talking about her disease and switched to topics that have consumed our mutual interests for decades, she seemed to focus less on her pain and more on engaging with us in discussing the interests we had shared for many years. Indeed, at some point, we all forgot about the fibromyalgia and simply remembered how good it was to be with each other.

Perhaps social contact should be added to the top of the long list of interventions for this disease. Pain may be present, whether the patient is alone or with others. But when others are around, good conversations, laughter, stories, arguments, etc., may prove an invaluable distraction from the pain. It may not always work; pain may cause social interactions to be delayed or canceled. But it is important to try, because the rewards of seeing a friend or family member relieved of chronic pain, even temporarily, are immense.

References

Goldenberg DL. Fibromyalgia syndrome. An emerging but controversial condition. JAMA 1987; 257:2782.

Björkegren K, Wallander MA, Johansson S, Svärdsudd K. General symptom reporting in female fibromyalgia patients and referents: a population-based case-referent study. BMC Public Health 2009; 9:402.

Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014; 311:1547.

When Bone Soup Promises More Than It Delivers

One of my neighbors was recently diagnosed with liver and pancreatic cancer. She is rapidly losing weight because eating and digesting food causes her pain, but her weight loss may make recovery from chemotherapy more difficult. She told me she is drinking bone broth in order to obtain the nutrients she needs, and to halt her weight loss.

Why? I asked her when we talked today.Everyone says it is good for me,” she answered, everyone upon further questioning being some relatives and a few friends. “But you need nourishment, I protested. You need to eat protein, you need carbohydrates for energy, and you need vitamins and minerals. You aren’t going to stop losing weight by drinking bone-flavored water.“

Fortunately, her oncologist referred her to a hospital dietician experienced in the nutritional needs of cancer patients such as my friend, and the bone broth is now watering some house plants. But this incident is an example of how popular food fads, health food supplements and neighborly advice may exacerbate, rather than solve nutritional problems.

Bone broth, a soup containing mostly water and the flavor and some nutrients from the bones cooked in it, is a broth that people have been eating for eons. It is, in some respects, like drinking liquid, salty Jell-O. When beef bones are cooked for long periods of time, they turn into a gelatinous mass, as I discovered when I forgot about a pot of water and bones I was simmering in order to make stock for soup. (Washing the pot became a major endeavor.) This gelatin in the hands of competent cooks can be turned into aspic, a translucent covering for pates and cold chicken, or a sweet “Jell-O” type dessert. Proponents of bone broth point to the gelatin as evidence of its vast nutritional value: all the good protein and the collagen from the bones is going to decrease inflammation, fortify your bones, and lubricate your joints. What is not mentioned is that gelatin is an incomplete protein because it lacks the essential amino acid tryptophan, and contains very small amounts of another amino acid, tyrosine.

Both tryptophan and tyrosine are needed for the synthesis of new protein in our bodies. Thus, if my friend depends on the gelatin in bone broth in order to make new protein for her muscles that are wasting away, she will be unable to do so. Moreover, the collagen in bone broth is digested in the intestinal tract, and is no more able to lubricate our joints than the butter or oil we may be eating.

Ironically, if a chicken were simmered along with the bones it would turn into (drum roll please) chicken soup. The chicken is a good source of protein, and although the power of chicken soup to heal the body may be exaggerated, its ability to soothe the distress of a bad cold or flu, or maybe restore the body after a bout of chemotherapy does not seem to be in dispute.

It is disconcerting to find bone broth sold in supermarkets and online for not inconsiderable amounts of money. In the old days, before this fad, people threw a few bones in a pot of water and whatever vegetables they had to make a very cheap soup. Bones also used to be given to dog owners or sold in enormous quantities to be turned into gelatin, or the fertilizer bone meal. Paying $10.00 or more for a box of bone broth containing mostly water seems absurd.

What is so worrisome about this food fad, and the many others that pop up like mushrooms after a wet spell, is that they suggest we don’t have to rely on food for our daily nourishment or to compensate for some nutritional deficit such as lack of vitamin C or iron. The health food store, not healthy foods at the grocery store, is promoted as the path to nutritional wellness. I receive updates from several online newsletters describing the latest supplement entering the health food market. It is often astonishing to read about the promises made, without any evidence, for these products. One of many entering the market this past month includes bitter melon, cinnamon bark, fenugreek seed, olive leaf and artichoke leaf, holy basil herb and lycium fruit. These are presented in a liquid and supposedly will maintain normal blood sugar levels in people with normal blood sugar levels (italics are my own). Apparently the makers of this supplement never heard of insulin that our pancreas secrete (for free) when we eat carbohydrates. Another product also just now for sale is made from Siberian rhubarb roots and promises to help menopausal symptoms like hot flushes. The research supporting these claims and many others is often not real or reproducible, but how would a consumer know this? 

My friend with cancer believed that the bone broth she was drinking, even though her weight was melting off, was nourishing her. Unfortunately, she was getting none of the nutrients she needed. People may hesitate to seek medical advice or ignore it completely because they are convinced that the promises made by the supplements will be the answer to their medical problems. Supplements can interfere with drugs one is already taking. Given the number of supplements on the market, and the sometimes bizarre source of ingredients (who knew that rhubarb could be grown in Siberia?), physicians may not know whether the ingredients are dangerous. Plus the dose of a supplement may be entirely too high. For example, many doses of melatonin range from 3 mg to 10 mg; the dose established by clinical research puts the dose at 0.3-0.5 mg and the higher dose may dampen the body’s own melatonin production.

The FDA has information about the ingredients, function and side effects of many supplements, and it is worth spending time learning about a supplement that has been recommended or advertised before taking it. Some are critically important, such as those providing the vitamins and minerals an individual may not be able to obtain through food. My friend does take a vitamin-mineral supplement because she finds it too painful to eat many fruits and vegetables.

Our health is too important to be left to the sellers of health products. Checking out the scientific validity of a product may not be possible without the help of dieticians or others knowledgeable about the contents and claims of these products. But it is worth making the time to do so.