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.”

Is It Safe to Eat Food This Summer? Or Ever?

If you want to feel paranoid about eating in restaurants, or buying packaged fruits and vegetables that may be also be pre-cut, and cooking chicken and eggs, then don’t look up current food-borne illnesses on the Internet. I have a relative who gets alerts from the CDC about the latest source of food poisoning, and immediately passes the information on to me before I read about it in the newspapers. She told me to avoid Del Monte packages of cut-up vegetables as they contain a microscopic parasite, and also to dodge Cyclosporai via pre-cut melon because of a multi-state salmonella outbreak, and a few months ago, she alerted me not to buy Romaine lettuce in the supermarket or eat salads containing this leafy vegetable at restaurants because it was contaminated with E.coli. Thankfully, it is now again safe to have salads with this lettuce.

My food contamination alerts decreased temporarily when she went on vacation, so I decided to find out for myself what other aggressive pathogens might be lurking in my food supply. A quick scan of websites devoted to reports of food-borne illnesses uncovered a report about Kellogg’s breakfast cereal Sugar Smacks linked to a Salmonella outbreak across 31 states, Canadian restaurant workers in danger of Salmonella if they handle raw or frozen uncooked chicken, and one horrifying story in the British press about a man who nearly died after he ate a chicken liver parfait (we would call it a mousse) at a dinner at which he got an award from his employer. His situation sounds like something out of an Agatha Christie novel: disgruntled employee kills co-worker who received an award.  But actually many of the 500 people who attended the event got sick as well. However, this individual spent seven weeks in intensive care because he was unable to move his arms and legs and could neither talk nor blink. His eyes remained opened and he could not sleep. This ghastly set of symptoms was due to the Campylobacter bacteria. According to the report, the chicken liver “parfait” should have been heated to a much higher temperature than it was in order to kill off the bacteria lurking within.

How was the awardee, or any of the others who attended the catered dinner, supposed to know this?

And this is the problem. It is all very well to read about the outbreaks and then check the refrigerator to see whether the contaminated item is there. But obviously we know about the problem only after people become ill. In the back of our minds we may find ourselves thinking, maybe I will be the one getting sick from the next contaminated food outbreak. When the Romaine lettuce recall occurred a few months ago, and people shared information about this with their family and friends, I saw more than a few horrified expressions that seemed to say, “Didn’t I just have a salad at a restaurant or homemade with Romaine lettuce?”

The same thing is true of food poisoning from restaurants. There is a website, “I was poisoned.com”, on which victims of contaminated restaurant food write about the unpleasant aftermath of the meals they ate at a particular restaurant. I suspect that fewer people check that website before going out to eat than looking up the menu options in a restaurant they are considering visiting. But maybe one should start on the website first.

It is disheartening to realize that all of us are in jeopardy. Even if you never eat in a restaurant, unless you grow your own fruits and vegetables, raise chickens for eggs and baked chicken breasts, and also make your own bread from your hand-milled flour (flour from certain mills was contaminated last year), you could be next.

Of course, we can and should use precaution in our own food preparation: cooking foods at a high enough temperature to kill the pathogens, refrigerate foods as quickly as possible, keep counters and sponges clean, wash our hands after handling raw eggs and poultry, and prevent what is called cross-contamination. This means not wiping the counter with the sponge you used to mop up raw chicken juice (ugh) or making a salad with hands not washed after touching same chicken.  Perhaps decreasing the number of meals we eat away from home might also help. Preparing your own container of cut-up fruit or chicken salad or smoothie rather than buying these items eliminates the uncertainty of where the food comes from and the whether it was prepared under strict sanitary conditions. Avoid eating foods at catered buffets that look as if they could shelter bacteria. A mousse of chicken liver , assuming one likes chicken liver, should be consumed with caution if only because unless it is kept cold, one doesn’t know whether it is a culture medium for bacteria.

But how does one protect oneself against an outbreak of food-borne illness if the food is something as unprocessed as lettuce or cantaloupe? Or how is the consumer to know that Kellogg had another company manufacture the cereal that was contaminated?

A start would be to stop being complacent about food safety. Rather, perhaps a bit of paranoia is worth having when reading a restaurant menu, checking out the cleanliness of a restaurant rest- room  (where unwashed restaurant workers’ hands may cause hepatitis A outbreaks) and taking a peak at the “I was poisoned” website.

Just don’t look at it after you eat.

Will Stress Lead to Autoimmune Disease?

A worrisome report from a group of Icelandic scientists linking stress to autoimmune disorders appeared in a recent edition of JAMA. The media alerted us to their findings in terms that were, well, stressful: If, or more realistically when, we experience severe stress, we will be increasing the likelihood of developing diseases ranging from thyroid to hair-loss disorders. This report resonated with me, as I did develop an autoimmune skin disorder at an age when it was rare to show the first symptoms.

My physician asked whether I had been stressed earlier in the year. The answer was yes. My stress was due to worry and sorrow over a close friend’s diagnosis of a terminal disease. Would I have been “immune” from this autoimmune skin problem if the year had been less stressful? The media description of the results of the study would have you believe it to be so. An acquaintance told me about her son who is working an impossible number of hours as a first-year associate in a large law firm. “He is so stressed,” she told me, “that I am worried he will develop some awful disease.” And she quoted from a news release about the study to me:

The study looked through medical records of more than 100,000 Swedish adults who had been diagnosed with stress-related psychiatric disorders, the medical records of 126,652 siblings of these patients and 1.1 million unrelated individuals. The two latter groups had no stress-related disorders. Forty percent of those with stress-related psychiatric disorders were male and their average age, 41.

What is striking about their results is that over a 10-year follow-up period, a significantly larger number of individuals who had a stress-related psychiatric disorder were diagnosed with an autoimmune disease compared to the other two groups. Some of the diseases included Addison’s disease, rheumatoid arthritis, psoriasis, multiple sclerosis (M.S.), Crohn’s and celiac disease. Also, the risk for developing a particular disease differed. For example, there was a higher risk for celiac disease than rheumatoid arthritis.

Does this mean that a stress-filled year or short-lived acute stress will lead to a lifetime struggle with an autoimmune disease such as M.S.? The answer is no. To begin with, the stress is not simply stress; it is a diagnosed psychiatric disorder. Post-traumatic stress disorder, acute stress reaction, and adjustment disorders are listed by the authors as associated with increased risk for subsequent autoimmune disease.  Being stuck in a two-hour traffic jam on the way home from work is very stressful but unlikely to cause the development of the skin lesions associated with psoriasis.

Moreover, as the authors point out (despite the hype in the media), “The relatively modest differences in the incidence rates of autoimmune disease between the exposed and unexposed,” (i.e. stressed and non-stress disordered individuals) “…should not lead to special monitoring of people who have been diagnosed with a stress disorder.”

But this conclusion still leaves the question as to why there should be a connection, even a weak one, between PTSD and M.S. or thyroid disease. Changes in cortisol levels, changes in pro-inflammatory cytokine levels, or an overly active inflammatory response/immune system are put forth to attempt to understand the process leading to the disease. But no workable answer is available yet.

What is so sad about the study results, however, is that those who have a stress-related disorder, such as PTSD, which in itself significantly affects quality of life, might then have to endure many decades of another disease that compounds the diminished quality of life.  However, the report found that antidepressant treatment for PTSD reduced the risk of an autoimmune disease. Thus treating the stress disorder may be the answer to preventing another lifetime disorder from developing.

“Association of Stress-Related Disorders With Subsequent Autoimmune Disease,” Song, H., Fang, F., Tomasson, G., et al, JAMA 2018; 319:2388-2319

Losing Your Sense of Smell to Lose Weight

A friend who went through an intense treatment of chemotherapy two years ago is still unable to smell, and thereby taste, most foods. She was warned this might be a treatment side effect, and when it would disappear was unknowable.  She used to eat chocolate, any kind of chocolate, as long as it was chocolate. “I don’t eat chocolate anymore,” she told me. “It tastes funny.”

That chocolate tastes funny to her is more likely to be from a loss of a sense of smell than taste.  According to Nancy E. Rawson, Ph.D. who is on the staff at the Monell Chemical Senses Center, Philadelphia, and Scientific Advisor to the Anosmia Foundation, it is our sense of smell, our olfactory system that gives us our taste sensitivity.  When people loss this olfactory function, when they have anosmia, they may not be able to taste the difference between an orange and a piece of chocolate.

As she and others explain, our ability to taste is almost totally dependent on our ability to smell. Of course, we can detect the basic tastes: sweet, salty, sour, bitter and umami, a savory taste sometimes associated with the taste of protein, even if we lose our sense of smell. But smell is the conduit to taste; without it the tastes of most foods are unrecognizable. We have cells high inside the nose, the olfactory sensory neurons, that connect directly to the brain. When we smell coffee brewing or popcorn popping, the microscopic “odor” molecules released by the food stimulate these neurons, and they message the brain, which then identifies the odor for us. (Dogs are much better at this than humans.) Interestingly, the smells come in not only through our nose, but also through a neuronal path connecting the roof of the throat to the nose. So when we chew our food, odors are also released that are picked up by the olfactory sensory neurons and sent to the brain.

A stuffy nose makes us aware of how important smell is in tasting what we are eating, and influences how much we enjoy or reject a particular food (think smelly cheese). But although it is frustrating to be unable to taste food when we have a cold, we know that once our stuffy nose disappears, we will be able to smell and enjoy eating once again.

It is this aspect of eating, enjoying the taste of food brought about by our ability to smell it, that has spawned interest in preventing the dieter from doing so.  If the food is tasteless, might the dieter eat less? Would the dieter stop eating when full, rather than continue to eat beyond fullness because the food tastes so good? Would impulsive eating of freshly baked chocolate chip cookies or French fries be thwarted because, without their scent, they lose their irresistible taste?

Apparently this occurred among subjects participating in a study in which they wore a nasal insert designed to redirect airflow in the nose away from those sensory olfactory neurons that tell the brain what we are smelling. Dror Dicker, MD, Rabin Medical Center, Israel, at the European Congress of Obesity a few weeks ago, described the device called Noznoz. The 65 subjects who wore the device while following a calorie-controlled diet lost significant weight; they especially reduced their consumption of sweet foods. In a sense, they had a perpetually stuffed nose.

Although the use of a custom-fitted nose device to reduce food intake is new,  the link between loss of the olfactory sense and altered food intake is well known. (“Olfactory Dysfunction Is Associated with the Intake of Macronutrients in Korean Adults,” Kong, Il, Kim, So, Kim, Min-Su et al, PLoS One 2016 ;11: 0164495)  Food intake among more than 1300 participants who had olfactory dysfunction (or inability to smell) was altered, compared to those who did not have this problem. Protein intake was reduced among males, the intake of sweet foods among young women, and consumption of high-fat food among young and middle-aged women. How the loss of the sense of smell differentially affected what was eaten or rejected was not explained in the paper.

Loss of the ability to smell odors may be one of the unwelcome aspects of aging. (“Effects of aging on smell and taste,”  Boyce, J. and Shone, G., Postgrad Med J. 2006 Apr; 82(966): 239–241)  The effect of aging on the deterioration of the sense of smell is so prevalent that one wonders if there ought to be generational-based recipes; foods made for an older population might have ingredients such as vinegar or lemon that can be tasted without a good sense of smell. Boyce and Shone state that in a recent survey almost 65% of 80-97 year olds have an impaired sense of smell.  The effects can be far ranging from the addition of too much salt and other spices to food in order to taste it, to malnutrition. Just as the loss of the sense of smell affects food intake among a younger population and decreases their food intake, so too the very old may eat less indiscriminately. They not only might avoid sweet or fat-rich foods, but food in general, thus causing them to be at risk for malnutrition. This is especially worrisome if their food intake is not sufficient to provide essential nutrients like protein, vitamins and minerals.

Fortunately the NozNoz and other interventions like a nasal spray that numbs the nose to smells, do not permanently eradicate this important sense. Indeed, its greatest utility might be putting them on when passing by sources of enticing food odors like sausages and onions cooking at a street fair that might tempt one into eating. It remains to be seen whether weight will be regained when and if the dieter removes the nose plugs. And of course, they may be helpful in cleaning up after a baby or dog.

 

 

Working Toward Weight Gain

A few days ago, I was in the office of my ophthalmologist for my annual eye exam. The practice is huge, and the volume of patients is processed–so to speak–by a row of administrative personnel, each sitting in a cubicle. I checked in at one such space and later checked out with the same clerk. As I watched her scan the computer to then print out the appropriate paperwork, it occurred to me that her job was almost totally sedentary. She did not have to move more than a few inches to access her computer, and the printer was under her desk so she did not have to walk over to another area to retrieve a printout. She was not chained to her chair, yet I doubt she was able to leave it until lunch and then again when the office closed. Unless she had far to go for lunch, or exercised during that noon break, she was completely sedentary for hours.

Until robots take over many of the routine jobs now performed by humans, more and more employees will be working in occupations characterized by an absence of physical activity. About seven years ago, a report was published on changes in physical activity related to occupation over the past fifty years in the United States. The authors used data from the United States Bureau of Labor Statistics that analyzed the amount of energy expended for jobs in private industry from l960 on. When the data were first collected in the early l960s, almost half of non-government jobs required moderate to strenuous physical activity. 50 years later, this number dropped to 20 percent. The authors translated these figures into changes in the number of calories that are expended in work and stated, “We estimated a reduction of more than 100 calories per day in occupation-related energy expenditure over the last 50 years.”

50 years ago, the woman processing my eye doctor’s records would have been using a typewriter and thus expending more energy than tapping on a computer keyboard. She probably would have to get up from her chair and walk to the office copy machine to make a copy of my record rather than pushing a button on her computer and reaching under her desk to retrieve the paper from the printer. Multiply this by every patient, every five minutes or so, and her calorie output would have been considerably more than it is today.

The authors of this report discussed the implications of the decrease in work-related physical activity as a risk factor for obesity. They suggested that as we increase the use of labor-saving, we are promoting the increase in weight of the population in general.

They recommend physical activity to compensate for the sedentary nature of many occupations. According to them, if the woman processing my paperwork engages in 150 minutes of moderate activity a week, she will compensate for her lack of activity during her work hours. But, as they point out, only one in four Americans meets this goal. Given the long commuting time many workers face, as well as the unending tasks to be done at home, it is unlikely that the three out of four Americans who are not exercising will suddenly find the time to do so during their limited after work hours. And even if some physical activity occurs on weekends, unless it is prolonged it probably will not compensate for the inert workweek.

Chairs perched on bicycle pedals and mini treadmills, are now being used by many who otherwise might be stuck unmoving an office chair. Those who fear the consequences of prolonged inactivity welcome the opportunity to move the bottom half of the body while the head and hands are occupied in writing reports or code. The use of these devices could be expanded to a much larger population such as medical office workers or anyone else forced to spend most of the workday seated. However, this is unlikely to occur; in addition to the obvious cost of such devices, it might seem strange to check into a medical office for an appointment and find the medical secretary bouncing up and down on her under-desk pedals.

Another option is to schedule walking breaks for workers who otherwise have little opportunity to stand up, let alone walk. This requires time and attention to the employee’s schedule; five-minute walking breaks when patients are waiting in line to be checked in or out means having someone available to cover while the break occurs. This may be too much trouble logistically and too costly financially. Ironically, employees who still smoke and must leave the workplace to do so have a built-in opportunity to move. If they can take a break to smoke, why shouldn’t others be allowed to take a break to move?

Another solution is to rotate the sitting employee into positions that require walking so that for some of the work day he or she is released from the chair. In the office I have referenced, another employee takes the patient to the area where the doctor’s office is located. (The practice is so large one almost needs a GPS system to find the appropriate office by oneself.) If the person checking people in and out were to be a patient escort for part of the day, or some other job that required walking, then the sedentary routine would be broken.

But these are rather weak solutions to a major problem confronting most occupations: How do all of us whose work is associated with being relatively inert get enough physical activity without sacrificing sleep, family, social obligations, and financial goals? Perhaps the answer is for workplaces to offer brief opportunities to stretch and to move, even if it is only for 15 to 20 minutes a day.

It may not be enough to compensate for all those hours of sitting, but it is a start.

Distinguishing Fact from Fiction in Supplement Claims

The June issue of Women’s Health ran an article describing several relatively new supplements that have been making news because they are supposed to confer a large variety of health benefits upon their users.  All of them are derived from parts of plants that are pulverized into a powder or mixed into a solution. The prices were mentioned; they are not inexpensive but if the claims made for them are true, then they should be able to replace very costly drugs now being used to treat the disorders these supplements are able to prevent/treat.

But how does one know whether they do what they are supposed to do? How do we go from brief descriptions of these supplements and suggestions as to how to ingest them, to using them to treat our health problems?

One answer is to spend many hours searching the Internet for valid information about the efficacy of the supplements in doing what they are supposed to be doing. However, even after doing so, there is no guarantee that a particular supplement will replace a well-researched drug for a particular disease.

Curcumin, a yellow spice derived from turmeric, is described in the article and elsewhere as able to decrease the symptoms of certain diseases like arthritis and intestinal disorders. A distant relative who has had an autoimmune disease of the intestinal tract, Crohn’s Disease, was so convinced by published research on ability of this spice to relieve her symptoms that she stopped her treatment with a drug she had been using for years.  Two symptom-filled months later, she returned to the drug; the curcumin did not work for her. But it may work for others and only large clinical trials comparing curcumin with a conventional treatment will provide the answer. The magazine suggested trying it by sprinkling the spice over eggs.  But, of course, the article did not say who should try it, for what disorder and how often to take it. And at $27.00 for 100 grams, it might be cheaper to use the spice, turmeric, from which it is derived instead.

Another featured supplement, Schisandra, is a berry that has the unique property of producing five taste sensations: sweet, sour, salty, bitter, and spicy. Used as a medicine in Asia and Russia for centuries, it is thought to activate enzymes in the liver that break down many compounds and making them available to the body or destroying their functionality.   A short list of Schisandra’s therapeutic effects from several Internet sites include: preventing early aging, increasing lifespan, normalizing blood sugar and blood pressure, protecting against inflammation, chronic night sweats, excessive urination, insomnia, depression, fatigue and treating high cholesterol, pneumonia, asthma, and premenstrual syndrome (PMS).  The magazine highlighted one of its functions: it has been found to enhance short-term memory, especially spatial memory, but so far only among rats. (For those of us who get lost easily, this might be useful.)

But it is hard to find a scientific basis for these claims, nor any specific information on whether we should be ingesting this herb for its prevention abilities.  Like the other supplements, it is not cheap at $20.50 for 8 oz. The article suggested sprinkling a teaspoon over popcorn, but it wasn’t clear whether this would allow the eater to locate the exit from the movie theatre with less difficulty.

What one does not learn from the article is that the supplement can cause myriad side effects such as heartburn, upset stomach, decreased appetite, stomach pain, skin rash and itching. In addition, because it affects liver enzymes, it may alter the metabolism of many drugs. For example, a drug, Warfarin (coumadin), used to retard blood clotting, can be broken down more rapidly by the liver if the patient is taking Schisandra, thus reducing its efficacy. In the Journal of Ethnopharmacology, Panossian and Wikman published a comprehensive review of studies using Schisandra, including the use of this herb for mental illness, gastrointestinal disorders and infectious disease like the flu.  (“Pharmacology of Schisandra chinensis Bail: an overview of Russian research and uses in medicine,” Panossian1Wikman, G., J Ethnopharmacol. 2008 118(2):183-212)

According to their report, Schisandra has been used in Russia for decades as a medicinal herb, but it is frustratingly difficult to figure out whether we should follow the Russian experience and use it for diabetes or high blood pressure or to prevent normal aging. What dose should be taken for what disease, how long should it taken, how often each day, and how will it affect other medications being used?

Maca, also described in the article, comes from a tuberous root found in the Andes in Peru. A placebo-controlled study carried out the Massachusetts General Hospital in Boston found that  Maca restored sexual satisfaction in women whose libido had been suppressed by their antidepressants.  (A Double-Blind Placebo-Controlled Trial of Maca Root as Treatment for Antidepressant-Induced Sexual Dysfunction in Women Evid Based Complement Alternat Med., Dording, C., Schettler, P., Dalton, E., et al ,  2015)

According to their report, Schisandra has been used in Russia for decades as a medicinal herb, but it is frustratingly difficult to figure out whether we should follow the Russian experience and use it for diabetes or high blood pressure or to prevent normal aging. What dose should be taken for what disease, how long should it taken, how often each day, and how will it affect other medications being used?

Maca, also described in the article, comes from a tuberous root found in the Andes in Peru. A placebo-controlled study carried out the Massachusetts General Hospital in Boston found that  Maca restored sexual satisfaction in women whose libido had been suppressed by their antidepressants.  (A Double-Blind Placebo-Controlled Trial of Maca Root as Treatment for Antidepressant-Induced Sexual Dysfunction in Women Evid Based Complement Alternat Med., Dording, C., Schettler, P., Dalton, E., et al ,  2015)

The caveat, however, is that the only group that responded were the 12 post-menopausal women in the treatment group. Younger women did not have a positive response. The magazine article did not mention that the drug might only be useful for older women as suggested in the research report.  Moreover, the magazine suggested Maca might help insomnia, while the Internet is filled with reports about Maca actually causing sleep difficulty.

The caveat, however, is that the only group that responded were the 12 post-menopausal women in the treatment group. Younger women did not have a positive response. The magazine article did not mention that the drug might only be useful for older women as suggested in the research report.  Moreover, the magazine suggested Maca might help insomnia, while the Internet is filled with reports about Maca actually causing sleep difficulty.

One would not expect to find a comprehensive description of the functions and efficacy of any supplement in magazines, or on an Internet site selling the product or giving anecdotal information on what it did for the individual writing about it.  But it takes entirely too much effort to ferret out the information necessary to know how to use these supplements, whether they will work better than traditional interventions, if they might interact with other medications one is taking, how pure they are, what the dose is, and whether they are worth the cost. Unfortunately, there is little money to do the research necessary to show whether or not the claims made for these supplements are valid.

Until that occurs, let the user be cautious.

The Unfortunate Association Between Pain and Obesity

Anyone who suffers from chronic joint and/or muscular pain and is also struggling with obesity realizes how much each impacts the other.  The pain makes it hard to move to exercise without discomfort. The pain of fibromyalgia also makes it hard to deny oneself food that is pleasurable (and possibly fattening) because such eating is a source of pleasure. Pain makes it hard to be in a good mood, and not surprisingly, may potentiate depression. That, in turn, affects eating, sometimes causing weight gain, as do most antidepressants.

Thus more pain is experienced.

Another concern is that insomnia can result from pain; few people can sleep through the night because of the unrelenting disturbance. The fatigue from lack of sleep often leads to overeating, weight gain, and more pain.  And, just to make things worse, two of the drugs prescribed to help pain, especially that of fibromyalgia, can cause weight gain (Neurontin and Lyrica). And so more pain occurs.

Pain comes in many varieties: headaches, abdominal pain, joint and muscle pain, and fibromyalgia.  A review by Okifuji and Hare in the Journal of Pain Research details the ways pain and obesity interact; their review makes the reader feel grateful for every minute that is pain free. (“The association between chronic pain and obesity,” Okifuji, A., and Hare, B., J Pain Res. 2015; 8:399) When obese individuals claim that it “hurts to walk, to climb steps, to get up from a chair, to lift anything,” they are describing the way their weight affects their inability to move without pain.

According to Okifuji and Hare’s review, as BMI (a measurement of weight relative to height) increases, so too does chronic pain.  In one study, fewer than 3% of people with normal BMI reported low back pain, but almost 12% of morbidly obese individuals did so. Anyone who has watched the television series “My 600-lb Life” has seen the pain on the faces of these extremely obese people when they have had to stand or walk. It seems unbearable, yet even at a considerably lower weight, the body may respond to carrying around extra pounds with chronic pain.  The Arthritis Foundation has some compelling information about the relationship of excess weight and pressure on the knees: every extra pound carried puts 4 pounds of extra pressure on our knees. So if one is only ten pounds overweight, forty pounds of extra pressure is placed on those joints. This means that weight gain associated with a painful disease like fibromyalgia, typically more than twenty pounds, may put enough pressure on the knees to cause another source of pain.

If obesity is exacerbating chronic pain, such as that associated with arthritis or fibromyalagia, the solution is simple but not easy to achieve: lose weight.  Many studies that have shown relief of pain with weight loss.  In a typical study, when adults suffering from joint pain are put on a diet with or without the kind of exercise that their bodies can tolerate, they lose weight and their pain is diminished.  (“Diet and Exercise for Obese Adults with Knee Osteoarthritis,” Messier, S., Clin Geriatr Med, 2010;26:461; Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial,” Messier, S., Mihalko, S., Legault, C., Miller, G., JAMA, 2013 Sep 25; 310(12): 1263-73)

But anyone who has experienced even transient pain from, for example, an overly ambitious workout, the first long bike ride of the season, too much weeding and hauling a wheelbarrow, or some unexplained back pain that thankfully disappears a week or so after it mysteriously arrived… knows how hard it is to move without pain. Unfortunately, our appetite rarely disappears when the pain arrives.  A friend who is extremely active was transported through an airport in a wheelchair after a virus-like infection caused severe back pain. His agony prevented him from walking more than a few steps at a time. After he recovered, he told me how reluctant he was to move when he was in such pain.

“Unfortunately, I didn’t lose my appetite so I was eating as much as before,” he said.

Increasing mobility as a way of preventing weight gain and supporting weight loss is advised for almost all situations in which there is chronic pain, as long as there is no possibility of damage to joints or muscles. The best way to go about this is with guidance from a physical therapist who can advise on movements that either will not hurt, or cause too much discomfort. Swimming and/or aerobic exercises in warm water is less likely to cause pain than activities involving some impact on joints. Gentle yoga is also recommended with instructors who know how to protect the participants from movements that will hurt. Recumbent bikes tend to be more protective of joints and muscles than other pieces of equipment in a gym, but even this piece of equipment should only be used with the advice of a physical therapist. Walking, if not too painful, should be done where there are places to sit and rest, should the pain becomes too intense to continue.

Dieting is equally difficult. When pain restricts most physical activity, it is hard not to gain weight since the individual requires many fewer calories than when normal activity is taking place. Muscle weight may be lost due to the inactivity, but excess calories will continue to be turned into fat. A dietician can figure out how many calories should be consumed in relation to the degree of inactivity caused by the pain. And just as important, the dietician can develop a food plan to make sure that all essential nutrients are being consumed within the calorie limits. Pain and attempts to lose weight should not lead to a nutritionally inadequate diet.

Even small amounts of weight loss are beneficial. If every pound gained may make the pain worse, every pound lost should bring some relief.

Accidental Weight Loss: A Gift for the Dieter

Three of my friends are suddenly thinner, and they are delighted because none of them was dieting.  One lost weight because work required her to travel across several time zones, and she found that she was sleepy, but not hungry, at mealtimes in the new time zone. Another had unexplained abdominal pain, was put in the hospital for tests, and did not eat for several days because of the tests and the pain.  When she returned home, she found that she had lost several pounds. The pain went away unexplained, but the weight loss remained. A third moved and was so busy unpacking, she ate when she remembered to eat, and that consumed were protein bars unearthed in one of the boxes. Because she couldn’t remember where anything she had unpacked was, she walked miles in her home trying to locate the stuff she needed, such as her cell phone.

None of these women was obese, but each wanted to lose between 15 and twenty pounds, but had not gotten around to doing so (one for several years). However now, after noticing their unexpected weight loss, they put themselves on a diet because as one of them told me, “My weight loss was a gift and I didn’t want to throw it away.”

Who knows what motivates someone to go on a diet at a particular moment? Sometimes it is done during a traditional dieting time, such as the first week in January. Diets are started because a special occasion is occurring several weeks or months hence and right now the article of clothing to be worn is tight. Or the occasion itself calls for appearing slimmer; weddings and reunions are noteworthy for being diet motivators. Medical reasons are often motivators for weight loss, too, but sadly are usually accompanied by the development of a medical problem like diabetes or painful orthopedic issues. Occasionally a picture of oneself from an unflattering angle strips away the ability to deny the excess pounds, or the inability to fit into the new season’s clothes that fit a year ago demand that either weight be lost, or a new wardrobe be purchased. But these reasons for starting a diet involve a conscious ‘before’ when the individual was not on a diet, and a conscious ‘now’, when the diet has been started. Accidental weight loss is just that; no conscious decision is involved, it just happens.

Perhaps the most positive aspect of accidental weight loss (in addition to the lost weight itself) is realizing that it is possible to drop pounds without even trying. Many who struggle to lose weight believe that they won’t be able to. The pounds appear to be stuck with permanent glue to various parts of the body. Diets are started and weight may be lost, but to do so requires a great deal of effort: meal planning, and preparation, and time for exercise. Of course this healthy way of life should be followed regardless of weight change, but we are human and unless weight loss is substantial, we may feel that losing weight is not worth the effort we are putting into doing so.

Accidental weight loss seems to produce a looser skirt or pants, a zipper that goes up easily, a shirt whose buttons close without any obvious effort.  “My unplanned weight loss proved to me that when I eat less and move more, the pounds came off, “said my friend, “and I didn’t have to follow any peculiar diet, or any specific kind of exercise.“

Accidental weight loss challenges the claims that the dieter must eat, or avoid eating, foods from specific food groups, must overcook the food, or eat it raw, must allow it to ferment to produce specific bacteria, must subject the body to fasting, cleanses, supplements made from herbs and twigs, injections of fat burning hormones, hypnosis, packaged foods made in an industrial plant, or the latest tabloid ‘miracle’ diet, in order to lose weight. When weight is lost accidentally, it seems that the body wasn’t paying attention to all these diet remedies. It just responded to less food coming in, and in some cases more energy was being used up by your body, and that simply equates to that your physiology used up some of its fat stores, for energy.

The realization that the body is capable of losing weight without formal dieting should be transformed into a strategy for continuing to lose weight. The first step should be reviewing in a non-judgmental way, the eating and physical activity habits that caused the weight gain, and next figuring out what acceptable changes can be made to sustain the weight that has already been lost. With a suddenly slightly lighter body, eating smaller portions, or going for walk rather than sitting on the sofa, may become easier. Throwing away high fat, high sugar, and high sodium snacks that have been an obstacle to weight loss, might seem sensible rather than a culinary sacrifice and exploring alternate methods of decreasing stress other than eating.

After accidental weight loss, you are unlikely to continue to lose weight without consciously making an attempt to do so, but you will be able to. Your body has shown you that it is able to remove a few of those pounds you once felt would never be lost. Now your body is just waiting for you to continue to lose more.