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.

When Mindless Eating Has a Function

Mindless eating is always trotted out as a significant factor in the increasing incidence of obesity. If we only paid attention to what we are eating, perhaps we would eat more 1) healthily and 2) frugally. We would never eat potato chips, butter-drenched popcorn, French fries, peanuts, M & M’s and nachos or, if we did, we would notice every peanut or M & M going into our mouths and would stop after eating only one or two (in our dreams, perhaps). We never would eat everything on our plates, unless the portion size was so small we noticed its reduced size.  When served the typical overly large serving, we would carefully portion out the amount we should be eating and leave the rest, or eat it at another meal.

But who eats this way?  Probably people during the early stages of a diet, or after bariatric surgery when they are left with a tiny stomach. Restaurant reviewers pay attention to what they are eating, as do judges on televised competitive cooking shows or at state fairs tasting pies.  Of course, pathological food restrictors are extremely mindful of what they put in their mouths (three slices of apple, two leaves of lettuce), as are toddlers who chase cereal bits around the trays on their strollers.  Picky eaters notice what they are eating in order not to risk putting anything in their mouths that is distasteful or has unacceptable mouth feel. But once they remove the offending food from their plates, they eat as mindlessly as the rest of us.

Stress is a significant trigger for mindless eating and is often cited as an obstacle to weight loss or its maintenance. Often the eating is so unnoticed that only the empty ice cream container or bag of chips signals that eating has actually occurred.

Some studies suggest that chewing and not the swallowing of food is what decreases stress. Supposedly the repetitive motion of chewing produces a decrease in physiological markers of stress such as blood cortisol levels. (“Mastication as a Stress-Coping Behavior,” Kubo K, Iinuma M, and Chen H Biomed Res Int. 2015; 2015:876)  Laboratory rats given wooden sticks to bite or chew will show lower levels of cortisol when stressed, than rats not allowed to chew. Humans may chew gum or gnaw on other objects (pencils, pipe stems, coffee stirrers, fingernails) when they are stressed and as with the rats, this chewing decreases levels of cortisol and other physiological indicators of stress. If chewing does easing worry and anxiety, then the chewed object should have few or no calories (for instance, gum or crushed ice).

Unfortunately, we usually swallow what we are consuming when stress-associated mindlessly eating. This, of course, may significantly affect our weight if the stress and the mindless eating are prolonged. But is mindless eating at a time of emotional distress all bad?

Recently, while dining with friends we had not seen for several weeks, we learned that the husband was scheduled for a medical test that would reveal whether his medical problem could be helped by a simple, safe procedure, or major surgery with considerable risks. We had ordered a variety of small dishes meant to be shared among us, including two types of pasta which were served in large bowls. One bowl of pasta happened to be set in front of the wife of the individual whose medical condition we were discussing. “I can’t believe I ate the entire bowl of pasta,” she exclaimed several minutes later when someone asked her to pass the now empty bowl.  I didn’t mean to eat so much,” she said. “I didn’t even realize I was eating it!”

Mindless eating? Yes. Might it have been related to her worry and anxiety that her spouse might not survive the more drastic medical procedure? Probably. Did it help ease her emotional distress? Perhaps.   Certainly the carbohydrate, the pasta, would have increased serotonin synthesis in her brain, and that, in turn, may have lessened her anxiety, helplessness at not being able to do anything but wait and worry, and maybe even increased her ability to cope with the unknown.

It wasn’t necessary for her to eat the entire bowl of pasta to ease her anxiety. Indeed, had she eaten a few skinny bread sticks, or a slice of crusty bread from the basket placed on the table as we sat down, she might have started to feel better before the pasta arrived. Once digested, the carbohydrate in the bread sticks would have initiated the physiological process leading to an elevation of her brain serotonin levels. The subsequent increase in serotonin activity and possible reduction in her anxiety and worry might have prevented her from consuming all the pasta without noticing what she was doing.

However, the mindless eating our friend experienced is not without some benefit in addition to an easing of her distress. It can be regarded as an early warning of her vulnerability to eating uncontrollably in order to feel better. Our friend should be asking herself: “ Why did I eat all that food without noticing?  Am I using food  to block out my emotional pain? Is it working?”

Positive answers do not mean that mindless eating should be continued. Rather, it should be replaced by mindful eating.  It is not necessary to eat large quantities of carbohydrates  to experience relief from stress. The stressed eater need consume only about 30 grams of a fat-free carbohydrate (i.e. rice crackers or oatmeal) that contains no more than 4-5 grams of protein to bring about an increase in serotonin and a decrease in stress.  (“Brain serotonin content: Physiological regulation by plasma neutral amino acids,” Fernstrom, J. and Wurtman, R. Science, 1972; 178:414-416). Eaten as a snack, or indeed in a meal, once the carbohydrate is digested, the increase in serotonin should bring about some emotional relief.

Stress happens to all of us, and usually when we are not prepared. A bowl of pasta or a few breadsticks is not going to take away the cause or offer a solution. But at least these carbohydrates may take the edge off of our emotional pain, and make the problem a little more bearable.

 

 

 

What’s the Best Way to Help People Lose Weight?

If weight-loss programs advertised on television were to be believed, then it is obvious that the best way to get people to lose weight and keep it off is to eat commercially available, calorie-controlled packaged meals and snacks. In just [insert number of days] you, the consumer, will drop at least 10 to 20 pounds, lose your hunger completely, and never have another food craving, according to the promises in the ads. Two runners-up would include an FDA-approved weight-loss drug that takes away appetite and replaces the pleasure you get from eating with something not defined, and/or an exercise device that melts off pounds and replaces them with a “ripped” body that looks good in a minuscule bikini or swim trunks.

Despite the allure of such advertisements, and the wish to look like the models proclaiming the efficacy of such weight-loss interventions, extensive research indicates that they are not the best way to lose weight and keep it off. No surprise.

A few days ago, the Journal of the American Medical Association (JAMA) published a paper that summarized several years of analyzing current interventions on weight loss and maintaining weight loss. The report did not include results from surgical interventions that reduce the size of the stomach, such as putting a balloon in the stomach or removing food from the stomach through a tube that empties into a receptacle. The criterion for review of the weight-loss interventions was whether or not they could be “provided in or referred from a primary care setting.”

The report stressed the importance of identifying the most effective means of bringing about weight loss because of the alarming prevalence of obesity in the states. The commonly accepted definition of obesity is a body mass index (BMI) of 30 or higher. (This is weight in kilograms divided by height in meters squared; there are websites that help with this calculation for the arithmetic-challenged reader.) More than 40 percent of women and 35 percent of men in the United States today meet the criterion for obesity.

Intensive, multifaceted weight-loss interventions were found to be the most successful based on the authors’ review of published studies. Such interventions lasted one to two years, with monthly or more frequent meetings. Although food plans that would support weight loss were part of the intervention, the report did not single out any particular type of diet, other than inferring it would have to be a food plan that could be followed for many months. People were encouraged to monitor their weight and exercise levels, to use food scales to weigh their food, and behavioral support was consistently offered. The settings ranged from face-to-face meetings with individuals or a group to remote interactions via Skype or other computer-assisted interactions.

Even though the review looked at programs that could be carried out in a primary care setting, as opposed to surgical interventions, primary care physicians were rarely involved in the programs. A “village” of behavioral therapists, dieticians, exercise physiologists, and life coaches offered a variety of services designed to enhance not only the weight loss but also its subsequent maintenance.

The study rejected the use of weight-loss drugs because the authors wanted to find interventions that caused the least harm. Such drugs come with a long list of side effects: anxiety, gastrointestinal symptoms, headache, elevated heart rate, and mood disorders, to name a few. The side effects from behavioral interventions might be aching muscles from a new exercise or a longing for highly caloric foods. The authors did note that when pharmacological interventions were combined with behavioral ones, the results were better than with either intervention alone. But there was a high rate of attrition, i.e. withdrawal from the studies among those taking weight-loss drugs, perhaps due to the side effects.

The takeaway message from this comprehensive report is that the thousands of people in need of weight loss should locate a primary care physician who will then direct them to an intensive and comprehensive behavioral weight-loss program meeting at least once a month for 18 months or longer. The program should help them buy and prepare the foods they should be eating, make sure that they have the time and money to participate in frequent exercise, identify or solve problems causing emotional overeating, and make sure that weight-loss successes are supported by family and friends and not sabotaged. The report did not mention cost; the studies the authors reviewed were free to the participants.

“When pigs fly!” might be the somewhat cynical response to this paper. Yes, of course, all these interventions will presumably work, except perhaps for those patients whose weight gain was a side effect of their medications. It is very hard to lose weight when drugs such as antidepressants and mood stabilizers cause hunger that does not go away.

But how many primary care practices have the money and time to formulate and carry out the intensive programs recommended? How many hospital-based weight-loss clinics have exercise physiologists, life coaches, therapists, and dieticians to pay personal attention to the participants? Where does one go to find such programs?

And yet, what are the alternatives? The list of medical problems associated with obesity, ranging from orthopedic disabilities to cancer, is not getting smaller. Might technology be the answer? Smartphones allow us to monitor many aspects of our daily lives, from how we sleep to whether we feel stressed. Might robots or some other form of artificial intelligence prevent us from eating portions that are too large or moving too little (some do already), or ask us what is really wrong when we open the freezer to look for the ice cream? Can a robot remind us to do our exercise routine, or meditate, or stop working and give ourselves some private time…or turn off the computer or television and go to sleep? And would we be less likely to deny that we have just eaten a bag of cookies to a robot?

Human interventions have not worked all that well; perhaps it is time to turn to the other.

References

“Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults,” US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force JAMA, 2018; 320(11): 1163-117.

Does Your Mood Fall Before the Leaves Do?

When fall officially arrives on September 22, the number of hours of daylight and darkness are equal. As we proceed further into fall and early winter, hours of darkness overtake those of light, and a well-rehearsed (because we sing this every year) chorus of “It is so dark in the afternoon!” will be heard.  By the end of November, the refrain of, “It’s so depressing!” is added to our song of complaint.

And every year, even before the leaves change color, we noticed changes in energy, appetite, sleep and mood. At first, these changes are hardly noticeable: sleeping a little longer, disinterest in new activities or commitments, feeling tired, craving for starchy comfort foods rather than large salad, and a bit of irritability, annoyance, impatience, and gloominess. That’s seasonal affective disorder, SAD or the winter blues,  arriving.

This seasonal disorder with its symptoms of overeating, fatigue, sleepiness, and grumpy mood is provoked by a decline in hours of daylight. Inhabitants of our northern states are more vulnerable than those in the south because the southern states have more daylight in the late fall and winter. For example, on  December 21, the first day of winter, Chicago has a little over 9 hours of daylight; Key West, Florida, 10 and a half hours.  The symptoms of SAD are not weather related (although there is a variant called summer SAD that seems to be linked to heat and humidity). Indeed, the early symptoms may begin during the early days of fall with its sunny crisp days, and naturally cool nights.

SAD was first described in the mid-l980s, but not much more is known today about how an environmental input like sunlight is able to bring about so many changes in our well-being.  The hormone that puts us to sleep, melatonin, has been implicated because daylight naturally reduces its levels in the blood. It was thought that the late sunrises of the fall and winter seasons delays melatonin destruction and leaves us sleepy, but how this would affect the other symptoms such as mood and overeating was (and is) not understood.

One of the first therapies offered to patients was exposure to artificial light that mimics the spectrum of sunlight. Sitting in front of a lightbox or “sunbox” for thirty minutes or so in the early morning upon awakening was shown to relieve the symptoms of SAD. Lightboxes are still used, and some who work in windowless offices often keep them on throughout the morning to brighten their mood. Treatment with antidepressants that increase serotonin activity is now an alternative treatment based on studies showing that serotonin activity seems to be reduced in patients with seasonal affective disorder.

However, many people fortunately never experience the clinical depression of SAD; rather they have milder symptoms which now have taken on the name “winter blues”. Although their weight, sleep, work productivity, and mood are all changed (not for the better), their symptoms may be relieved in part simply by using light therapy.

One of the problems with winter depression is that it creeps up silently, triggering an almost imperceptible change in behaviors that seem to have their own justification, rather than associated with diminishing daylight. Fresh fruit desserts are less appealing than the fruit baked in a cake or pie; fall activities make a good excuse for skipping the gym; new projects or commitments are better off delayed until spring because the holidays will be coming; the irritability, depressed mood, anger symptoms are justified because of work/kids back to school/ family or financial stress; and sleeping longer is necessary because of a persistent tiredness.

Recognizing the early symptoms of winter blues, such as cravings for sweet carbohydrates or increased fatigue, allows strategies to be put in place (like rakes before the leaves drop) to decrease their impact on quality of life.  For example, weight is often gained due to the dual effects of craving high-fat sugary foods (like chocolate and cookies) and drastically decreasing exercise because of fatigue. Recognizing this should lead to removing highly caloric carbohydrate snacks like chocolate and ice cream from the kitchen. Once the full blown carb cravings of winter blues hit, it will be difficult to resist eating cookies or ice cream or chocolate, especially when the sun sets by late afternoon.  Replacing these highly caloric foods with very low fat breakfast cereal—such as oat or wheat squares or cornflakes—will increase serotonin, turn off carbohydrate cravings, and increase satiety without doing damage to your weight.

Fatigue and disinterest in taking on new activities may shut down any commitment to frequent (if any) exercise. Plenty of excuses will be available as weather, early afternoon darkness, work, holiday, and family commitments erode time for a workout at home, at the gym, or outdoors. It is all too easy to stop going to a yoga or Pilates class or cancel a walk with a friend. One solution is to use an APP, or wearable exercise tracking device that will nag you into taking 10,000 steps a day, or indicate how many calories you are eating and how many you are using for energy. The APP doesn’t care what your excuses are for not moving, but if programmed correctly, will ping and alarm and buzz until you do move.

Better yet, be competitive with someone at work or in the family so that you have to display daily (or at least weekly) whether you met your exercise goals. If you start doing this before the fatigue of the winter blues sets in, it is possible that you will continue with the exercise even if one part of you is begging to lie down on the couch and watch Netflix. There is no cure for SAD or the winter blues other than moving to states where the days are longer. Fortunately, the days start to get longer on the second day of winter, and the symptoms will go into remission by mid-spring.

We can’t keep the leaves from falling, or snow, for that matter. But it should be possible with the right interventions to keep weight from rising, mood from falling, and energy levels intact until that happens.

References

Seasonal affective disorder: a description of the syndrome and preliminary findings with light therapy Rosenthal N, Sack D, Lewy A et al Archives of General Psychiatry  1984 ;41: 72-80

(β-CIT SPECT imaging shows reduced brain serotonin transporter availability in drug-free depressed patients with seasonal affective disorder  Willeit M, Praschak N, Rieder A et al Biological Psychiatry  2000 ; 47: 482-489

Can Being Put on Hold Cause You to Gain Weight?

It is entirely possible to spend an entire week talking to computers, or whatever records the messages that act as an impenetrable wall between you and communication with a human. My problem was trying to reach a human employee in a county courthouse to trace a seemingly lost file for a minor, but important, transaction. Various phones were answered, but by robotic voices and the one time, after at least a dozen calls, a human answered, I was put on hold for about 20 minutes.   Unlike the old days when my wall-mounted kitchen phone had a cord that barely reached to the sink, now I could wander over to the refrigerator or kitchen cabinet while waiting for the human voice on the phone. It was only worrying that when or if someone would respond I would be too busy chewing to talk that prevented me from eating my way through these hold times. But I wonder: Is frustration at being put into cyberspace, instead of personal space when a problem needed to be solved, an overlooked cause of obesity?

A friend who works at a large US government agency complains incessantly at computer problems that no one is able or willing to fix. Another friend, a doctor, was visibly shaken when he could not understand the information given at a mandatory orientation on how to use the hospital’s new computerized record keeping system, and muttered about early retirement. An office mate goes into a high-stress mode about every 3 ½ days when a document he spent hours revising is nowhere to be found in the Cloud or Dropbox or wherever those files are stored. And an aunt moans constantly about having to navigate her way through online forms every time she wants to refill a prescription for her dog’s heartworm medication. The animal hospital’s pharmacy no longer takes refill orders by phone.

A recent talk by the New York Times columnist Thomas Friedman, at an endowed lectureship at MIT, provided the not too shocking information that we spend on average over 60% of our time in cyberspace. Presumably only a small amount of this time is spent stressing over glitches in our cyber interactions.  And given the intensity and severity of stress previous generations experienced in their jobs, family, and communities, stressing out over confrontations with recorded messages or errant computer programs seems frivolous.

And yet: not being able to talk to a human when a problem really needs to be solved, now. Not being able to get through to a physician’s office because the recorded message does not allow the patient to say, “It is not a crisis, but I have to talk to the doctor.” Not understanding the accent of the technician who is attempting, valiantly, to figure out why the cell phone is not responding and is simply not communicating.  These, and other situations too numerous to count, impose a stress on our lives.

And what do many of us do when we are stressed? Eat, of course. To be fair, we often don’t eat when we are attempting to follow directions as to what to click to fix a computer problem, because our hands are busy (one on the phone and one on the mouse). And when our adrenaline is extremely high because we are not sure we will ever get a human on the phone or a technician to resolve a phone issue, we are not eating, because the our stress and agitation has taken away our appetite. But afterward, to calm ourselves when the problem is fixed, or to calm ourselves when the problem cannot be fixed, we eat. And we are not racing to the refrigerator to steam broccoli or rip open a container of fat-free cottage cheese. We eat the foods we always eat when we are stressed: sugary or salty high-fat carbohydrates like cookie or chips, ice cream or French fries.

If technology is causing our stress and overeating, might technology take it away?  There are apps that monitor our stress levels by picking up changes in heart rate, and some other physiological measures of distress. However, then what? Wouldn’t we know we are stressed without the app telling us? There are apps that will keep track of our caloric intake, so if we are munching on peanuts while listening to the on-hold recorded music, we will know how much we are eating. But of course we have to do mindful munching; otherwise, how can we tell the app how many handfuls of peanuts we have thrown in our mouth?

But perhaps someone will/can develop apps that help us meditate when we are on hold to calm our breathing, to speak to us in reassuring tones when we cannot get through the. “Listen carefully because our menu choices may have changed…” message without grinding our teeth, to detect when we are opening a bag of cookies or the freezer to get at the ice cream and gently remind us that eating isn’t going to fix the computer.  Another exercise-oriented app can suggest useful pacing techniques, and record the number of steps we are taking while waiting for a technician to come on the line. A third should tell us to stop hunching over the computer or tablet and to relax our neck and shoulders and remind us that even though we think having our computer crash, or never being able to though to a human on the telephone, is not the end of the world.

It only feels like it is.

Medication-Linked Weight Gain & Clothing Discrimination

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

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

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

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

She was right.

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

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

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

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

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

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

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

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

References

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

Should a Personal Trainer Be Present at a Wellness Exam?

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

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

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

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

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

The test to measure balance is simple. For example:

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

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

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

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

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

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

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

References

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

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

Should Unhealthy Foods Become a New Food Allergy?

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

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

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

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

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

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

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

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

When Competing Athletically Ends, Does Weight Gain Begin?

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

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

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

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

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

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

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

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

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