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We are all gluttons, more or less. Augustine was right when he wrote, “Who is it Lord, that does not eat a little more than necessary?“ However, I believe that there are various categories of gluttons ranging from those who consider themselves overindulging when they eat one more M&M than appetite dictates, to competitive eaters who win prizes for devouring stacks of food appropriate for a hippopotamus. These eating athletes should heed the warnings of St. Gregory who claimed,”When the belly is distended by gluttony, the virtues of the soul are destroyed by lust.” Foodies and food critics could also be tagged as gluttons, although they would dispute this. Thomas Acquinas would see them as tempted by the vice of gluttony because such people seek “costly meats”, costly foods in general, and want foods to be prepared too nicely. Of course they also continue to eat after they are no longer hungry. According to Acquinas, all of us are gluttons when we eat for pleasure, novelty, and taste; we should instead be content with simple foods whose only purpose is to take away hunger.
Interestingly, gluttony during biblical and post biblical times was not condemned as a major cause of obesity. Acquinas stated that the glutton does not intent to harm his body but seeks food because of the pleasure he receives in eating. If injury results to his body, (think obesity) it is accidental. There were no stores selling triple X size robes at the time to remind the glutton of the impact his and/or her excessive intake. It's now the resulting disease from gluttony that concerns us. The Government statistics on the prevalence of obesity in 2010 reports that over 30% of adults are obese and 17% of children between 2 and 19 are obese. The health risks associated with obesity, as well as the increased health costs are well known. But is this epidemic of weight gain caused by people who like being gluttons? Yes and No. I propose that there are two kinds of gluttons: intentional and involuntary. Intentional gluttons delight in eating whatever they like, in as large an amount as they can. I saw a woman a few nights ago in a restaurant served what looked like a 20 ounce steak with a gigantic baked potato. To my amazement, after filling the potato with 4 or 5 pats of butter, she ate everything on her plate. It is hard to believe that it took that much food to take away her hunger. Intentional gluttons rejoice in ‘all you can eat’ eating venues like cruises or Sunday brunch buffets, because such situations give legitimacy to their food intake. Foods are savored for their taste and little attention may be paid to the weight gain potential of eating large amounts of eggs, butter, cream and bacon. Involuntary gluttons may also overeat or eat inappropriate foods but they seek food not for the sensory pleasure it gives them but because of eating such foods improves their mood and controls their appetite. Let me describe some types of involuntary gluttons. The most common gluttons are those (you and I may be among them) who feel a need to snack in the late afternoon or a few hours after dinner. The need to eat is not driven by hunger, but a nagging feeling of wanting something on which to munch. Usually this feeling is associated with restlessness, impatience, distractibility and fatigue. The foods sought are sweet or starchy- crunchy snacks. Winter darkness also produces involuntary gluttony during for the months with minimal light. Lack of light causes a depression called ‘winter blues’ or Seasonal Affective Disorder. People eat large amounts of food intake, especially carbohydrates, and this overeating may persist for months. Premenstrual women are involuntary gluttons, usually for chocolate. They may eat carbohydrates excessively during the last few days of their menstrual cycle, and like people with Seasonal Affective Disorder, feel depressed, angry, irritable, and exhausted. Others are involuntary gluttons because they can’t stop eating when a sufficient amount of food has been consumed. Psychotropic drugs such as antidepressants and mood stabilizers prevent people from feeling full or satisfied after eating. People on such drugs may eat two meals, one after the other, or snack constantly. Why are carbohydrates the preferred food sought by these involuntary gluttons? When we studied them, we found that they eat carbohydrate because they have learned, perhaps unconsciously, that after carbs are consumed, they experience an improvement in mood, increased satiety, or both. These improvements in mood and satiety are associated with the increase in serotonin synthesis that follows carbohydrate intake. When any carbohydrate, except fruit, is eaten, an insulin mediated change in the profile of amino acids in the blood occurs, and the uptake into the brain of the amino acid tryptophan increases. Tryptophan is the precursor of serotonin, and its availability drives the synthesis of this neurotransmitter. Behavioral testing of afternoon carbohydrate snackers, women with PMS and people with winter depression showed a consistent pattern: better mood, increased focus, calmness and greater energy. Indeed the most significant changes were among women with PMS who found that even a small amount of carbohydrate took the edge off of their premenstrual symptoms. A weight loss program based on the consumption of a small carbohydrate snack ( 20-30 g with less than 5 g each of protein and fat) two or three times a day was effective in increasing satiety among people on medications whose side-effect caused overeating. One reason that these populations of involuntary gluttons tend to gain weight is that they often eat more than is needed to bring about serotonin synthesis. Only 30grams or so of a fat free or very low fat carbohydrate must be eaten. This is about the carbohydrate content in a cup of plain cheerios. People also may consume the carbohydrate with protein (milk with the cheerios), or following a protein containing meal (eating desert after an entrée of chicken or fish. But bear in mind that when carbohydrate is eaten along with protein, or immediately following protein intake, no serotonin is made. Involuntary gluttons also make the mistake of choosing carbohydrates for their sensual rather than neurochemical effects, eating doughnuts rather than dry toast, or French fries rather than steamed rice. The fat in these carbohydrate foods not only slows digestion and thus serotonin synthesis, it also may contribute to weight gain. But if the right kind and amount of carbohydrates are eaten, then everyone, glutton or non-glutton alike, do not have to worry about the sin of overindulgence. Indeed, they will instead fulfill the biblical injunction from the book of Deuteronomy: eat and you shall be satisfied. | permalink | related link |   ( 3.1 / 38 )Even the more graphic dissections on the CSI television programs do not point out the different kinds of fat in the body lying on a morgue table. Indeed, most people, if asked about good fat and bad fat, would reply that good fat gives a pleasing shape to certain desirable parts of the anatomy and bad fat makes us shapeless. That may be true, but it’s not the whole story. Our bodies contain two types of adipose tissue, which are distinguished as white fat and brown fat. White fat is the repository of our excess calories and it is used to provide energy when too few calories are coming into the body (for instance when dieting or starving) or during prolonged periods of exercise. Brown fat (that color because it contains a cellular component, mitochondria, that gives it its brownish hue) is the furnace of the body. These mitochondria generate heat and use up calories to keep our bodies warm in cold environments. Adults have very little brown fat. What they do have is located in the upper back, in the hollow between the collarbone and shoulder and along the spine. Newborns have much more, about 5 percent of their total body mass. Newborns are susceptible to the cold and cannot shiver to generate heat. The brown fat prevents them from suffering from hypothermia. Even the small amount of brown fat we have as adults uses up or “burns” calories when the body is exposed to cold. In a study in the Journal of Clinical Investigation by endocrinologist Dr. Andre Carpentier, men were kept in a cold environment so they were chilled but not shivering. The heat-burning brown fat increased their metabolic rate by 80 percent and even though they were just sitting in an under-heated room, they expended or used up 250 calories in three hours. The relationship between cold exposure and burning fat for heat suggests the less-than-enticing possibility of losing weight by spending each day sitting on an ice floe in a T-shirt and shorts. However, other recent studies have shown that one does not have to go to the Antarctic to increase brown fat and become thin. The solution may be as close as the nearby health club. Scientists are excited about discovering a hormone called irisin that is secreted by muscle cells after exercise and turns white fat cells (the kind we want to get rid of) into cells that act like brown fat cells. Dr. Pontus Bostrom and colleagues, who discovered the white to brown fat cell conversion, reported in the journal Nature that these new fat cells are not identical in color to the brown cells we have from birth. He named them brite, or brown-in-white, cells. (Presumably the color beige did not occur to him.) They act like brown cells by increasing heat, burning calories and decreasing elevated glucose levels. Although most of the research has been carried out in mice, some studies on humans found a significant increase in this hormone, as well as metabolic rate in humans after 10 weeks of regular exercise. It has also been suggested that the increased metabolic rate seen for a couple of hours following completion of exercise may be due to the continuing fat burning by these newly-formed brite cells. Studies using mice suggest that increasing the level of irisin may reverse obesity and its related problems, such as diabetes. Obese mice did not have to go on a treadmill to increase their irisin levels. They were genetically manipulated into producing a high level of this hormone, and the result was every dieter’s dream. The mice increased their energy production, thus using up calories and losing weight while improving glucose tolerance. Might irisin be the magic weight-loss pill everyone has been waiting for? Would taking it in pill form eliminate the need to exercise to lose weight and decrease elevated glucose levels? An editorial in the April 19th New England Journal of Medicine suggests that irisin would be beneficial for those who are unable to exercise because of severe muscle or skeletal disability or cardiovascular conditions. For example, people with spinal injuries or congestive heart failure who cannot exercise would experience the benefits of this hormone. It doesn’t take much imagination to envision how most people would respond if such a pill were available. Gyms would lose their members who work out primarily to lose weight (why bother if one can take a pill?) People obsessed with the need for quick weight-loss might exercise and take irisin in pill form to increase its benefits. What would we lose, beside weight, if we replaced working out with a pill? How about: Muscle mass. Might we all have big heads and shrunken bodies? Cognitive improvement. Exercise benefits our ability to think and remember. Would we forget where we left the irisin pill? Recreational sport. Will golf courses and tennis courts be turned into vegetable gardens and sheep pastures? Escape from unrelenting obligations. What excuse would we have to turn off our computers, smart phones and iPads and thus the stress of constant bombardment of work and family obligations? A pill will give us no excuse to hide from this stress. Social interactions. What will happen to conversation if people can’t talk about their running time or how cute the new spin class instructor is? So as someone said, “Be careful what you wish for.” At this point, what we all should be wishing for is more time to exercise. | permalink | related link |  ( 2.8 / 38 )"I think if I gain another five pounds, " said a friend, who was about 15 pounds overweight told a group of us over dinner, "I will be eligible for the new weight-loss surgery." She was helping herself to a piece of luscious chocolate cake that the rest of us were trying to avoid eating. "Don't you have to be at least l00 pounds overweight before you can have bariatric surgery?" I asked. Apparently not. She described a suddenly popular new surgical technique that shrinks the stomach by folding the stomach lining and stitching it in place. Patients who want to lose as little as 25 pounds are going through the procedure because although it requires general anesthetic, there is no cutting of skin or muscle. As some of us gagged, our friend told us that the procedure called POSE, or Primary Obesity Surgery Endoluminal, uses an endoscopy tube that passes through the mouth and esophagus to reach the stomach and then makes tummy tucks. POSE is so new that it has not gone through rigorous clinical testing to see whether it is more successful than other surgical techniques in producing permanent weight loss; nor has it received FDA approval. Nevertheless, people who want to be thin are using this procedure to get rid of weight that does not respond (so they say) to conventional diets and exercise. Our friend said that she had considered liposuction to get rid of some of the fat she could not seem to diet of,f but the stomach-shrinking technique seemed a better option. "This way I will never be able to eat very much, so losing weight and keeping it off will be easy." Is POSE the so-called magical weight loss option every overweight person has been seeking? Is its relatively quick and non-surgical procedure the answer to a permanent way of keeping off weight? It is much too early to tell. Other surgical procedures to reduce the amount of food that can be swallowed and contained in the stomach have been effective in producing massive amounts of weight loss in the first year or so after the procedure. Yet long-term outcomes are inconsistent. Patients have found that if they consume high-calorie liquids food like melted ice cream, or gradually introduce large amounts of food into their stomachs, they can enlarge its size. Eventually, they are able to eat enough to regain the weight lost during the first year after the operation. The question I would have liked to ask my friend who is considering the POSE procedure was this: Why couldn't she lose 20 or 25 pounds the conventional way? I didn't, of course. There are some things one cannot discuss, even with close friends. But I think I know the answer. She, like so many others, is consistently inconsistent in her weight-loss efforts. Weeks of a stringent diet and exercise will be followed by an equally long periods of paying little attention to calories and avoiding the gym. Not surprisingly, at the end of every diet year, her weight has not changed by more than a few pounds. She did lose some weight for her daughter's wedding, but put it on a year or so later when her mother was diagnosed with Alzheimer's disease and her father had a stroke. Like it is for so many of us, food became her source of comfort. She claimed that diets simply never worked well enough to get her to lose 25 pounds. But we all know that under the right circumstances, we all can lose weight. I am sure that if she were shipwrecked and forced to live on raw fish and coconuts, she would be a size 0. She had been on diet programs so many times, she could recite the list of foods that should be eaten every day and could demonstrate how to use the exercise equipment at the gym. But time and again, she abandoned these positive habits, ate whatever she wanted and never went to the gym. How can an operation on her stomach have any effect on making her choose healthy foods and engage in regular physical activity? What was also worrisome was that she automatically turns to food when she is stressed, eating large amounts of carbohydrates, like potato chips and cookies, that are packed with fat. Will the surgical procedure stop her emotional eating? Can any surgical procedure to reduce stomach size accomplish this? Our brains are behind our overeating when winter darkness makes us depressed, when PMS causes major mood swings, when we are exhausted from too much work or too little sleep, or stressed to our limits because of financial, family, or health problems. How can a smaller stomach make these stresses less painful and upsetting? We have learned, perhaps unconsciously, that when our brains respond to our consumption of carbohydrate by making new serotonin, the edge is taken off the stress. We are able to cope and become calmer, more focused and able to handle or endure whatever has upset us. The amount of fat-free or low-fat carbohydrate that has to be eaten to increase serotonin contributes less than 200 calories to our daily food intake. Moreover, the increase in serotonin also has the added benefit of making us feel less hungry. Bariatric surgery may be lifesaving for people whose weights are propelling them into life- threatening medical disorders. But bariatric surgery, whether a stomach bypass operation or sewing together bits of a stomach lining, is not sufficient to prevent emotional overeating or the failure to accept a permanent commitment to health eating and exercise. The only solution -- and there is nothing magical about it -- is to understand how to use serotonin to stop emotional overeating and to employ self-discipline for healthy eating and exercise as a program for life. | permalink | related link | ( 3 / 50 )At a dinner with friends a few days ago, someone commented that his parents would not even recognize some of the foods we were consuming. “My father insisted on red meat at least six times a week,” he said. “If he saw this seaweed salad and brown rice, he would assume it was for our pet bird.” Indeed, if one compares the way people ate 50 to 60 years ago with the food choices today, it is obvious that our options have changed immensely. We know much more about what is healthy and unhealthy to eat. In the middle of the last century, few were concerned about calories, cholesterol, transfat, anti-oxidants, high fiber or omega-3 fatty acids. Foods found in supermarkets today, like bok choy, tofu, oat bran, fat-free Greek yogurt and sushi, were almost unknown. Back then, only a few so-called health-nuts made any connection between food and the quality and longevity of lives. Food was eaten to take away hunger and prevent malnutrition; that was all. However, our current focus on the impact of food on our physical and mental health did not occur overnight. We did not wake up one morning, throw out the cold cuts and start eating soy products. It took decades to recognize that we should use canola oil rather than solid white shortening and eat more fish and less red meat. Our healthier food habits developed very slowly, and many of us are still struggling to make them a habit. The story is entirely different for dieters. When they go on a diet, they are asked to make radical and instantaneous changes in their food choices. They are told to stop preparing meals with butter, cheese, cream, bacon and eggs and start using low-calorie ingredients instead. Familiar, comforting foods like macaroni and cheese and meat loaf must be abandoned, and steamed spinach with poached salmon eaten instead. Most important, instead of making these changes over years, the dieter must make these modifications in a New York minute. The diet plan is presented, the guidelines reviewed, and diet foods put in the refrigerator. Fattening foods are thrown out and the diet begins. For dieters, making these changes is like moving to “Thin Country,” where everything is new and disorienting. This place, with its restrictions, forbidden foods, portion control, demands to exercise, and insistence on making food choices based on nutrient and caloric content, rather than taste alone, feels strange and uncomfortable. Anyone who has traveled to a place where the language and customs are hard to decipher is familiar with the bewilderment and even helplessness that comes from not knowing how to communicate. The dieter staring at a bunch of kale in the supermarket or trying to figure out what to order at a restaurant where every item is coated with batter and fried may feel the same confusion and helplessness. Keeping the weight off after the diet is over is even harder. It is the difference between staying in a strange country with the knowledge that you will go back home in a few weeks and emigrating to a new land. Losing weight is like being a tourist with an extended visa. Keeping it off means applying for citizenship. Obesity experts have failed to recognize that the dieter who has reached the end of his diet and taken up residence in “thin country” needs as much support to survive as any new immigrant. If the dieter is to keep his weight off permanently, then he needs help in dealing with the issues that caused the weight to be gained, strategies for resisting the temptation to go back to his old ways of eating, aid in making him feel comfortable in his newly thin body, and ways of dealing with those around him who don’t believe he will succeed in staying slim. Compare the absence of group support for successful dieters to the presence of support for people who stopped drinking. Recovering alcoholics can find meetings everywhere, every day, to help them maintain sobriety. Where are the comparable support groups for the formerly fat who are now thin? Except for some weight-maintenance programs that deal mainly with modifying food intake to keep weight stable, there really are no groups to help the dieter who has reached his goal adjust to a life of being permanently thin. For example, many newly thin people feel that they are being treated differently than when they were obese and don’t know how to deal with this. I have had weight-loss clients who complained that they were always the same inside so why were they being treated better now that they are thin? Why were they now getting attention from the other gender when they were ignored while fat? The newly thin need to form new friendships with people who speak the language of healthy eating, rather than returning to old friends who speak the language of overeating and poor food choices. That decision, and the action that it requires, only adds to the difficulty of maintaining new lifestyle choices. Many of us who are now thin after years of being obese should reach out to those who have just crossed the border into this country. Like any new immigrant, they need our help and support to stay on the road to better health and long term happiness. Isn’t that what all newcomers seek, after all? | permalink | related link | ( 3 / 1149 )There are choices for almost everything these days. Call the customer service department of your cell provider or cable company and you will be offered (in a maddeningly slow computerized voice) at least a half a dozen options from which to choose. We are now also given choices of what type of therapeutic intervention we want when faced with a medical problem. The choices include immediate intervention, wait-and-watch drugs, dietary changes, physical therapy or surgery. Even chemotherapy is personalized whenever possible in order to target specific cancer cells with chemicals designed to eradicate them. Not so with diets. Sure, one can choose among different weight-loss options such as packaged portion-controlled meals, low-calorie liquid diets, calorie counting, point counting, reducing stomach size through surgical techniques or following a celebrity-generated fad. But once the dieter is enrolled in a program, little attention is given to how he or she may differ in metabolic, psychological or hormonal characteristics from the other dieters. Some diet programs with gender-specific plans don't take into account that some women may be as large as men and vice versa. For example, should a 5'6" man whose starting weight is 190 pounds be given more calories to eat than a 5'11" woman whose starting weight may be 250 pounds just because he is following the men's diet and she, the women's? Should someone who is used to consuming 4,000 plus calories a day be started on the same diet as someone who eats 2,500 calories a day? Predictably the former is going to be really hungry for the first week or two and perhaps leave the diet because of that. Recent surgical interventions take into consideration the individual physical differences of the patient, but how much attention is given to the differences in their psychological profiles and reasons for gaining so much weight? A patient, morbidly obese because of years working as a chef, and a patient with the same excess weight who gained it because of childhood sexual abuse may have totally different long-term outcomes from the surgery. A friend who is on Weight Watchers was staying with us recently and expressed her frustration with the program because it is simply not set up to deal with individualized diet counseling. "The program is wonderful for people who have been eating unhealthily and really didn't know that a bacon double cheeseburger with fries has more calories than a grilled turkey sandwich on whole wheat bread. They not only lose weight; they learn to improve their food choices. But I know all this. My problem is that when I have to go to court [she is a litigator] I eat my way through hours of preparation. And of course I pay no attention to the diet. I want someone to tell me how to lose weight when I am stressed -- and I am always stressed." It is time for personalized weight-loss therapy? There is no (at least to my knowledge) facility that does in-depth analysis of a dieter's life style, emotional health, susceptibility to hormonal and seasonal changes in eating, exercise commitment and previous diet history. So the dieter or potential dieter has to figure out whether a diet fits their life profile and/or push for more personal intervention if a diet is not working. A home hospice worker and I talked on the phone for an hour so we could figure out how she could eat most of her meals in the car, as she spent sometimes up to 10 hours driving from home to home. And more importantly, we talked about what she should eat to take away her own emotional pain after a day of helping the families of someone on hospice care. A neighbor who lost the first 100 of the 200 pounds he has to lose after lap band surgery sat in my living room and confessed that he was gaining rather than losing weight. "I am lonely," he said. "I eat all evening. I am careful not to put too much food in my stomach at once but I can consume several hundred calories after supper." He thought if the band was made tighter, reducing even more the size of his stomach, that his problem would go away. But I pointed out to him that what he really needed was therapeutic support so he could turn away from eating to solve his loneliness. Personalized weight-loss programs must become part of our efforts to decrease the national rise in obesity. It will initially be more expensive than simply recommending a program without determining if it offers the best support for the personal needs of the dieter. But, like identifying specific types of cancer cells before settling on a chemotherapeutic protocol, it may have a better long-term outcome. One thing is certain: Failure to reach a weight-loss goal and/or to maintain the loss does not mean the dieter can never lose weight. Like finding the perfect pair of jeans, it is simply of matter of seeing what fits best. | permalink | related link | ( 3.2 / 1150 )Next |
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