Archive for June, 2008

Taking a “vacation” from healthy eating

June 27, 2008

I am on vacation – several weeks of sharing a beach house with friends and family – and I am eating (and drinking) very well! People often say to me “Have some more of this [fill in the blank: junk food, fried food, rich desert, Bloody Mary], you are on vacation!”  For many people who succumb to this kind of peer pressure, the result is unwanted weight gain that is very difficult to reverse. They rationalize: “As soon as I get home, I am going on a strict diet, and will work out twice a day!”  The diet doesn’t work and the rigorous workout routine rarely lasts a full week.

Fortunately, my eating and drinking patterns do not change when I am on vacation or having a “special occasion” because I have figured out a way to eat and drink very well ALL the time.  In that sense, I am always on vacation when it comes to healthy behavior and good eating.  True, I may overeat (or drink) for one meal or event, but easily compensate by eating and drinking less for two or three other meals. Here is some advice for coping with vacations and other special occasions (from Weight Management for Your Life):

If you have been successfully working on changing your eating and exercise patterns for some time, you will encounter situations where someone will say to you “This is a special occasion, so go ahead and eat that cake!” The cake is not the issue, but the implication behind the statement is. People observing your healthier lifestyle will assume you are in a constant state of self-deprivation, and will want to see you “loosen up.” It is important to them to feel okay about their own “indulgences.” The problem with your buying into that theory is that it discounts the fact that you already are eating (and exercising) the way you want to. You are not depriving yourself – in fact, by doing what you want, you are indulging yourself. Your ongoing healthy lifestyle is its own reward. Another problem with going back to old unhealthy habits, even temporarily, is that such “special occasions” come up frequently: out-of-town trips, weddings, graduations, birthdays, holidays, cruises, office parties, etc. etc. Add the special occasions with their special “indulgences” or “rewards” up over the course of a year and you have put on an unwanted five to ten pounds.

The process of self-change: “Reality TV” gets real

June 21, 2008

I watched “What Not to Wear” (TLC network) last night. I’m on vacation, had a nice dinner at a Mexican restaurant, including Margaritas, sat down in the living room of our rented beach house with my wife, and it was on.  The format is that friends and family nominate someone to be on the show because of how badly they look and dress and how much they need a makeover.  Last night it was a woman in her late 30s or early 40s (hard to tell) who either wore baggy clothes or party clothes from the 1980s, had frizzy permed hair, and of course no makeup.  The male and female co-hosts (who are very hip and very blunt) ridiculed her choices of clothes and style and pointed out that she clearly did not know and/or like her own body. She reluctantly admitted she might need some help “to feel more confident” so agreed to let them destroy her current wardrobe and send her on a $5000 shopping spree in NYC.  So far, so good.

As the show progressed, however, the woman became distressed: alternately tearful and angry, expressing doubt as to why she needed to change, longing for the comfort of her old clothes and style, and disliking most of what she was now to wear.  The co-hosts made fun of her, pushed her, empathized with her and encouraged her.  Finally, after a hair and makeup session, she was re-introduced to her friends and family to applause and much praise, some of which may have been a bit forced. She smiled, said she really liked the “new me” and then confessed she would probably go back “half-way” to her old style. Still, the process jarred her out of her fearful complacency and enabled her to see a lot more possibilities for the future. Watching it, I agreed that she looked much better (younger, happier, more attractive and more likely to be accepted in her profession).

So why am I writing about this?  Because it illustrates beautifully the process we go through when we change our behavior. It also demonstrates how persistent, and sometimes aggressive, we might need to be to help someone at least try new behavior.

You didn’t really think I would write a post without including some research, did you?  Here is a section from Weight Management for Your Life that talks about the change process, followed by my observations of how the woman in the TV show fits the model:

James Prochaska, Carlo DiClemente, and John Norcross (in a series of articles reporting on their research into how people make important changes in their behavior over time) describe their “Stages of Change Model,” which applies very well to weight management and is especially useful because it predicts and confronts the common problem of early success and later failure. The model covers a time period of many years.

Briefly, the stages are:

Pre-contemplation. This is the “ignorance is bliss” stage before one is aware change might be needed. One may be aware s/he is overweight, but tend to shrug it off as “genetic” and not think of it as something to actually control.

Contemplation. This crucial stage may last for years and is characterized by ambivalence. One may think, “I really should lose weight,” and may even read about it and try a few diets in a half-hearted way. Words people use when they are in this stage are “can’t,” “won’t,” “might,” “maybe,” “we’ll see,” “I’ll try,” and, finally, “I want.” A thought, feeling, comment from another, or event may trigger movement toward taking action.

Preparation. Here is where serious planning begins. There will be more focused education and consideration of many of the issues covered in this book. If special supplies (e.g., notebooks, pedometer) are needed, they will be acquired. Time and space in one’s schedule/environment are arranged. People say, “I’m going to do this!”

Action. Now the plan is implemented. This stage tends to last from three to six months.

Maintenance. This is perhaps the most important stage, and the one most often ignored. It consists of a continued commitment to sustaining new behavior, and lasts for many years or a lifetime. Changes in one’s environment and even relationships may be required, so that the positive new behaviors will be encouraged and supported.

Relapse. Commonly, a person will relapse and resume pre-Action behavior at some point (or points). Relapse, also called “a slip,” can provide valuable information about ways the plan needs modification. After a relapse, a person may need to go back to the contemplation or preparation stage, or, if no major change in plan is indicated, go right back to maintenance.

None of the stages is absolute in any way, and people spiral back and forth from one stage to another as needed. It is important to realize that the self-change stages apply to all sorts of decisions you are trying to implement, and therefore you may be in one stage regarding one decision (e.g., eating less) and another stage regarding any other decision (e.g., exercising more, or reducing family stress). In my experience, teaching people the stages, and helping them assess where they are in the process at any given time, empowers them to keep on track with their decision.

Our “What not to wear” woman went through almost all the stages in a very short time. First she was unaware of any problem with her appearance (pre-contemplation). After her nomination for the show and in the beginning of the show, she began to realize she had a problem, though was not sure quite what it was (contemplation). Then, she agreed to allow the co-hosts to influence her shopping and other decisions (preparation) before becoming an active participant (though still ambivalent) in the change process (action). When she returned home, she saw that her friends and family would be supportive of the new behavior and described how she planned to continue it (maintenance).  Finally, she talked about how she might slip back into the old ways (relapse).

Portion Distortion

June 20, 2008

Joe Average has lost over 50 pounds in the past four months, and one of the main ways he did it was to cut portion size. It is amazing how we all distort (underestimate) the amount of food we eat in a “serving.”  To really get a feel (with good visuals) of your own tendency to do this, check out the Portion Distortion site right now! Here is a bit more about portion size in an excerpt from Weight Management for Your Life:

Much research supports the fact that portion size is a major determinant of how much we eat. For example, Brian Wansink, Professor of Marketing and of Applied Economics at Cornell University, conducted several studies which showed that:

• Moviegoers ate 45% more popcorn when served in a large tub compared to a medium sized container.

• People watching a movie ate twice as much M&Ms from a large bag compared to a small bag.

• In neither of the above studies were the research subjects able to guess the number of calories they had consumed; people consistently underestimate the amount they eat.

• While people tend to acknowledge that portion size and container size may influence other people, they often wrongly believe they themselves are unaffected.

We all suffer from “portion distortion” when we estimate the amount of food we consume, not only at mealtime, but when we snack and eat without being mindful (automatic eating). To see whether you have this problem, check out the Portion Distortion Quiz on the Internet (http://hp2010.nhlbihin.net/ portion/).

Lessons for living longer

June 15, 2008

Author Dan Buettner (The Blue Zones: Lessons for Living Longer from the People Who’ve Lived the Longest), in partnership with National Geographic and the National Institute on Aging, traveled the world to find out who lives the longest and what we can learn from them.

From the NPR story:

Buettner says one such zone, the Italian island of Sardinia, has the highest number of male centenarians in the world, while another, Okinawa, Japan, has the longest disability-free life expectancy. In Loma Linda, Calif., a community of Seventh Day Adventists has a life expectancy that’s nine to 11 years greater than that of other Americans. And middle-age mortality is lowest on Costa Rica’s Nicoya Peninsula — where Buettner says middle-aged residents have about a four-fold greater chance of reaching age 90 than people in the United States do.

Some commonalities which seem to correlate with long, healthy lives:

“One of the idiosyncrasies we discovered is that people who eat nuts four to five times a week, 2 ounces at a time, tend to live two to three years longer than people who don’t eat nuts. That was a big surprise for us,” Buettner says.

Some may think the secret to longevity lies in strenuous physical activity, such as running marathons or triathlons or pumping iron. But Buettner says he has identified four things people can do that can potentially increase life expectancy: Create an environment that encourages physical activity, set up your kitchen in such a way that you’re not overeating, cultivate a sense of purpose and surround yourself with the right people.

“These are long-term fixes that have been shown over and over to add not only more years of life, but better years of life,” Buettner says.

These findings are consistent with the findings from Vaillant’s book Aging Well (see previous post), and with many other studies (for example here).

The weakness of this kind of research is that it only shows correlations (does not prove cause and effect) and suffers from the “cohort effect” — all the people studied, by virtue of their similar age, grew up under unique socio-cultural-historical conditions which may never occur again.

Rethinking Thin

June 12, 2008

Gina Kolata, author of the book Rethinking Thin, has a point of view: it is almost impossible to lose significant amounts of weight and keep it off. I respect her work, but take issue with her pessimistic tone. Here is a review of her book I placed on Amazon.com:

Most books on diet and weight control, and there are hundreds, fall into one of two categories: research-based but narrowly focused and selective in order to promote a specific point of view; or completely opinion-based and hyping some fad or promoting a product (which may be the book itself). Rethinking Thin falls into the first category.

Author Gina Kolata, a New York Times science reporter, contends that being “overweight” has been oversold as a health problem. She correctly criticizes the hugely profitable “diet industry” for capitalizing on people’s belief that they can and should try to change what they weigh. Her major argument is that people have little control over their weight and that, like height, it is mostly biologically determined through a poorly understood interaction of heredity and environment.

I agree with Kolata that being overweight is not necessarily a medical problem and also agree with her criticism of dieting, but I disagree with her emphasis on how little effect our behavioral choices have on the outcome. For example, she writes, “It must be that free will, when it comes to eating, is an illusion.” She throws out the baby “willpower” with the bathwater of self-blame and shame. The problem, as I see it, is not with willpower but with the misuse of it in trying to comply with worthless diet plans and attempting to achieve unrealistic goals.

For some people there is a major genetic and/or biochemical component to their difficulty in maintaining the weight they desire. Ongoing research concerning the roles of leptin, ghrelin, insulin, and many other hormones in regulating body weight and hunger demonstrates that some obese individuals (perhaps as many as 5% or more) may have genetic mutations affecting their ability to control their appetite. Related lines of research indicate there are biological forces that make it difficult for most people to lose weight once it has been gained. Such evidence suggests that once fat tissue accumulates, a system of overlapping neurological and hormonal mechanisms works to prevent it from diminishing. Even so, most of us do have a significant degree of control over our eating and activity level, and this means we have some control over what we weigh.

Here are some relevant lines of research that Kolata essentially ignores:

  • The important role of “non-exercise activity thermogenesis” (NEAT) in determining what we weigh;
  • The thousands of success stories of people who have lost significant weight (and kept it off) through conscious control of eating and activity (this may be a small percentage of the overweight population, but a significant group);
  • The proven role of social networks and support systems in affecting our weight and lifestyle choices;
  • Exciting research (using sophisticated neuro-imaging) which shows how and where the “conscious” brain exerts influence on our eating and impulse control (including the role of “won’t power”);
  • Extensive research on consumer behavior when it comes to food choice, portion control, and automatic or impulsive eating behavior;
  • Research on stages of self-change and willpower fatigue (and ways to increase self-control and overcome learned helplessness).

Kolata concludes her book with this statement, which is a bit pessimistic in tone, but also offers realistic hope for people who are interested in taking action toward improving their health: “The lesson is, once again, that no matter what the diet and no matter how hard they try, most people will not be able to lose a lot of weight and keep it off. They can lose a lot of weight and keep it off briefly, they can lose some weight and keep it off for a longer time, they can learn to control their eating, and they can learn the joy of regular exercise. Those who do best tend to be those who learn to gauge portions and calories and to keep their houses as free as possible of food they cannot resist. The effort, the lifelong effort, can be rewarding – people say they feel much better for it. But true thinness is likely to elude them.”

Please let me know what you think; are you an optimist or pessimist where weight management is concerned?

Bikini-clad women make men impatient

June 9, 2008

New research highlights an old problem — anything that interferes with our ability to delay gratification can lead to unhealthy choices. The latest study along these lines shows that men who watched sexy videos or handled lingerie sought immediate gratification—even when they were making decisions about money, soda, and candy. Being aware of this tendency in ourselves (men) can lead to successful efforts to stop ourselves from acting foolishly. (Click here to see the full study in pdf file format).

Many other studies (of both males and females) over the years have shown that exercising self-control and being able to delay gratification is a skill that leads to higher social and educational achievement and healthier choices. How can we increase our ability to resist temptation? Ongoing research strongly suggests that willpower can be strengthened through use (the more we practice it, the more of it we have), and also can be budgeted like any other limited resource (for example, see this New York Times article).

More on “Who needs exercise?”

June 8, 2008

After writing my last post on exercise, I came across this article, which has some very important implications for young people. Again, it shows how complex the question “who needs exercise?” is and how important it is to specify “for whom?” and “exactly what do you mean by exercise?”

Preventing Childhood Obesity: Vigorous Physical Activity—YES, Restricting Calories—NO*

by Bernard Gutin, PhD

My colleagues and I at the Medical College of Georgia investigated the relationship among diet, physical activity and body composition in 661 African American and white adolescents ages 14 to 18.1 We hypothesized that fatter youths would have higher levels of energy intake and lower levels of both moderate and vigorous physical activity.

To our surprise, we found that higher levels of percent body fat were associated with lower levels of energy intake and lower levels of vigorous (but not moderate) physical activity. Youths who did the most vigorous physical activity and consumed the most calories were the leanest. Those who did no vigorous physical activity had a percent body fat of 28.6 and consumed 1744 calories a day, while those who did at least 1 hour of vigorous physical activity each day had a percent body fat of 19.4 and consumed 2203 calories a day. See Relationship of Vigorous Physical Activity, Caloric Intake and Percent Body Fat.

Although moderate physical activity, such as brisk walking, burns calories, we found that lower percent body fat was linked to greater amounts of vigorous, but not to moderate, physical activity. Vigorous activity includes sports, games and dance activities such as running, swimming, soccer and aerobic dancing. These activities impart a significant “mechanical load,” which means they work your body’s muscles and bones. This type of activity stimulates stem cells to differentiate into bone and muscle rather than fat.2 A healthy body composition in youths requires both a large amount of vigorous physical activity and ingestion of sufficient calories and nutrients to support this tissue-building process.

This idea is further supported by experimental studies that looked at the effect of mostly vigorous physical activity, without restriction of calories, on body composition. Research on youths with varying levels of fatness and fitness found moderate physical activity to be ineffective in preventing obesity, so we conducted studies using 300 to 400 minutes a week of mostly vigorous physical activity and found positive effects on body composition, including reduction of visceral adipose tissue (the fat around abdominal organs). Within the intervention groups, those youths who participated regularly and maintained the highest heart rates during the physical activity sessions showed the greatest decreases in percent body fat and the greatest increases in bone density.3,4

Youths who are obese and unfit can benefit from exercise of relatively low intensity and duration. For example, in obese youths, studies using 155 to 180 minutes per week of physical activity at moderate to high intensity produced favorable reductions of percent body fat and visceral adipose tissue and increases in bone density and aerobic fitness.5 As children improve in fitness, they should be encouraged to progress to higher amounts and intensities of physical activity.

An expert consensus panel has suggested that youths engage in at least 420 minutes a week (about 60 minutes a day) of moderate to vigorous physical activity.6 The research reviewed here suggests that greater emphasis should be given to vigorous rather than moderate physical activity.

Taken together, these findings suggest that a paradigm shift is needed to improve the effectiveness of pediatric obesity prevention interventions. It is well known that eating a nutritious diet supports the development of muscles and bone and other aspects of proper growth and development, as well as good health. However, limiting energy intake runs counter to the biologic demands of growth, which require adequate calories and nutrients. When youths engage in adequate amounts of vigorous physical activity, calories and nutrients are preferentially directed to the production of lean tissue (muscle and bone) rather than fat. So, insuring a high quality diet and plenty of exercise, rather than calorie restriction, is the model to pursue to prevent obesity and improve body composition.

References

* A longer version of this editorial will soon appear as a Perspective article in the journal Obesity.


Bernard (Bob) Gutin, PhD, is Adjunct Professor of Nutrition at University of North Carolina in Chapel Hill and Professor Emeritus at Teachers College of Columbia University and the Medical College of Georgia.

Exercise — who needs it?

June 6, 2008

There has been a lot of controversy about the role of exercise in weight management. The old conventional wisdom has been that, to maintain weight, one needs to balance calories in with calories out, and that exercise is the way to boost the “out” side of the equation. That is still basically true, except we now know that it takes a lot of exercise to counterbalance a large intake of calories, and our bodies are real good at seeing that we eat more to fuel the extra exercise. Most research shows that the amount of exercise that improves our general physical and mental health (like 2 hours of moderate-intensity walking per week) is simply not sufficient to affect weight very much.

The fact that exercise had been oversold as a weight-loss aid has led to some very cynical articles claiming that exercise is practically useless for weight management (such as this and this). But these articles overlook two important facts:

1.) Thousands of reports of people who have lost significant amounts of weight and kept it off reveal that exercise is a key reason for their success. Many of these reports are featured on the National Weight Control Registry website (nwcr.ws), which tracks people who have been successful in losing weight and keeping it off. Here is how the co-author of the website summarizes the role of exercise:

The key [according to James Hill] is exercise. ‘Activity becomes the driver; food restriction doesn’t do it. The idea that for the rest of your life you’re going to be hungry all the time – that’s just silly.’ People in the registry get an average of an hour of physical activity every day, with some exercising for as much as 90 minutes a day. They also keep the fat in their diet relatively low, at about 25 percent of their calorie intake. Nearly all of them eat breakfast every day, and they weigh themselves regularly. ‘They tell us two things,’ Hill says. ‘The quality of life is higher – life is better than it was before.’ And ‘they get to the point with physical activity where they don’t say they love it, but they say “It’s part of my life.” … I think you pay the price for having been obese and you have to do a lot of activity to make up for that.’

2.) There is a very important form of activity that is technically not exercise, but is crucial in determining our ability to lose or maintain weight. It is “non-exercise activity thermogenesis” or NEAT, and it accounts for a very significant proportion of our energy output. An excerpt from Weight Management for Your Life summarizes this research:

Research at the Mayo Clinic by James Levine, MD, has clearly shown that the more we move throughout the day, the more weight we lose (or don’t gain). He calls this kind of movement NEAT, which stands for Non-Exercise Activity Thermogenesis. For most of us, NEAT accounts for far more of our daily calorie expenditure than formal exercise does (even fidgeting uses calories!). Levine found that thin people are on their feet an average of 2.5 more hours a day than their overweight counterparts. NEAT is responsible for between 20 percent (in very sedentary “couch potatoes”) and 50 percent of our total daily energy expenditure. Most of the rest of our energy expenditure is due to “basal metabolism” (calories used when we are at complete rest) which accounts for up to 60 percent; and “thermic effect of food” (digestion, absorption, storage) which accounts for 10 to 15 percent. Levine discovered that our individual NEAT level is largely biologically determined (possibly genetically) and that people with a naturally low level can be taught to increase their “non-exercise activity.” He recommends that we aim for 40 percent NEAT by changing the way we work, such as standing while working and walking around during meetings and while on the phone. He uses a treadmill going very slowly (1 mph) throughout the day (a “walking workstation”); this kind of easy activity doubles our metabolic rate and uses an extra 100 calories per hour (compared to sitting). This would be a great way to watch TV!

What is the take-home message from all this?

First, be wary of articles, even from prestigious sources, that take an extreme view. Life is never so simple, and weight management is especially complicated and multi-faceted.

Second, how active we are (whether through formal exercise or NEAT) has a major effect on our health and our weight: the less sedentary the better.

Finally, what and how much we eat is just as important as exercise and activity.

Please let me know what your experience with exercise and non-exercise activity has been.

Beware of “food fraud”

June 1, 2008

What is a great way to save money and be healthier, too? The answer, for many of us: stop spending money on packaged foods with added vitamins etc. and cut back on the vitamins and supplements you take. Most recent research on the effectiveness and safety of supplementary vitamins and minerals (supposedly to prevent heart disease, cancer and other ills) has shown that people who take them have no better, and often worse, health outcomes than people who don’t take them. Even daily multivitamins may put us at risk for negative effects, when taken on top of vitamins added to cereals, breakfast bars, fruit drinks, and other processed foods that make health claims. For example, here is what might happen when you take too much:

  • Vitamin A — increased risk of hip fractures, liver abnormalities, birth defects, and lung cancer (in smokers)
  • Vitamin B-6 — neurological damage
  • Iron — constipation, iron overload
  • Selenium — increased risk of skin cancer, diabetes
  • Vitamin E — in some studies, people on high doses died at a higher rate
  • Vitamin K — interference with some “blood thinning” drugs
  • Folic Acid — increased risk of cancer (if you are going to get pregnant, you may need to take extra Folic Acid to reduce risk of some birth defects)
  • Calcium — in men, increased risk of prostate cancer
  • Phospohorus — can interfere with calcium absorption
  • Zinc — associated with higher rate of advanced prostate cancer

For most of us, there is no need to worry about these potential risks, but if you are eating vitamin “enriched” foods and taking other supplements, you could be getting too much of something. Plus, there is very little evidence that we need supplements in the absence of specific deficiencies. Many of us are deficient in Vitamin D, for example, and we should have our blood tested for current levels to see how much extra we might need.

If you want to take a multivitamin for “insurance” against possible deficiencies, it may be wise to take it every other day, rather than daily. For much more on this topic see Nutrition Action Health Letter, June, 2008 (available here soon).

For an excellent and entertaining take on overly-hyped and overly-processed food, follow this link.