Recovery

Diet and Obesity

Obesity is a worldwide epidemic. Fortunately, you don't have to be part of it.

In the 2004 documentary movie, "Supersize Me," film-maker Morgan Spurlock makes himself a human guinea pig by eating nothing but McDonald’s fare for one month and reducing his normal exercise. He is 32, six foot two and 185 pounds, with an enviable cholesterol count, triglyceride levels to die for, and certified by three doctors and a workout coach as being in excellent health. The three doctors concur that the worst that can happen is his triglycerides will rise a little and perhaps a little weight gain. Famous last words.

By the end of the experiment, Spurlock gained 25 pounds, raised his cholesterol by 60, dropped his libido, and to the utter astonishment of his doctors began to turn his liver into goose pate. Such was the state of his liver, along with chest pains, that his doctors strongly advised he end his affair with Mickey D’s well before scheduled and to prepare for immediate admission to a hospital. That wasn’t all. By day nine, Spurlock was experiencing depression and soon after was developing wild mood swings from all the sugars and other McPoisons. And the unkindest cut of all - he eventually became addicted to the stuff, where he literally craved Big Mac highs.

Spurlock may have taken things to an extreme, but he was quick to show in his film how we have become a fast food nation with alarming numbers of supersized citizens. Seven percent of the American population eats at a McDonald’s every day, and 43 million people a day worldwide head for the golden arches. In 1996, fast food sales in the US exceeded $213 billion.

Obesity Epidemic

In 2001, the US Surgeon General declared an obesity epidemic, reporting that approximately 300,000 US deaths a year are associated with obesity and overweight compared to more than 400,000 deaths a year from cigarette smoking. A federal study estimates the health-care costs of overweight and obesity in the US at $92.6 billion. In 1993, according to the CDC, the prevalence of obesity in most US states was less than 14 percent. In 2001, it was approaching 24 percent. Preliminary findings indicate we have broken through 30 percent, with some estimates as high as 35 percent. Fifteen percent of children are obese, with a rise in type II diabetes. In 2002 the World Health Organization reported that "[u]nhealthy diets and physical inactivity are ... the leading causes of the major noncommunicable diseases ...."

"Obesity hits every organ system in the body," endocrinologist Judith Korner MD PhD of Columbia University told a session at the 2004 American Psychiatric Association’s annual meeting. This includes the heart, sleep, diabetes, cancer, and psychosocial ills. Ten years from now, she said, obesity will exceed lung cancer in terms of death.

Piling on Weight

At the 2003 Depression and Bipolar Support Alliance conference, Diana Lipson-Burge, a nutrition consultant and co-author of "Un-Dieting", cautioned that 80 percent of the dieting information out there is inaccurate, especially the gimmick diets found in just about every magazine. Ironically, dieters are told to consult a doctor who typically has had only one nutrition class in med school. Not surprisingly, according to one 10-year study, there is only a 5.2 percent success rate with diets.

This is what it takes to form one pound of fat: The average person burns 1,300 calories a day just to stay in bed. This is called the basal metabolic weight. An additional 600 calories are burned, on an average day, for getting out of bed and moving around, resulting in 1,900 calories to maintain natural body weight. One would have to consume 3,500 calories more on top of that in one day to add a pound of fat, which is almost impossible (disregarding meds and other exceptions). Even binge eaters, said Ms Lipson-Burge, don’t eat that much.

But eating the wrong food can result in the weight piling on fairly quickly. Dr Korner cited one example: One New York City muffin, she said, contains about 600 calories, and a 20-ounce cola 250. Assuming this little snack begins as a temptation that turns into a daily habit, in addition to normal regular food intake, it takes just four days to cross the 3,500 calories/one pound threshold and one month to put on seven pounds

How easy is it to take off weight and keep it off? Unfortunately, we run into a wall when we lose 10 percent of our body weight, Dr Korner reported. Adipose tissue shrinks, which results in less leptin, which puts the hypothalamus on red alert. The body goes into survival mode, increasing hunger pangs and lowering metabolism. Within three to five years, she said, almost all dieters are back up to original body weight.

All this comes as cold comfort to those of us caught in the pincers of our illness and our meds. Depression sends many of us into the warm embrace of ice cream and chocolate while our meds can amount to hot fudge sundaes in pill form with none of the pleasures. Weight management obviously needs to be regarded as a lifetime task - eating the right foods and getting plenty of exercise, while setting realistic goals.

Setting realistic goals may mean that aiming for a Rubenesque ideal is okay for now. Trying to accomplish too much too soon is counterproductive and will only lead to disappointment.

Keep in mind that BMI (body mass index) - which purports to define ideal weight according to one's height, gender, and age - fails to account for body fat. Muscle is heavier than fat, which may mean that working out after a certain point could put on weight (which is good, in this context). A 5' 9' light heavyweight boxer who tips the scales at 175 pounds is only overweight in BMI Land..

The BMI is also blind to body type. Ectomorphs - with light bones, slight muscles, and long limbs (such as marathon runners) are not going to turn into mesomorphic Tarzans - with large bones, broad chest, and well-defined muscles - simply by gulping down protein drinks and going to the gym. Likewise, medical science has yet to find a way for endomorphic Santas to stretch their soft round, short-limbed bodies into a mesomorphic or ecto-meso ideal.

Basically, we have to work with what we've got, but this should not discourage you. Athletically chunky is beautiful, as is pleasingly plump. Ignore the computer-enhanced cover girls that bombard our environment and pay attention, instead, to the paintings of the old masters.
Sensible Dieting

Throw away your scale, Ms Lipson-Burge urged, and listen to your stomach. The stomach, she explained, works like a gas gauge on a car. On a one to 10 scale, two corresponds with a growling sensation in the stomach, when all that’s left of a previous meal is a thin lining on the stomach wall. X-rays have shown that fit adults and infants and toddlers (who instinctively know how to eat right) start eating when the stomach is at two.

This contrasts with the "it’s lunchtime I must be hungry" mentality.

The fit eaters always stopped eating at seven on the "stomach gauge," with no pressure on the stomach wall.

No one agrees what a best diet is, Dr Korner told her audience at the APA meeting, but whatever diet works is okay, so long as it’s healthy. Exercise is essential, such as brisk walking at three to four miles per hour at least 2.5 hours a week. Cognitive-behavioral therapy also works well. A realistic treatment goal is a five to ten percent reduction in initial body weight over six to 12 months followed by long-term maintenance of that weight.

So-called diet aids - the type that promise, "I lost 12 pounds in five days and ate everything I wanted" - are harmful in more ways than one, she went on to say. If they don’t work, it reinforces the notion that "something is wrong with me."

Two drugs are FDA-approved for weight loss. Sibutramine (Meridia), originally developed as an antidepressant that blocks reuptake of serotonin, norepinephrine, and dopamine. The drug results in eight percent of body weight loss over one year. The drug is contraindicated for MAOIs. The labeling warns that owing to risk of serotonin syndrome Meridia should not be taken with SSRIs. Orlistat (Xenical) works in the gut and blocks 30 percent of fat from being absorbed, with improvement in total and LDL cholesterol. The non-absorbed fat comes out in the stool, with predictable results.

Off-label meds include: The diabetic drug Metformin (Glucophage), Wellbutrin, Topamax (which may also help reduce binging), and the anticonvulsant Zonigran.

Drugs in phase II or III development include: Axokine, originally developed as an ALS med, and riminabant, that works as an anticannabis to stem the munchies.

As researchers learn more about how leptin talks to the hypothalamus, Dr Korner reported, we will see drugs that target those pathways. Some 200 drugs are already in development.

Watching What You Eat

Dr Korner also said that a calorie is a calorie in the sense that if one's intake of total calories is the same, one will wind up weighing the same regardless of the fat/carb/protein ratios. Other experts take issue with this, pointing out that a person on a high protein diet is going to turn out physiologically different and at a much reduced risk of diabetes and other illnesses than someone eating a lot of bad fats and sugars.

Unfortunately, the fast food restaurants we find ourselves eating out at offer us little choice but this disastrous fat-sugar duo. Following is some basic nutrition (?) information from the website of Ronald McDonald and his buddies:

* Quarter Pounder with Cheese: Total fat 29 g, saturated fat 13 g, cholesterol 95 mg, sodium 1240 mg, sugar 9 g, 540 calories.
* Medium Fries: 25 g total fat, saturated fat 3 g, cholesterol 0 mg, sodium 340 mg, sugar 0 g , 350 calories.
* Medium Chocolate Shake (16 oz): 12 g total fat, saturated fat 8 g, cholesterol 65 mg, sodium 210 mg, sugar 61 g, 580 calories.

The site does not list transfats, considered just as dangerous as excess saturated fat, but from the Burger King site, which includes transfats in its nutritional information, we find that the medium fries contain 4.7 g of transfat (none in the burger and shake). Two years ago, with great fanfare, McDonald’s announced it would cook its fries in oil free of transfats, but later dropped those plans, this time with no blast of the trumpets.

The American Heart Association recommends that no more than 10 percent of one’s calories should come from saturated fat. One gram of saturated fat equals nine calories. On an adult diet of 2,000 calories a day, then, that single burger-fries-and-shake meal well exceeds the daily saturated fat limit at 252 calories. The American Heart Association also recommends restricting cholesterol consumption to less than 300 mg a day and sodium intake to less than 2,400 mg daily.

If one ordered a medium Coke (21 oz) instead of a shake, the sugar would nearly be the same at 58 g. One teaspoon contains four g of sugar, which means the shake or the Coke equates to 15 teaspoons of sugar. Imagine emptying 15 packets of sugar into a large Starbucks coffee and you get the picture. But don't expect to get off easy on the artificial stuff. Diet Coke contains the artificial sweetener aspartame, which Ralph Walton MD of Northeastern Ohio Universities College of Medicine in a small study concluded: "Individuals with mood disorders are particularly sensitive to this artificial sweetener and its use in this population should be discouraged."

McDonald’s advertises on its website that "McDonald’s wide range of high quality foods can fit into a balanced diet." It's entry nutrition page shows uber-athlete Serena Williams happily nibbling on a salad (significantly not gorging down fries). Recently - in apparent response to bad publicity from lawsuits and the Spurlock film - the company introduced salads into its menu and says it is phasing out supersizing.

But the salads can be worse than the traditional fare. A McDonald’s fully-loaded fiesta salad contains 27 g of total fat and 13 g of saturated fat, more than a quarter pounder. Its ingredients include salad mix, seasoned beef, cheddar/jack cheese, salsa, sour cream, and fried tortilla strips. (The Caesar salad without chicken, on the other hand, appears to be a safe bet with 4 g total fat and 2.5 g saturated fat.) For obvious reasons, the low fat balsamic vinaigrette is a healthier choice (3 g total fat, 0 g saturated fat) than the ranch (15 g total fat, 2.5 g saturated fat) and the creamy Caesar (18 g total fat, 3.5 g saturated fat).

No article on fast foods would be complete without mentioning pizza. According to the pizza industry, Americans eat 100 acres of pizza each day, or about 350 slices per second, adding up to 46 slices a pizza a year for every man, woman, and child. Two slices of a Pizza Hut 12-inch pizza with pepperoni (America's favorite topping) add up to 30 g total fat, 10 g saturated fat, 50 mg cholesterol, 1120 mg sodium, 12 g sugar, and 580 calories. Amazingly, Pizza Hut has this to say on its entry nutrition page on its website:

"At Pizza Hut, we take great pride and care to provide you with the best food and dining experience in the quick service restaurant business.

"We believe eating sensibly, combined with appropriate exercise, is the best solution for a balanced lifestyle. ... Pizza can be a part of a well-balanced meal. Ingredients in our pizzas include protein, complex carbohydrates, Vitamin A and calcium. And, depending on the toppings you choose, our pizzas have items from all of the four major food groups - meat, dairy products, fruits and vegetables, and grains!"

Subway, on the other hand, is one fast food franchise that appears to live up to its hype, with a menu of six grams of fat or less sandwiches. Just say no to the meatball subs topped with cheese.

Immediately following his McDonald’s experiment, Morgan Spurlock went on an eight-week vegan diet and resumed his normal exercise. By five months he lost 20 pounds, but it took him another four to shed that last five pounds. His liver returned to normal, along with his other functions.

The McDonald’s diet may have been a gimmick, but it was a good one that provided a ready hook for the airing of serious issues. For instance, Spurlock visited a school lunchroom that resembled a Seven-Eleven, with the next generation of obese individuals slurping and gobbling away under no adult supervision. He contrasted this with a school for disturbed youth in Appleton, Wisconsin, where Houdini grew up. There, school officials pulled off a magic act worthy of the great master - simply by eliminating sugary foods from the premises and serving healthy lunches, behavior problems - presto! - considerably dropped off.

WHO Recommendations

In May 2004, the World Health Organization issued the final draft of its "Global Strategy on Diet and Health." Its main recommendations concerning diet include:

1. Achieve energy balance and a healthy weight.
2. Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids.
3. Increase consumption of fruits and vegetables, and legumes, whole grains and nuts.
4. Limit the intake of free sugars.
5. Limit salt (sodium) consumption from all sources and ensure that salt is iodized.

The WHO also recommended at least 30 minutes of regular, moderate-intensity physical activity on most days.

My Weight Gain Experience

In January 1999, when I first sought help for my bipolar disorder, I was first put on a notorious weight-gaining mood stabilizer and equally notorious antidepressant by a crisis intervention psychiatrist who only saw me twice and failed to warn me about their side effects (why is this no surprise?). Within a few weeks, I had ballooned from 156 pounds to 187, an alarming gain of 20 percent of my original body weight. Since I am six-one, the meds ironically filled out my bean pole frame and made me look better than I ever looked in my life, bald head and all. I managed to get my weight down to about 180, but by 2003 - as a result of eating out more - it had climbed to 190 and in 2004 to 200, just outside ideal BMI for my height. A recent visit to a doctor revealed my cholesterol was in the danger zone, so onto a statin I went, along with some common sense restrictions in my diet and more exercise. At the same time, independently, my psychiatrist recommended I be weaned off my antidepressant. So now (May 2004) I’m back to my original balloon weight of 187, which I oddly see as a great relief.

(Update Feb 2008: On a much lower meds dose, I am now around 180.)

Had I started out at a more normal 200 pounds for my height, a 20 percent weight gain would have represented 240 pounds, well on my way to looking like the "Before" Jarred Fogel of Subway diet fame. Any temporary gain from stabilizing my mood, I am convinced, would have been lost by the long term depression from weight-induced sluggishness and the mood swings of extra sugar and other poisons in my diet. My meds would have been engaged in a losing battle with my runaway metabolism, which would have turned me into one of those cases psychiatry calls treatment-resistant, which implicitly lays the blame on the patient. I would be a prime candidate for diabetes, which runs in my family, and considering my current cholesterol count my heart probably would have stopped beating by now. As it was, with my base metabolism so skewed toward being skinny, the meds worked like a charm.

If Calvin Klein calls asking me to appear in an underwear ad, tell him I'm busy ...

Medications and Weight

Thoroughly discuss the weight implications of any new drug your psychiatrist may recommend and hold him or her fully accountable. Psychiatrists are notorious for not bringing up weight side effects. Moreover, many of them mistakenly regard the extra weight as a fair trade-off for stabilized mood, failing to consider how putting on pounds affects one's mental well-being in the long-term. Accordingly, consider switching to no-fat/sugar or low-fat/sugar food alternatives from the very beginning of treatment on the general principle that an ounce of prevention is worth 20 of more pounds of a diet cure. Stop paying your cable bill, if you have to, and consider seeing a nutritionist.

Everyone responds differently to meds, and the weight side effects are no exception. Some patients may actually lose weight on their meds. Among the antidepressants, Effexor and Wellbutrin are considered weight-friendly while Remeron is such a notorious weight-gainer that some doctors use it for treating anorexia. Originally, SSRIs were thought to reduce weight, but that misconception was based on short-term studies, usually eight weeks or less. A 2000 Massachusetts General Hospital study of 284 patients on either Paxil, Prozac, or Zoloft found Paxil patients experienced a significant weight increase over 26 to 32 weeks compared to modest gains for Prozac and Zoloft. The older antidepressants are even greater weight-gainers.

Among the mood stabilizers, both lithium and Depakote are weight gainers. The mean weight gain for lithium over eight weeks in one small study was 13 pounds, and 8.8 to 22 pounds over seven to ten years, according to another. For Depakote, one study found that 57 percent of patients gained more than 8.8 pounds during treatment.

The other mood stabilizers are considered weight-neutral, while Topamax (not effective for mania) is often used as a diet pill.

As for the antipsychotics, a 1997 study by Nemeroff found patients on Zyprexa gained 27 pounds over one year. Other one-year studies found weight gain leveled off in the single figures for Risperdal and Seroquel and was negligible for Geodon and Abilify. Product labeling shows nearly 30 percent of Zyprexa users added seven percent or more weight. Twenty percent of Seroquel users, more than 15 percent of Risperdal users, around 10 percent of Geodon users, and less than 10 percent of Abilify users crossed this "clinically significant" threshold.

The meds cocktails most of us find ourselves on can add up to recipes for dietary disaster. In 2003, for instance, the FDA approved Zyprexa as combination therapy with lithium or Depakote for treating initial phase mania. Zyprexa with either of these drugs, however, is simply begging for an audition as the next Macy's Santa. Adding drug number three or four virtually clinches the deal.

But as bad as these meds are together, one must always bear in mind that absolutely none of them should be taken with a Big Mac. Or a shake. Or fries. Or a Coke. Or a loaded salad. Or a pizza. We may have no choice with our meds - especially if the weight-friendly ones fail us - but we can choose to eat smart and exercise right and use every sensible weight-management technique to our full advantage.

Calvin Klein is calling ...

Updated July 30, 2004, reviewed Feb 10, 2008