The other Kenny Rogers (Texas Ranger pitcher) with arguably the best first half of the season in the American league lost his composure if not his mind before a game in Arlington, Texas on Wednesday, June 29, 2005. Footage of him pushing away TV cameras, knocking down a cameraman and kicking the camera dominated the national news today. One of the cameramen was evaluated at a local hospital and is reporting injuries to his neck and back.

What pushed the most valuable player on the Rangers to join the ranks of Bobby Knight, Ron Artest, and other notorious athletes with violent tempers? Is it the intense competition that has driven their success since childhood? Is it the constant media pressure and scrutiny? Is it the fault of a social system that elevates our sports heroes to positions loftier than us mere mortals with their multi-million dollar a year salaries? Is it the fact that if they don’t continue to perform they are history? Is it the fact that they are really just commodities that can be traded away? Is it because overnight they can lose a team mate who has been traded? Yes, to all of the above plus sometimes you can add in performance enhancing substances including but not just steroids.

The biggest problem is that we are not learning from experience. The Indiana Pacers of the National Basketball Association lost their star player, Ron Artest, for the season after he charged into the stands during a game with the Detroit Pistons in the fall of 2004. The Texas Rangers were aware of Kenny Roger’s temper and his progressive loss of control during the prior month but they apparently took no action.

What causes this behavior from a biological, psychological and cultural perspective?

Related Article: Violence in Sports …

Your interview with Tom Cruise is an evocative tour de force. You were criticized, admonished and belittled. Is it possible for someone to be condescending squared? You maintained total composure and continued to elicit additional information and opinion. You aroused in him the passion he feels about this subject. You weren’t critical but you shared from your experience enough to hopefully leave the viewer with the idea - Matt seems reasonable and Tom seems over the top.

Imagine yourself sitting in an emergency room as part of your training to be a psychiatrist. Tom Cruise is brought in by two sheriff’s deputies. His family has gone to a mental illness court and convinced a judge that there is sufficient evidence of a mental disorder and that he could be potentially dangerous to self or others. As a psychiatric resident in training it is your job to evaluate his mental status and decide whether he needs to be committed. During the interview he tells you that you are "glib". He says, "you don’t understand, I do". He tells you he doesn’t agree with psychiatry and never has. He generalizes that antidepressants and stimulants are antipsychotics. He says, "you don’t know the history, I do and there’s no such thing as a chemical imbalance". He tells you that you are irresponsible when you say that some people have been helped by these types of medication.

You, of course know that religion is based on faith. You accept it or you don’t. Philosophy is based on logic - it invites argument and discussion. Science is based on hypotheses/theories and invites data. If new data comes out that doesn’t support the hypotheses/theory further careful research confirms the new data - you modify the theory. An example of science is the blood pressure range that is considered normal. When new data found that systolic pressure of 130-140, or diastolic of 80-90 was associated with increased heart disease the standard for blood pressure was lowered.

Covey talks about principles that are timeless and unassailable. He compares these principles to the direction north. If you and I are lost and we disagree as to which way is north - one of us may be more persuasive or passionate, or we could take a vote but that wouldn’t change the fact that north is north.

An example of an unarguable principle is that prejudice and racism is wrong. Harming someone because of their color, religion, or sexual preference has always been and will always be wrong. Is it possible that I’m wrong? No, I feel passionate about that - not because it’s science but because it is an ethical principle. Tom Cruise treats religion, philosophy, and science as though they all follow the same rules.

Cruise says that psychiatry is pseudoscience, that medication "masks the problem" and that postpartum depression and other mental health problems can be better solved with vitamins and exercise.

Go back to our emergency room scene. You ask Mr. Cruise, "is it possible that you’re wrong?" He would of course reply in an agitated voice, "absolutely not"! An opinion or belief that is adamantly defended as a fact is a delusion.

Now you have a patient who is agitated and delusional. Your next question, "is he likely to do harm to himself or others?" He’s a celebrity. He has a huge fan base. He seems knowledgeable and speaks with authority. There may be many people who might think, "he’s right", and stop their medication. The consequences could be harmful or even deadly.

As a responsible physician your only choice is to hospitalize him. He would obviously refuse medication - especially antipsychotics. He accuses you of being part of a plot to control the world with medication (Brave New World). You know medication would help him. You also know that he will sue you if you force him to take it. You don’t know what to do. A nurse approaches you - "Dr. Lauer, there is a mob of people surrounding the hospital. They have come to set Tom free. They are threatening to break in. They are threatening you".

You decide, "this is not worth it!" He won’t let me treat him anyway. You write the order to let him go. His fans cheer. The crowd dissipates. Fortunately they didn’t know which car was yours so it’s still in one piece. You sit quietly pondering your day. Suddenly you have an epiphany. You go to the director of training. You say, "I am resigning from my psychiatry residency. I’ve decided to become a television news show anchorman!"

P.S. I don’t think he’s really psychotic, but too much narcissism where intelligence and accurate information would serve him better.

In general, when we are aroused, vigilant, or alert and especially when in a “fight or flight” mode our appetite is suppressed.  The brain transmitters serotonin, norepinephrine, dopamine, and histamine decrease appetite, and being in a relaxed vegetative state increases appetite and low blood sugar causing carbohydrate craving. During physical activity appetite suppression occurs, but after activity hormones stimulate appetite to replace the energy  depleted energy sources.  When stress causes depletion of brain serotonin we eat to raise serotonin levels, or stress stimulates appetite by raising cortisol and insulin.  When we’re bored eating raises dopamine levels.

Inactivity as in hibernation causes excessive eating, and eating because of stress or boredom causes excessive intake of calories.  Eating sweets increases insulin, and insulin stimulates low blood sugar, carbohydrate craving and the roller coaster of high blood sugar and low blood sugar levels.  Intermittent acute stress leads to intermittent release of adrenaline, which causes the liver to dump sugar into the blood stream.  This high level of insulin then causes the low blood sugar cycle.  

Weiging the Risk Vs. Benefits of Medications that Affect Weight

Managing stress and eating the right foods is of preeminent importance in combatting the blood sugar cycling.  Further, some medications protect against these negative cycles, while helping you to lose or control your weight.  Many patients gain weight from certain medications, many of these patients feel a lot of guilt and shame because of their weight gain. Lack of self discipline and self indulgence can be a problem but for many patients it’s out of their control.  Some medications change brain functioning, and like a person with genetic obesity, they begin to save every extra calorie as extra fat.  Weight gained on medication sometimes comes off fairly easily with discontinuation of the medicine when no longer needed, but sometimes it seems the medication resets the weight-o-stat making it difficult to return back to previous weight.  

When using medications to lose weight, especially those that work by decreasing appetite or increasing control of eating, it is important to realize that stopping them could lead to the gaining the weight back.  Frequently with a couple of extra pounds for good measure. In other words, there’s no medication that can be taken just to lose weight that effectively helps keep the weight off after it is discontinued.  Because of this,  it only makes sense to use medication  for  weight control if you need it for another condition, like stimulants for ADHD or thyroid medication for low thyroid. Sometimes long term use of pure appetite suppressants is useful just because the risks associated with obesity versus the relative long term safety of appetite suppressants is greater.

Fenfluramine (Pondimin) and d-fenfluramine (Redux) were used for 10 years in France and an additional 3-4 years in the U.S. before discovery that they caused serious complications, especially heart valve abnormalities and/or pulmonary hypertension, and especially when used in combination with phentermine. The reason for this is because Fenfluramine increases serotonin activity and Phentermine increases norepinephrine activity, both which can constrict arteries.  The combination fen-phen was never promoted by any pharmaceutical company but became popular after a paper was published by a doctor who had good success with this combination. After realizing the harmful effects of the combination, Fenfluramine was taken off the market, and since then many law suits have been filed.  Though there is not doubt that this combination can be dangerous, claims of damage most likely exceed actual damage. The lesson learned from phen-fen is the same as the one recently learned from Vioxx. Controlled studies of most medications are relatively short term. There is always some potential risk with the long term use of medications, so it is alway important to ask, “What are the Potential Benefits vs. the Potential Risks”?

Medications and Weight Control From the Worst to the Best

The following medications are commonly used in treating stress disorders.  I will list them starting with the worst for weight management (the one most likely to cause weight gain) and end with the best medication for weight management. 

Clozaril, Zyprexa & Symbyax: Symbyax is a combination of Prozac and Zyprexa, and these three are tied for the most likely to cause weight gain. They block the serotonin receptor associated with satiety. In addition they block histamine, some dopamine, and increase the hormone prolactin.  Both medications are considered a high risk for causing metabolic syndrome, and patients taking these medications should have blood work done regularly to check their lipids and glucose. 

Remeron:  This antidepressant blocks histamine and the satiety receptor, but because it also increases serotonin and norepinephrine, it is not as bad as Zyprexa and Clozaril.

Seroquel:  This atypical medication poses moderate risk for metabolic syndrome and sometimes causes substantial weight gain, because it acts strongest as an antihistamine.

Risperdal: This medication also poses moderate risk for metabolic syndrome. The moderate risk for weight gain may be related to the fact that it has a strong blocking effect on dopamine and is the most likely of the newer medications to increase the hormone prolactin which may contribute to increased appetite.

Lithium and Depakote:  These medication are generally used to treat Bipolar disorder and they pose a moderate risk for increased weight over the long haul.

Neurontin and Anafranil: Neurontin and the tricylic antidepressant Anafranil (Clomipramine) can also lead to significant weight gain over time.

SSRI’s: The most commonly prescribed medications for depression and also commonly used for anxiety are the group referred to as SSRI’s (selective serotonin reuptake inhibitors). These include Prozac, Zoloft, Paxil, Lexapro, and Celexa and low doses of Effexor. The first one (Prozac) has been available since 1987.  Again, to quote Einstein, “keep it as simple as possible, not simpler”. The effect of SSRI’s on weight is complicated because there are 3 different phases in the mechanism of action.  To simplify this process, here is a breakdown of the phases:

    Phase 1  By blocking the reuptake of serotonin into the sending cells, Serotonin builds up in the synapses and stimulates multiple receptors on adjacent cells.  This happens within 24 hours and goes on for several days.
This immediate boost in serotonin can help premature ejaculation, decrease carbo craving and can help premenstrual dysphoric disorder. It can also destabilize bipolar disorder.

    Phase 2  After one week on Effexor, 10 days on Lexapro, 2 weeks on Celexa, Prozac and Paxil or 3 weeks on Zoloft, the effects of the increase in serotonin begin to modulate activity within adjacent cells and will begin to change receptor activity on the sending cells also.  These modulating effects help clinical anxiety and depression.

    Phase 3  The least well understood phase of SSRI activity occurs after several weeks.  Because most controlled studies of SSRI’s only last 6-8 weeks, the information on how they work long-term is limited.  However, the proof that changes continue to take place can be explained when used to treat Obsessive Compulsive Disorder, because it usually takes 12 weeks to see positive changes.  The down regulation of serotonin activity in the brain presumably causes the change, because when serotonin levels increase a messages goes from the brain to the cells and says “we have enough, you can decrease production”.

This mechanism may explain how SSRI’s help anxiety and panic disorder by decreasing serotonin release  where there is hypersensitivity to serotonin.  A common phenomenon seen in patients on SSRI’s has been referred to as “poop out”.  It is not clear whether this is due to excessive down regulation of serotonin release or if it is due to the fact that serotonin causes a decreased release of dopamine  which is the drive and motivation system.  Symptoms of “poop out” include feeling "blah", blunting of normal emotions, sexual dysfunction and weight gain that can occur due to decreased serotonin activity and/or decreased dopamine release.  Because the weight gain doesn’t occur until several weeks or months of being on an SSRI most doctors and patients don’t see the cause and effect relationship.  In some cases, it may be correctible by decreasing the dose.  Unfortunately more often the "blahs" are seen as a return of the depression so the dose is raised, which temporarily helps by raising serotonin but eventually down regulates serotonin even lower.  Sometimes lowering the dose or stopping the SSRI causes return of severe anxiety, OCD, or depression. Adding Wellbutrin XL or a stimulant may help.  Finding a different medication that is as effective for anxiety and depression that does not cause weight gain is difficult, sometimes impossible.

Of the SSRI’s Paxil seems to be the most likely to cause weight gain but any of them can be a problem in the long term.  Effexor XR is mainly an SSRI at 37.5-75mg but does have some norepinephrine effect even at the lower doses, which may help protect against the “poop out” syndrome.  Doses of more that 150mg of Effexor XR and Cymbalta are not as likely to cause long term weight gain presumably because of the combined serotonin and norepinephrine modulation, but weight gain does occur in some patients over the long term.

Abilify and Geodon: These atypicals have the least likelihood of causing metabolic syndrome and tend to be weight neutral. Thin people may gain a little weight on these meds long term, but overall they don’t pose a huge risk of weight gain.

Hormones - Some women gain weight on the hormones estrogen and or progesterone. Estrogen, especially estradiol, may be a particular problem if taken orally.

There are several meds or groups of meds that are essentially weight neutral:

 Meds that can help with weight control:

I have been prescribing medication for stress disorders since 1966, and over the long term, the medications that have been the most helpful in controlling weight are the amphetamines prescribed for ADHD.  Although, when short acting forms of the stimulants are taken they sometimes cause rebound overeating in the evening and this can also occur on days when not taken.  Despite popular belief, the efficacy of stimulants on weight loss is not due to appetite suppression, although appetite suppression occurs when initially starting some stimulants, especially in kids and teens, but I believe it mainly increases control and decreases impulsivity.  This prevents eating out of stress or boredom. I have the most experience and success with Adderall XR, the long acting form, since tablets, the short acting form, are more likely to cause rebound.  Dexedrine and Desoxyn also work, most likely by setting the “weight-o-stat” lower.  The methylphenidate type stimulants are usually not as effective for controlling weight, and the longer acting Concerta (soon to be available), Focalin XR, Ritalin LA, and Metadate CD are better than short acting meds.  Stimulant often increase energy and motivation, which may be another attribute associated with their weight loss efficacy.

ADHD and Weight Issues

ADHD increases an individuals risk of abusing alcohol or drugs because part of the physiology of ADHD is the need for more stimulation than the non-ADHD person. There are several different polymorphic genes more commonly seen in ADHD and nearly all result in low dopamine activity in the brain, specifically the nucleus accumbens.  Every addictive substance or activity increases dopamine, and food is one of the strongest enhancers of dopamine.  For this reason, being ADHD may result in overeating and excess body weight. In one study using Adderall XR in people who were ADHD and obese, they found the obese individuals lost a significant amount of weight. In contrast, people who were ADHD but within normal weight range did not lose a significant amount of weight.

Summary

All of this is not say you need medication to control your weight. But if all of your efforts to maintain not only healthy weight but fitness have failed, you may consider trying medication. When contemplating the use of medication the question is always, “what are the potential benefits vs. what are the potential risks”? Nietzche said “first be a good animal”.  You can’t be mentally healthy if you’re not physically healthy. Two thirds of the U.S. population are overweight.  Being overweight, especially abdominally, increases risk for cardiovascular disease, diabetes, stroke and other health problems, and it’s not so good for self-esteem either.  I believe the main reason weight has become a rising epedemic exists because  we weren’t made for this world.  The world of hunting and gathering that we adapted to was a much more active lifestyle.  Food was not always plentiful, and additives and refined foods did not exist.  People were at the mercy of ice ages, droughts and Mother Nature and our brain conspires to protect us from food shortage by storing energy as fat.  Unfortunately in today’s world, genetics (polymorphism) and behavior (brain plasticity) conspire to make us overweight.  There are behaviors to help you lose and behaviors that make you gain, including ironically, dieting just like there are medications that make it hard not to gain weight and medications that make it easier to lose weight.  It’s more important to be physically fit than to be within the ideal range of body fat, which is where  in realizing your full potential you have to “first be a good animal”.

“Keep things as simple as possible not simpler”     - Albert Einstein

This isn’t rocket science but it is a little complicated. To really understand craving and other issues regarding eating and weight control you have to have a sense of how the brain works. Serotonin is one of the neurotransmitters that enables brain cells to communicate with one another. Brain transmitters are mostly made from amino acids (building blocks of protein). Some of them the body can make but some have to come from the proteins that we eat - another reason that our diets need to include adequate healthy protein.  In response to stimulation nerve cells release various transmitters. These transmitter are like keys that cross the synapses, spaces between nerves and other cells, which plug into receptors, like locks on other brain cells. Sometimes transmitters activate other cells.  While other times they plug up plug up the receptors preventing other transmitters from activating them.  

Serotonin, the oldest and most primitive brain transmitter, is found in single cell organisms. If you recall Maslow’s Hierarchy of Needs and Motivation, you know that the first level is our basic biologic needs. Of these biologic needs, air is the most urgent need, but water and food come in second and thrid.  Produced in the brain stem, serotonin’s primary responsibilities include maintaining homeostasis, or balance, of temperature, blood sugar and many physiologic systems. Serotonin raises when blood sugar increases, and this increase in serotonin stimulates satiety receptors and decreases craving for carbohydrates. Conversely, low serotonin or low serotonin activity due to certain medications working certain receptors leads to carbohydrate, or sugar, craving.  Don’t get between someone with carb cravings and sweets.  It’s dangerous, because the next level up on Maslow’s hierarchy has to do with safety and interaction with our environment.

Another neurotransmitter, norepinephrine (Noradrenaline) releases when changes occur, especially dangers in the environment. Norepinephrine activates our Cortisol stress system muscles for “fight or flight” while releasing adrenaline in the body. This has to do with avoiding danger and basic survival.  Adrenaline causes us to dump sugar from the liver into our blood stream, because sugar provides emergency fuel for muscle activity and is the only fuel for brain cells.  Muscles burn fat and carbohydrate (sugar), but the brain can only burn carbohydrate (sugar).  Norepinephrine increases arousal while decreasing appetite and libido, so it is not surprising that some appetite suppressants work by increasing norpinephrine levels.

Once our basic biological needs are met, and we feel safe, the next level up on Maslow’s Hierarchy is well being.  The next brain transmitter, dopamine drives us to pursue well being.  Every addictive substance increases dopamine.  Dopamine should not be confused with endorphins, which make up the pleasure system, but dopamine activates us and enables us to pursue the things that provide the feelings of pleasure and well being.  Experiments with male dogs found that their first experience with female dogs in heat or their first T-bone steak didn’t release dopamine but did stimulate the endorphin system. The next time they were given a T-bone steak or a female in heat, their dopamine release was off the chart. In other words, Mother Nature provided a brain system that learns where fun and well being are driving us to pursue this pleasure when future opportunity arises.  In another experiment, male rats had all their brain dopamine depleted. They were then given female rats in heat and an All-the-Cheese-You-Can-Eat buffet.  The rats acted completely normal, though, making passes at the females and chowing down on cheese. This meant dopamine wasn’t necessary to enjoy something pleasurable that’s put in your lap.  However, when a barrier was put up separating the food and females on one side and the males on the other,  the rats without the dopamine said, "Screw it, I can’t do it," and the normal rats with dopamine went right over the wall.  

Addiction is a process where the brain is hijacked by some substance(s) or activity and the individual loses control (dyscontrol).

The other primary symptom of addiction is denial to self and/or others.  A book title on alcoholism tells you everything you need to know about addiction: I’ll Quit Tomorrow. Other books, The Selfish Brain and The Craving Brain also paint the picture. The need for well being and the pursuit of pleasure can drive us to love and creativity or lead us down a path of self destruction. Losing a patient to an addiction is a painful and sobering experience. Mother Nature wants us to do things that are pleasurable like eat and have sex.  Though, not necessarily in that order and the survival of the human race depends upon these activities.  

People with ADHD need more stimulation, because their dopamine systems are not as naturally reactive.  People with addictions are low in dopamine in the area of the brain that is activated during pleasurable pursuits, the Nucleus Accumbens. One of the technological advances in the past decade enables us to look at not just brain structure but brain activity. Functional MRI’s are being used more often now because they don’t require radioactive material to be injected. PET scans using radioactive glucose were previously the most useful. Compare the PET scans of a normal individual on a normal day. Notice the dramatic difference between the normal brain and a chronic cocaine user. The cocaine user’s brain is like the rats with their dopamine systems depleted. They are useless unless pleasurable things are put in their lap. They need cocaine or some other powerful stimulant to turn on their brain.

The alcoholic brain is not as bad but still reflects low motivation and drive. The surprising finding is the low brain activity in the Nucleus Accumbens in the individual with obesity. What turns on their brain? The answer is food and especially carbohydrates.  Many experts now show that sugar can be as addictive as alcohol, speed, and cocaine and that addictions overlap to some degree. Periods of abstinence from addictive substances increases cravings, and the longer the abstinence the greater the craving. Sugar addiction increases response to amphetamines and visa versa. Some food addicts eat when bored, others eat when stressed.  Addiction occurs when you lose control meaning: You don’t control it, It controls you.  That’s why the first step in AA is admitting powerlessness, but change starts with awareness. The next step occurs with the decision to change and finally the hard part comes on the day you decide to start the process of change.  Fortunately there are things to help. See Part Six

Wow! That sounds like a copout - “genetic obesity”. But for many people it is reality. I have seen people who have more self-discipline than God (so I exaggerate a little), who have always maintained an ideal weight, and then they get on one of many types of medications and 3 months later they are 10 pounds overweight. That’s not a lack of discipline. That’s a change in brain function. When the “weight-o-stat” in the brain has been set higher, it can be next to impossible to avoid gaining weight.  There’s the constant push to eat more food, the wrong food, and there’s a decrease in metabolism even when you’re sleeping.  The power of the brain and the power of Mother Nature are hard to fight against.

One third of the U.S. population is obese (not just overweight). If you have one obese parent then the incidence of obesity goes up to 50%. If you have two obese parents your chances are over 70%. You might argue that this is due to learned habits regarding types of food, importance of food, learned attitudes about exercise, etc. But this increase in obesity risk is also found in people who had obese biologic parents and were adopted at birth.  The chance of being overweight is clearly influenced by genetics and not just the home you grow up in.  

Several years ago a study was done using identical twin adults. Most of them didn’t live together. Many were living in different cities than their twin sibling. Each person was asked to make no changes in their diet or activity level. The only thing they were to do different is drink a 1,000 calorie supplement at bedtime every night for 3 months. The results of the study were very striking. About one third of the individuals converted basically every extra calorie from their night beverage to extra body fat. So they added 7000 calories per week which meant they gained 2 pounds per week since 3500 calories equals a pound.  They did this for 13 weeks, which meant a total gain of 26 pounds. Another third of the individuals gained about 1/2 that amount, and the final third gained essentially no weight at all. Very interesting.

The most striking finding from this study was that the identical twins were always in the same group. Something in our genetic make-up helps determine what we do with extra calories or what adjustments we make in our overall intake or physical activity in response to an extra 1000 calories daily. I want to be clear that you are not born obese or genetically programmed to be fat. In fact, being born below normal weight and gaining more than the usual weight in the first few months actually increases the risk of obesity. Having the genetic predisposition for obesity, in which you are programmed to store a lot of extra energy, or fat, makes it a lot harder to be lean.  Just as some people are lean no matter what they eat or how physically inactive they are.  Don’t you just hate ‘em! Only Joking.  See Part Five

Many of the important systems in our body like sleep, body temperature, cortisol (stress hormone) and growth hormone go through a 24 hour cycle or Circadian Rhythm. How alert and effective we are is largely determined by where we are in our cycle. Where we are in the cycle is determined by when we are exposed to bright light (usually meaning outside during the day).

Light intensity is measured in lux and during the day the typical intensity is around 10,000 lux. Indoors in our offices the intensity is only about 500 lux or 1/20th that of the outdoors. Our homes are frequently even less. Light intensity is reduced by going through glass like in your car and by sunglasses. You don’t have to be in direct sunlight to get an adequate intensity level - it can be reflected light.

Bright light means, time to be productive, crank up the energy, and get motivated. Decreasing light means time to start shutting it down. Bright light raises serotonin. Low light decreases serotonin. Low serotonin increases carbohydrate craving. Studies are finding that during the shorter, less bright winter months our serotonin levels are lower (in all of us) and we are inclined to eat more carbs. People who are susceptible to certain kinds of depression will actually feel depressed when their serotonin levels are low. Eating carbs raises serotonin.

For many of us it’s not practical to be outside much, especially in the morning. If you go outside at noon and spend an hour or so you may be setting the sleep clock in your brain for 16 hours later, which would be 4 am.  This is probably one of the causes of insomnia for many people. However, there are lamps you can buy that provide adequate light intensity and though they are somewhat costly at about $150, they have come down some since originating. There is some debate as to whether you need full spectrum light including ultraviolet (tanning rays) and infrared (heat rays) or just intense bright (white) light. White light is probably all we need. These lights can be put by the bed to read the morning paper, or on our desks, and the one I have is about the size of a loaf of bread.

These lights may improve energy, mood, and sleep, and bright light can even decrease bingeing in some bulimics. They may replace or lower the dose of antidepressants for some people, and many antidepressants make it hard to lose weight since they can make the brain act as though they have genetic obesity.  Increasing bright light can help with weight control by increasing energy and metabolism and by reducing the need for meds that cause weight gain.

 See Part Four - Genetic Obesity

When people say they’re on a diet they usually mean restricting calories. But the word diet comes from the Greek word diaita, which means “way of life”. The first definition in Webster’s is “what a person or animal usually eats or drinks”. While there is minimal value or even harm to fad diets there is value in changing the way you eat and what you eat.

Dr. Robert Atkins devoted most of his career to research and education about the problems with excess carbohydrates, especially those with high glycemic index (usually sweet and quickly digested) that rapidly raise blood sugar especially when consumed alone (without fat or protein). Rapid increase of blood sugar causes release of large amounts of insulin. This causes two problems. First, insulin results in part of the carbohydrates being converted to fat and second, over time high insulin levels can lead to insulin resistance. The Atkins diet was frequently but erroneously referred to as high protein but is most importantly low carbohydrate. When we eat a meal or snack of primarily protein/fat, (e.g., cheese, eggs, nuts, meat, chicken, fish), instead of releasing insulin we release a hormone called glucagon. Glucagon releases fatty acids from our fat stores as though to say we’re not getting any/much carbos here so we need to burn more fat and/or convert some of the fat to carbos.

Good Diet vs. Bad Diet

Now with additional research we have an improvement on the Atkins diet - the South Beach diet. The South Beach diet emphasizes “good carbs” and “good fats”. Like the Atkins it starts out with more restrictions - not primarily in calories but in carbohydrate choices. The reason both diets start low in carbs is that we have to stimulate our bodies to metabolize fat. Carbohydrates are easier to burn and if they are always available to excess in our diet we don’t fully develop the enzyme systems to burn fat. Once we achieve our goal weight then our selections can be expanded.

A good diet is high in nutritional quality and doesn’t generate increased fat storage. A bad diet is either a short term fad crash program - doing more long term harm than good, or calorie restriction that actually increases our body weight set point in our brain. When in doubt, think about how our ancient ancestors ate for thousands of years - good carbs, unrefined natural grains, fruits and vegetables. They ate good fat, like wild meat that contained Omega 3 fatty acids. We eat fast foods, highly processed foods and fattened up meat high in the bad fats like Omega 6 fatty acid. Unless we live on a farm we should all use supplements to insure adequate quantities of basic vitamins, minerals, and Omega 3 fatty acid. Remember, the original concept of diet is “way of life” and needs to be a balance of good carbs and good fats and adequate protein.

Weight and Fitness: "Let’s Get Physical"

You might be thinking, “I recently read an article that said the number of deaths due to obesity has been exaggerated and that being over weight is not really as bad as we’re being told.” The problem with that article is that it didn’t distinguish between big gut and big butt. Abdominal fat (40”+ waistline for men and 35”+ waistline for women measured at the umbilicus) is a heart risk factor. But even more relevant in that study concluding obese people are no worse off than thin people - the thin people included those that were thin due to chronic illnesses like lung disease and cancer. Studies have proved it is better to be a little overweight and physically fit than thin and out of shape.

One study at the Aerobic Center/Cooper Clinic in Dallas, Texas concluded after extensive testing that people who were over weight but physically fit (i.e., worked out regularly and could walk a brisk 2 miles) were healthier.  Another study by physicians at Johns Hopkins Weight Center found that physically fit overweight individuals were less likely to have high blood pressure or diabetes than overweight individuals who were sedentary. Other studies have found obesity to be a risk factor independent of fitness level.

In general for most people to improve their fitness level they need to lose a significant amount of weight. One technique that I have found useful in disciplining myself to workout every day is keeping a record in my day timer. I convert everything to miles - based on effort level (reflected in estimated average pulse) and duration. For example, tennis singles counts as 4 miles/hour and tennis doubles 3 miles/hour. On days I don’t exercise I put a “R” for rest, which to me means lazy - I hate “R”s. Since I’m competitive, I run in at least 2 races per year, and every day I feel like I’m either staying the same, getting better, or losing ground, which I gauge from my log. Knowing that I’ll be competing in the future provides motivation and discipline for those times when I’m not in the mood.

For me, having a treadmill and other machines in front of a TV is better than driving to a health club.  I tape sporting events or other programs I’m interested in and watch them while I work out. It also helps that my wife and I can work out together - on different machines at different effort levels but still getting to talk and share. Committing to meet someone for any kind of workout helps to prevent last minute procrastination or excuse making.

To be continued…bright light, genetics, meds that help and meds that hurt. See Part Three

When I first heard that Michael Jackson was found innocent I was glad. But didn’t he get away with pedophilia? Not really. He is not a slippery sociopath who manipulates his way out of being responsible for his actions. He is clearly a tortured soul. The ordeal of public shame, humiliation, facing criminal charges and going through this long painful trial didn’t kill him but took years off his life.

Michael Jackson will never again be a super star loved by all. He will always be looked at with different eyes and will always feel he’s being judged if not scorned by many. The evidence for him being a pedophile is too strong to be ignored. But he seems so immature. His sexual interests are probably much more voyeuristic and possibly tactile - I bet any kind of penetration to him would be disgusting.

I don’t feel that he will be a danger to society - those around him will help keep him paranoid enough about aberrant behavior - "sharing his bed" with young boys.

I am also relieved we don’t have to hear every day about how he’s coping with prison. The shower was cold, the towel was rough and gray, his jammies were scratchy, his eggs were staring at him and on and on and on.

The prosecution chose the wrong case and presented it poorly. Money buys the best attorneys. The best attorneys usually win. What else is new?

Thank God it’s over!

 

We can put people on the moon but we can’t help them control their weight. Our population is growing - faster in total mass than in total numbers. A lot of people spend a lot of time, money, and energy dieting - mainly restricting calories. Guess what? They end up heavier than the people who don’t even try to diet. Some people have gone to the extreme of having fat removed by liposuction. Guess what? They gain it all back. What’s the problem? It doesn’t seem fair.

If you are trying to lose weight you have two powerful forces against you: mother nature and your brain. You have almost no chance - unless you understand what’s going on with your basic physiology and survival instincts. The medical problems associated with obesity are too big to ignore. Pardon the pun. In this weeks prestigious Lancet Medical Journal they report a study that obesity (presumably mainly abdominal obesity) causes us to age faster. This results on average in 9 years shorter life span. Obesity is associated with:

2 Greater Risk of High Blood Pressure (40% vs. 20%)

2 1/2 Times Greater Risk of Diabetes (23% vs. 9%)

2 Times Greater Risk of Arthritis (39% vs. 19%)

2 Times Greater Risk of Insomnia (30% vs. 15%)

2 Times Greater Risk of Depression (26% vs. 12%)

Of course with insomnia and depression it’s a chicken and egg problem. Insomnia increases cortisol which can increase weight, but obesity also can cause sleeping problems, especially difficulty with breathing. Remember, to understand the way things work with our bodies and minds you need to understand immediate causality, e.g., carbohydrates increase serotonin and protein decreases it. But even more important than immediate causality is ultimate causality. Why does this phenomenon exist in the world? What is its purpose?

I hate to use the word evolution because for many people - ironically especially in this country - it causes a defensive reaction. It is as though to believe in evolution is to not believe in God. But evolution has nothing to do with religion or faith. Evolution is the process of adaptation over time. This is the same process that leads to resistant strains of bacteria or viruses. If you really want to understand the problem of obesity and weight control you have to understand its role in our adaptation over the millennia.

What exactly is fat?

Why do we have a lot more of it - again especially in this country? Unfortunately one of the reasons is that we Americans diet more than other people anywhere else in the world or in all of recorded history. Fat is the main way we store energy. We also store energy as glycogen made up of glucose (sugar/carbohydrates). But glycogen is stored in water and for every pound of this stored energy we store 4 pounds of water. Not very efficient is it? But because it is more quickly accessible in an emergency we need to have some.

Our total energy stores of glycogen would only get us through one day. If we burn glucose (glycogen) anaerobically (without enough oxygen) as in sprinting or hard weight lifting we burn it many times faster because we’re only partially breaking down the glucose molecules (to lactic acid). Breaking down big molecules to small molecules releases energy. Building up bigger molecules requires energy. A sprinter in a 100 meter dash uses up all their glycogen in 10 seconds. So most of our stored energy is fat, and gemerally women have more of it than men. This is presumably related to hormones and the fact that women provide the nutrition to their babies. In the old days women were usually pregnant or nursing following puberty all the way to menopause.  There is a story, possibly apocryphal, about a group of pioneers traveling to California. They became trapped for months by an avalanche, and of all the pioneers, only the women survived.  

Why do some people store more fat than others?  Why does it matter where you store it? It starts with genetics, and the concept of polymorphism. The survival of the group is enhanced by having a variety of traits. It is better if everybody is not the same. Some people are more naturally lean and therefore more mobile. Other people store more energy as fat - protection against scarcity of food.

What is our “weight-o-stat”?

It seems like simple math: calories in vs. calories out. Too many calories taken in and you gain weight. Burn more calories than you take in and you lose weight. 3,500 calories equals one pound, so 500 extra calories taken in per day (e.g., 3 cola drinks, 3 beers or glasses of wine), and you gain 1 pound per week. An extra five miles or so walking, jogging or the equivalent per day and you lose 1 pound a week. The problem is the formula is wrong. Just as a thermostat will turn an air conditioner or heater on and off to maintain a preset temperature, we have a rheostat (or “weight-o-stat”) in our brain - in the hypothalamus - that adjusts our appetite and metabolism to maintain a preset weight.

You can change the setting but guess what, dieting (in the context meaning calorie restriction) raises your weight setting. It’s all about homeostasis (meaning same state). Our brains maintain our body to electrolyte balance and many other things including our weight. When we restrict calories our survival brain mechanism assumes it means there is not enough food available - if that’s the case we better turn down our metabolism to save energy (i.e., fat) and when food becomes available we better eat as much as possible. This process is also activated when we go several hours without eating. One solution is to eat smaller more frequent meals. Eat at least 3 times per day. If you take in the same total calories in 4-6 meals/snacks you will increase your metabolism. Research has found that people who don’t eat breakfast end up weighing more. Solution - eat breakfast including protein and fat, not just carbohydrates.

Another concept in brain physiology is plasticity. The brain changes in response to experience. Our ancestors were outside all day every day and they were physically active. We on the other hand are mostly indoors and relatively sedentary. We are much more mentally active - which generates a lot of stress. Stress causes release of cortisol (stress hormones) and insulin, both which cause weight gain. Because our exposure to bright outdoor light is miniscule compared to that of our ancestors, the survival brain thinks a lot (or most) of us are hibernating.  What does hibernation mean? To the survival brain it means the environmental conditions are not suitable for productive activity, such as food gathering. The natural response is again to turn down our metabolism to save energy (fat) and when food is available to eat as much as we can.

Low brain serotonin levels cause carbohydrate craving and eating carbohydrates raises our brain serotonin, dopamine, and endorphin levels - we can become food addicts. Bright light and carbohydrates increase serotonin, and vigorous physical activity increases endorphins. So is bright light one of the answers?  Yes. This means being outside more without glass between you and the reflected sunlight (you don’t have to be in the direct sunlight) contributes in keeping your metabolism healthier. If it is impossible for you to incorporate sunlight into your daily routine, full spectrum artificial light can be substituted. (More about this later).

Another behavior that causes weight problems is getting inadequate sleep. You need 7-8 hours of quality sleep per night. Even one night of inadequate sleep raises cortisol levels which can increase weight, so another solution to weight control is getting good sleep every night even with a sleeping pill. (See my article on best sleep meds)

 How do we lower our “weight-o-stat”?

Probably the most important component is physical activity. “But I hate to exercise”, you might say. Well don’t call it exercise, call it work - vigorous house/yard work or call it play - go dancing, but having a vigorous life style tells your brain that you are a mobile person.  Being physically active is the best way to reset your “weight-o-stat” lower.

As hard as it is to lose weight, maintaining weight loss is even harder.

Studies at UCLA and the University of Colorado found that the only thing that correlated with maintaining weight loss was 30-60 minutes per day of vigorous physical activity.  Most individuals have to work up to the ability to sustain physical activity for a period that long at a vigorous intensity.

How do I Start to Become More Physically Active?

First, you need to be checked out by a physician, especially if you have risk factors for heart disease, including high blood pressure, diabetes, high cholesterol, smoking, abdominal obesity, etc. Second, you need to start slow.  One of the most common reasons for failure is too much too soon leading to extreme overuse, soreness and even injury.  Walking is probably the best activity, because it is easier on joints. You don’t have to do it all at once. You can walk around your house or outside while talking on your cell phone, or you can park further away at work or at the mall.

How to Keep the Weight off

A very disenhartening statistic is that 95% of people who lose weight gain it back.  Fortunately someone had scientific curiosity to do a study to find out what is different about the 5% of people woh maintained weight loss.  Dr. Jim Hill at the Center for Nutrition at the University of Colorado has established a National Weight Control Rigistry for the 5% of individuals able to maintain significant weight loss.  To qualify for the study, participants had to maintain a minimum of 30 pounds for at least one year.  There are over 6,000 individuals registered who have maintained a 67 pound average weight loss for an average of 5 1/2 years.  What is different about this uniquely successful group?  CNN did a special report on these individuals in a program called "the 7 Habits of Highly Sucessful Dieters" and here is what they said:

1. Expect Failure and KEEP TRYING! 90% of the Successful Group had failed several times.

2. Don’t Deny Yourself.  This means if you are craving chocolate have some chocolate.  Moderation is the key, and having a little of the things you crave most can prevent binges.

3. Weigh Yourself Often.  For maintenance purposes it is probably helpful to weight yourself at least 3 times per week, but when trying to lose weight it is better to weight somewhat less often.  For example once a week or once every 2 weeks. 

4. Exercise or be Physically Active for 1 hour per day.  This may seem tough, but learning to incorporate physical activity in you life is vital to no only maintaining a healthy weight, but preventing chronic disease and living a higher quality of life.

5. Add Little Bouts of Activity During Daily Routines.  This means taking the stairs instead of the escalator. Pacing the house while you talk on your cell or cordless phone or taking a 5 minute walk on your lunch break.

6. Eat a healthy Diet.  Among other things, eating healthy means decreasing the amount of saturated and trans fat in your diet and eating fewer foods high in simple carbohydrates and more foods high in complex carbohydrates.

7. Eat 5 Times per day Starting with Breakfast.  Eating smaller portions more frequently keeps your metabolism active while maintaining a more stable level of blood sugar which not only keeps you burning more calories, but results in feeling better too. 

 

More about genetics, the best quality foods to eat, and medications that can help will be discussed in Part Two. See Weight Do’s and Don’ts

Metabolic Syndrome was the headline issue at last week’s annual meeting of psychiatrists (APA). What is it? Do you fit the criteria? What can you do about it? What Is It? Metabolic Syndrome is common and it increases your risk of dying from a heart attack by 3 1/2 times. If you or a loved one meet the criteria you can do something about it. I’m sure I have been embarrassing people lately when I whip out my tape measure and measure their waist - at the level of the umbilicus. It turns out that abdominal fat is much more of a health problem (the apples) as opposed to hips and butt fat (pears) which has no increased heart risk. In fact, recently the big "booty" has been in fashion. But a waistline of 35" or more in women or 40" or more in men is one of the 5 criteria for Metabolic Syndrome. (If you have any 3 of the 5 criteria you get the diagnosis). The 2nd factor is increased blood pressure and the standard now is tougher, 130/80. If either systolic is >130 or diastolic is >80 you have elevated blood pressure. The other 3 criteria require a fasting blood test (8 hours with nothing but water). Fasting blood sugar should be 100 or less. Triglycerides should be less than 150 and good cholesterol (HDL) should be 40 or more in men and 50 or more in women. These tests are simple and inexpensive and everyone should know where they stand. A family history of any of these problems increases your risk. Metabolic Syndrome and Psychiatry Why are psychiatrists taking a lead role in expanding public awareness? It turns out that some of the medications we commonly use can increase the risk of any or all of these factors. Three commonly used antidepressants used long term can cause weight gain. Some antidepressants can increase blood pressure but most striking is the group of mood stabilizers called Atypicals. Some of these medications can seriously increase risk of weight gain, increase fasting sugar, increase triglycerides and increase bad cholesterol. A consensus panel including members from the American Psychiatric Association and Endocrinologists convened in November of 2004. They concluded that the medications Clozaril and Zyprexa have a significant risk of causing Metabolic Syndrome. Seroquel and Risperdal have a lesser risk and Geodon and Abilify have the lowest risk. But the FDA is cautioning doctors to screen for these problems and to monitor patients that are on any of the medications from this category. Doctors consider the benefits vs. risks of all the medications that we prescribe. Ironically the "Atypicals" are among our most useful medications. At higher doses they treat the most severe symptoms of mania and schizophrenia, but they are also used for refractory depression and anxiety disorders, including hair pulling and skin picking. In fact, they are the most versatile of any group of medications used for stress disorders. Although we can’t say with absolute certainty that some of these medications are a lot safer than others, the consensus panel and clinical experience strongly suggest that this is the case. It will take large comparison studies to prove it. What Can You Do About Metabolic Syndrome? If you meet criteria for Metabolic Syndrome and you are on one or more of these medications you shouldn’t just stop them. You may want to consider changing if you are on the higher risk medications. Or you may discuss with your physician some of the behavioral and medical options to help reduce your risk. Of course the main cause for the Metabolic Syndrome is our fast food, sedentary life style. Dieting is not the answer - I will address that issue in my next article. Heart disease is by far the most common cause of premature death in men and women. Even if it doesn’t kill you it will lower your quality of life. Don’t wait for your doctor to pull out his blood pressure cuff and measuring tape. Be proactive! Take action now to find out where you stand on all 5 criteria.

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Metabolic Syndrome Criteria (If you answer “yes” to 3 or more of these questions you could be diagnosed with Metabolic Syndrome.) 1. Is your waistline 35" or more (for women) or 40" or more (for men)? (Measured at the belly button, not under the gut!) 2. Is your blood pressure above 130/80? (either systolic is >130 or diastolic is >80) 3. Is your fasting blood sugar above 100? 4. Are your triglycerides above 150? 5. Is your HDL cholesterol less than 40 (for men) or 50 (for women)?