Archive for the ‘Weight Management’ Category
My doctor prescribed methylphenidate for weight gain from Effexor and Lexapro. It makes me sleepy/drowsy. Is there a better drug for appetite suppression?
There are occasional patients who become sluggish or sedated with methylphenidate for reasons that aren’t clear. If you are taking Effexor or Lexapro in the am then these could interfere with the activating effects of the stimulant. Lexapro and Effexor are usually taken in am when first started, but after a few weeks they generally work better taking them at night (Lexapro) or supper (Effexor XR), and this is especially true when combining with stimulants.
See how to take Effexor: http://test.askdrjones.com/2005/12/29/how-to-take-effexor/
The most effective stimulant for appetite suppression and weight loss is Dexedrine (Vyvanse is the most effective form). Adderall is the next best. Methylphenidate is the least effective for appetite/weight.
In general, using stimulants to lose weight needs to be a long term commitment. If the stimulant is stopped the weight is almost always regained – usually with 5 extra pounds for good measure. This is not usually the case if weight gain only occurred on an antidepressant and the antidepressant is no longer being taken. All antidepressants except Wellbutrin are sometimes associated with weight gain, but may not occur until several months of being on the medication. Weight gain is partly due to changing set points for serotonin receptors that help regulate carbohydrate intake. Another possible mechanism is that serotonin up regulation by antidepressants can down regulate dopamine and eating is one way to stimulate the dopamine system. Stimulants, especially amphetamines (Dexedrine, Vyvanse, Adderall) increase dopamine release to counteract the serotonin effect.
When my mother died my doctor prescribed Meridia and I like it very much but recently it has not worked. Is there anything similar to Meridia?
Meridia (sibutramine) is FDA approved for weight loss. It combines the effects of antidepressants like Effexor (at doses of 225mg or higher) or Cymbalta with dopamine effects like stimulants. One possible side effect is increased blood pressure.
Years ago I tried Meridia for several patients and most of them didn’t like it enough to stay on it. If you are looking for a medication that helps with depression and weight loss then I would recommend Wellbutrin. test.askdrjones.com/2005/12/29/how-to-take-wellbutrin/ If you are mostly interested in the mood/anxiety effects I would recommend Effexor XL at least 225mg per day possibly in combination with Wellbutrin. This would closely duplicate the effects of Meridia. An alternative that might even be better would be Effexor and Vyvanse.
We have heard it since we were kids, but do we really need to take our vitamins?
· Homocysteine levels by 17%
· C-reactive Protein Levels by 32%
Chromium is a mineral present in our diet and in trace amounts in our body. Diets lacking in adequate fruits and vegetables may result in low levels of chromium in our system. Controlled studies done in multiple major medical centers found that chromium supplements aid in fat loss and weight control.
It is thought to work by increasing the efficiency of insulin both increasing insulin sensitivity and lowering high insulin. Additionally, it helps decrease carbohydrate cravings and it helps maintain muscle mass even when caloric intake is low. Even when not restricting calories, chromium can help increase lean mass, which results in an increase in metabolism and the body’s ability to burn fat.
When using chromium supplements, it is important to use the piccolinate form, which can be purchased over-the-counter at most pharmacies, grocery stores and health food stores. The recommended dosage is 400 to 600 micrograms taken in the morning every day.
For prescription medications that can help with weight control see: Part Six of Medication and Weight Control
Probably the most common cause of carbohydrate craving is eating too many starches and sweets. Eating or drinking carbohydrates without much protein or fat causes blood sugar levels to go up. How fast sugar levels go up also depends on the Glycemic Index. In general the sweeter and more easily digested the carbohydrate is the more rapidly sugar levels go up and more insulin is released. Sudden surges of insulin cause the blood sugar to be taken up by muscle and liver cells and blood sugar rapidly falls, and oftentimes to low levels, which is known as reactive hypoglycemia. The resulting low blood sugar causes craving for more sweets and starches.
Many people spend the whole day in a yo-yo effect with blood sugar rising and falling. Eating more complex carbohydrates like whole grains, including protein with meals and eating small healthy snacks slows down the uptake into the blood system preventing the yo-yo cycling. Going longer stretches without eating or not eating adequate amounts of carbohydrate can also result in low blood sugar resulting in possible carbohydrate craving. If a very low carbohydrate diet is maintained for several days the body will learn to burn more fat resulting in a build up of ketones that may suppress carbohydrate craving, but carbohydrates should be incorporated back into the diet eventually.
That is how the first stage of the Atkins diet works. The South Beach diet replaces very low carbs with “good carbs” and “good fats”, but the first stage of the South Beach diet also restricts carbohydrates such as fruit – in order to force an increase in the use of body fat for energy. Another cause of carbohydrate craving is using certain medications such as SSRI’s and certain mood stabilizers. See Part Six Medication and Weight Control Diabetes also causes carbohydrate craving even though blood sugar is elevated. The problem in diabetes is that there is either a lack of insulin or a resistance to insulin.
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, which is also coined Syndrome X, is a common chronic condition that disables the body from being able to efficiently burn the food you eat. People with Metabolic syndrome have some insulin resistance leading to high concentrations of glucose and insulin within their bodies. Many people are not aware that they even have this condition and even fewer are aware of the implications and seriousness of the disease, but individuals with this condition have increased risk of:
Peripheral Vascular Disease
Nervous System Disorders
In addition to increased risk of cardiovascular diseases, your risk of actually dying from a heart attack is 3 1/2 times greater. The good news about Metabolic Syndrome is that it is treatable and preventable, since it is largely a product of lifestyle.
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, but since it turns out that abdominal fat is much more of a health problem (the apples) as opposed to hips and butt fat (pears), it is necessary for diagnosing Metabolic Syndrome. Recently the big “booty” has been in fashion, and interestingly butt fat poses no increased heart risk. However, 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.
What are the Determining Factors for Metabolic Syndrome? (You must meet 3 out of 5)?
Waist Circumference greater than 35 inches in women and 40 inches in men.
Blood Pressure) must be greater than or equal to 130/80. Only 1 of the 2 values needs to be elevated to be considered a risk.
Fasting Glucose greater than 100.
Triglycerides greater than 150.
Good Cholesterol (HDL) less than 50 in women and 40 in men.
You can measure your own waist circumference and blood pressure easily, but for the other values you must get a fasting blood test done. This means no food or drink, other than water, at least 8 hours prior to testing. These tests are simple and inexpensive and everyone should know where they stand, so if you have never had your labs done or have not had them within the past year, you should ask your doctor about having them done.
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 atypical medications Clozaril and Zyprexa have a particularly significant risk of causing Metabolic Syndrome. Seroquel and Risperdal have a lesser risk and Geodon and Abilify have the lowest risk of all the atypicals.
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 should consider the benefits vs. risks of all the medications that we prescribe, and 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 useful for treating 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, but 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, it is important to point out the main cause of Metabolic Syndrome related to lifestyle and our world of fast food and sedentary lifestyles contributes to the problem. 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, and consider lifestyle intervention if you qualify.
Our office now offers weight loss and health coaching by providing fitness and nutrition guidance. For more information about lifestyle coaching, contact our office or go to the PATH link.
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.
Weighing 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 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 no 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 medications 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:
- Benzodiazepines - Xanax (Alprazolam), Niravam (Alprazolam in wafer form), Klonopin wafers, Clonazepam, Tranxene, Valium
- Sleep meds – Ambien, Lunesta, Sonata, Rozerem (Although lack of sleep can contribute to weight gain, so it could be argued that the sleep medications help control weight)
- Tenex (Guanfacine)
- Strattera (for ADHD)
Meds that can help with weight control:
- Wellbutrin XL (antidepressant) – not as good for anxiety as SSRI’s. It works by enhancing norepinephrine and to a lesser extent dopamine
- Thyroid - especially Cytomel or Armour, but also Synthroid if at an adequate dose. People occasionally report weight gain on Thyroid and this is presumably due to taking too low a dose.
- Meridia – This medication is approved for weight loss. It has moderate effects on serotonin, norepinephrine, and dopamine. It may increase blood pressure. Effects aren’t dramatic and it is not used very much.
- Xenical - is sometimes helpful. It reduces absorption of part of the fat consumed. It doesn’t help if eating a low fat meal and it can be problematic if you eat a high fat meal as in diarrhea and “accidents”. It is also not used much.
- Phentermine – part of the old fen-phen. It has been around for a long time. It shouldn’t be used unless the plan is to take it long term. It may raise blood pressure and it may cause nervousness or irritability. Some people like it but it’s not used by very many.
- Didrex - is like phentermine and neither one requires a triplicate prescription, which is an advantage.
- Provigil - increases alertness and usually leads to increased activity and more calories burned per day.
- Chromium picolinate 400-600mgm See Chromium Picolinate
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.
If you don’t take care of your body, where are you going to live? – Anonymous
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 epidemic 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”.
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.
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
“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