Credit Andrew Scrivani for The New York Times
Credit Anna Parini
The universal truth of puberty and adolescence is body change, and relatively rapid body change. Teenagers have to cope with all kinds of comparisons, with their peers, with the childhood bodies they leave behind, and with the altered images used in advertising and in the self-advertising on social media.
It may be that the rapid way the body changes during these years can help adolescents believe in other kinds of change, including the false promises that various products can significantly modify their size and shape. A study published last month in the journal Pediatrics looked at two kinds of risky behavior that are increasingly common over adolescence: the use of laxatives for weight loss and the use of muscle-building products.
It used data from an ongoing study of more than 13,000 American children, the Growing Up Today Study (GUTS). The participants’ mothers took part in the Nurses’ Health Study II, and the children were recruited in 1996, when they were 9 to 14 years old, and surveyed about a variety of topics as they grew up.
By age 23 to 25, 10.5 percent of the women in this large sample reported using laxatives in the past year to lose weight; the practice increased over adolescence in the girls, but was virtually absent among the boys. Conversely, by young adulthood, about 12 percent of the men reported use of a muscle-building product in the past year, and again, this increased during adolescence.
So a lot of young women are taking laxatives to try to become very thin, and a lot of young men are using products to help them bulk up and become more muscular. The researchers were interested in how these practices were associated with traditional ideas of masculinity and femininity. They found that, regardless of sexual orientation, kids who described themselves as more gender conforming were more likely to use laxatives (the girls) or muscle-building products (the boys).
“The link is the perception that they are going to alter your weight, shape, appearance,” said Rachel Rodgers, a counseling psychology researcher who studies body image and eating concerns and is an associate professor of applied psychology at Northeastern University.
“The representations of ideal appearance in society are very restrictive and very unrealistic both for men and for women,” she said. “They portray bodies that are unattainable by healthy means.”
Jerel Calzo, a developmental psychologist who is an assistant professor at Harvard Medical School, and the lead author on the study, said that one important aspect of this research was the way it highlighted the vulnerability of those who identify with traditional gender ideals.
“Usually in research we tend to focus on youth who are nonconforming, who we might focus on as more at risk for negative health outcomes, depression, who might be ostracized or victimized,” he said. But there are risks as well for those who are trying to measure up to what they see as the conventional standard.
The GUTS participants were asked to describe themselves as children in terms of the games they liked and the movie and TV characters they imitated, and this was used to score them as more or less “gender conforming.”
The early patterns of gender conformity were significant, Dr. Calzo said, because they were linked to behaviors that lasted through adolescence and into young adulthood. “Laxative use increases with age, muscle-building product use increases with age,” he said. “There is a need for early intervention.”
Chronic use of laxatives can affect the motility of the bowel so that it can be hard to do without them, and overdoses can alter the body’s balance of electrolytes, to a really dangerous extent.
“There’s a lot of shame and guilt for laxative abuse,” said Sara Forman, an adolescent medicine specialist who is the director of the outpatient eating disorders program at Boston Children’s Hospital. And many products marketed as cleanses or herbal teas are not labeled as laxatives, though they contain strong laxative ingredients.
The muscle-building products in the study included steroids, creatine and several others. The risks of steroids are well known, from hormonal imbalances and shrinking testicles to acne and aggression. With other commercial muscle-building products, the risks may have more to do with the lack of regulation, Dr. Calzo said. The products can contain banned substances or analogues of banned substances, like the amphetamine analogue found in popular diet and workout supplements last year.
And of course, the muscle-building products won’t reshape you into the photoshopped model any more than the laxatives will.
As Dr. Calzo says, we need to worry about the vulnerabilities of children who are growing up with issues of gender identity and sexuality. But don’t assume that more “mainstream” or “conforming” kids have it easy when it comes to body image. Parents can help by keeping the lines of communication open and starting these conversations when children are young. We should be talking about the images that our children see, about how real people look and how images are altered.
And that conversation should extend to social media as well; in a review by Dr. Rodgers, increased social media use was correlated with body image worries. “Teenagers are looking at their friends on social media and seeing photos that have been modified and viewing them as something real.”
The other message for parents is about helping to model healthy eating, family meals, realistic moderation around eating and exercising, and to refrain from any kind of negative comments or teasing about a child’s body. “Research has shown people who have more body satisfaction actually take care of themselves better, which suggests that the approach of making them feel bad is actually not helpful,” Dr. Rodgers said.
Every adolescent, across gender, gender identity, gender conformity, and sexuality, lives with a changing body and the need to navigate body image and identity. There are a lot of unrealistic images out there to measure yourself against, and a lot of false promises about how you might get there.
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Credit The author with her daughter, Devon.
“I’m so jealous. You’ve lost so much weight, you look amazing,” a friend says to me. “I’d love to catch the stomach bug this year and lose a few pounds myself.”
I smile. I don’t know what to say.
Since January, one of my 12-year-old twin daughters, Devon, has been in isolation in a Boise, Idaho, pediatric oncology unit receiving chemotherapy for acute myeloid leukemia. Her sister, Gracie, remains behind, in a little town south of Sun Valley. To cope, she has assigned herself as captain of Devo’s Fight Club, a band of peer supporters started with a sweatshirt she designed in the first 36 hours of her sister’s diagnosis.
Their dad and I have been driving the two and a half hours between home and hospital, splitting the week between our daughters, our jobs, middle school’s demands, puberty’s capriciousness, sports, music and running a household that includes cats, dogs, horses, cows and fish.
Devon’s cancer was as random as a dice roll. She had swollen gums for a week and then, a simple blood test to rule out mono instead declared that this sleek, athletic, freckle-faced cowgirl had a rare and often fatal leukemia.
My husband says he has gained weight since Devon’s diagnosis. I have lost weight. A lot. Neither one of us notices the other because we relate over phone or email mostly, and offer a country-style, four-finger half wave from the steering wheel as we blow past each other on the highway between towns.
Over the next 120-mile drive I am perplexed and obsessive.
“I’m so jealous. You look amazing.”
I’m nearly 51 years old and was prepared for the idea that menopause would keep me round despite my best efforts. How much weight have I lost? Was I really that fat before? Should I eat before I get to the hospital or after? The smell of food makes Devon sick. Eating in front of her seems torturous and unfair.
After I arrived at the hospital, a friend stopped by to visit. Before acknowledging Devon, she looked at me. With purrs of envy, she commented on how thin I looked. Again, I was at a loss for words. My daughter was not.
“My mom is not skinny because she worked at it,” Devon told our visitor. “It’s because I’m sick.”
The friend waved it off in the way that one deflects praise of a nice outfit with “this old thing,” and we all moved on. But every time someone notices my weight loss with a tinge of envy it makes me cringe.
Please, I want to tell them, do not admire how thin I have become since my daughter’s diagnosis — unless you are suggesting I look undernourished and want to give me a cupcake. My weight loss is not a goal you should aspire to, nor should it be confused with health and well-being. I was perfectly happy and fit in my pre-cancer-kid size, and a little hurt to hear that this shrinkage that could cost me a lot more than new pants makes me more beautiful than ever.
But what is most painful for me is the collateral damage to my daughters. When they hear that Mom is enviably thin, they hear that this is a reward, a take away for the suffering. That thin is best no matter the circumstances.
Gracie, a minute ahead of her twin, but always an inch and a pound behind, is now getting stretch marks from growing so fast. When her peers note how she “swims” in her choir dress, her mind begins the dance with body consciousness. Weight fluctuations are somewhat inevitable in adolescence and during menopause, but certainly magnified under the circumstances.
Devon’s physical changes are pushed to the bottom of most people’s thoughts now, because in this setting of a hospital room, she’s supposed to look wan and pale. Instead, her inner beauty and sense of humor are noted.
I’ve been sick and thin enough times to know I don’t want to be either. But my girls are facing this for the first time, and the ripple effects of this entire traumatic episode will surface the farther we get from the cancer. Hospital social workers are preparing us to watch for anxiety, regression, depression, eating disorders, apathy and sleeping issues. And signs of cancer returning, of course. And survivor’s guilt in Gracie, which could carve out a whole new emotional journey.
Devon, thankfully, is home now. But I’ve just been told that five months in the hospital have cost Devon nearly a third of her body mass. That her overall strength is that of a 90-year-old, and that after the chemo, her heart, which once pounded fearlessly, is in danger of failing. Her brain is wobbly from the lack of nutrition and her skin is translucent and cold where it once was earthy and warm.
When she returns to school next year, navigating the social riddle of middle school — now half a year behind her peers — and still mostly bald, and undoubtedly still thin, she will return with a self-consciousness she has never known.
Do not covet her thinness. Admire her resilience, and tenacity, and sheer will to live.
And, if you look into her eyes and you can see they are dim from the struggle, a happy-to-see-you smile or just saying nothing at all will do more than you know to help her find her way to loving herself as life has created her in this moment.
If you want to know how someone is, look in their eyes, because their size is not where the information is.
Preschool children who are in bed by 8 p.m. are far less likely to be obese during adolescence than children who stay up late, a study has found. Their risk of teenage obesity is half the risk faced by preschoolers who stay up past 9 p.m.
The research analyzed data gathered on nearly 1,000 children born in 1991 whose bedtimes were recorded when they were 4½ years old, and whose height and weight were recorded at age 15. The children were part of the Study of Early Child Care and Youth Development, done under the auspices of the National Institute of Health’s Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Among the children who were in bed by 8 p.m., 10 percent were obese as teens, compared to 16 percent of those who went to bed between 8 and 9 and 23 percent of those who went to bed after 9, according to the study, published in The Journal of Pediatrics.
The researchers adjusted for such factors as socioeconomic status, maternal obesity and parenting style and still found that the children who went to bed by 8 p.m. were at less than half the risk of teenage obesity as those who were up past 9, said Sarah E. Anderson, the paper’s lead author and an associate professor of epidemiology at the Ohio State University College of Public Health in Columbus.
Although the study does not prove that early bedtimes protect against obesity, Dr. Anderson said, “there is a great deal of evidence linking poor sleep, and particularly short sleep duration, to obesity, and it’s possible the timing of sleep may be important, above and beyond the duration of sleep.”
“This provides more evidence that having an early regular bedtime and bedtime routine for young children is helpful,” she said.
Credit Paul Rogers
To stem the current epidemic of obesity, there’s no arguing with the adage that an ounce of prevention is worth a pound of cure. As every overweight adult knows too well, shedding excess pounds and keeping them off is far harder than putting them on in the first place.
But assuring a leaner, healthier younger generation may often require starting even before a baby is born.
The overwhelming majority of babies are lean at birth, but by the time they reach kindergarten, many have acquired excess body fat that sets the stage for a lifelong weight problem.
Recent studies indicate that the reason so many American children become overweight is far more complicated than consuming more calories than they burn, although this is certainly an important factor. Rather, preventing children from acquiring excess body fat may have to start even before their mothers become pregnant.
Researchers are tracing the origins of being overweight and obese as far back as the pre-pregnancy weight of a child’s mother and father, and their explanations go beyond simple genetic inheritance. Twenty-three genes are known to increase the risk of becoming obese. These genes can act very early in development to accelerate weight gain in infancy and during middle childhood.
In the usual weight trajectory, children are born lean, get chubby during infancy, then become lean again as toddlers when they grow taller and become more active. Then, at or before age 10 or so, body fat increases in preparation for puberty – a phenomenon called adiposity rebound.
In children with obesity genes, “adiposity rebound occurs earlier and higher,” said Dr. Daniel W. Belsky, an epidemiologist at Duke University School of Medicine. “They stop getting leaner sooner and start putting on fat earlier and put on more of it.”
Still, twin and family studies have shown that many children with these genes remain lean. Furthermore, these same genes were undoubtedly around in the 1960s and 1970s when the obesity rate in children was a fraction of what it is today.
So what is different about the 2000s? Children today are surrounded by a surfeit of unwholesome, easy-to-consume calorie-dense foods and snacks accompanied by a deficit of opportunities to expend those extra calories through regular physical activity. And countering a calorie-rich, sedentary environment is now harder than it should be, with the current heavy emphasis on academics, parental reluctance to let children play outside unattended, and intense competition from electronics. All these circumstances may give obesity genes a greater chance to express themselves.
“There is no going back to a world in which calories are scarce and obtaining them is physically demanding,” Dr. Belsky wrote in an editorial in JAMA Pediatrics. “And governments and their publics have shown little enthusiasm for regulations restricting access to palatable, calorie-dense foods.”
Curbing consumption of sugar-sweetened beverages and keeping calorie-dense junk food out of the house and other settings where young children spend time is crucial. This is especially important for infants and children with large appetites that are not easily satisfied.
It’s also essential that parents model good eating habits, experts agree. “If you do it, they’ll do it,” David S. Ludwig, an obesity specialist at Children’s Hospital Boston, said. “Young children are like ducklings, they want to do what their mothers do.”
Equally important, Dr. Belsky said, is “allowing children in institutional settings – in day care, preschool and elementary school – to be as active as they choose to be rather than forcing them to sit quietly in chairs most of the day. Being physically active encourages a healthy metabolism. Active children are not constantly hungry.”
He added, “In the face of the obesity epidemic, eliminating the handful of opportunities for kids to be active during the day is a shame. Sedentary behavior becomes a life pattern.”
Another critical issue is the vicious cycle of overweight that starts with future mothers and fathers who are overweight or obese. “If we want healthy kids, we need healthy moms before pregnancy and during pregnancy,” Dr. Belsky said. “There are multiple pathways by which unhealthy levels of weight before and during pregnancy can influence a child’s weight going forward.”
As Dr. Ludwig explained, “Although genes are not modifiable, the weight of the mother before and during pregnancy is. Excessive weight gain during pregnancy predicts not just the baby’s birth weight but also the likelihood of obesity in middle childhood.”
The father’s weight is also turning out to be important, Dr. Ludwig said. “Acquired factors influence gene expression,” he said. “Being heavy alters DNA in the father’s sperm that changes gene expression and can be passed down to the next generation.”
Most, though not all, studies have linked a longer duration of breast-feeding to a reduced risk of overweight in children. Although Dr. Ludwig said that the effect “is not dramatic,” a more important benefit of breast-feeding may be “exposing the baby to a wider range of tastes based on what a mother is eating. If a breast-feeding mom eats a large variety of nutritious foods, the child is more likely to like them.”
Antibiotics given early in life, however, may counter any potential benefits of breast-feeding for weight gain, a new study found. Researchers at the University of Helsinki in Finland reported that when breast-fed infants are treated with antibiotics, the antibiotics kill off health-promoting bacteria that live in the gut. “The protective effects of breast-feeding against infections and overweight were weakened or completely eliminated by early-life antibiotic use,” the team wrote in JAMA Pediatrics last month.
Even if children have already started on a path of poor eating habits and excess weight gain, Dr. Ludwig said it is not too late to make healthful changes. As founder of the Optimal Weight for Life program and author of “Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/Fake Food World,” he advocates an authoritative, but not an authoritarian, parenting style that eliminates stress and conflict over what and when a child eats.
“Never force food on a child,” he insists. “Stand your ground in a gentle but firm way and be prepared to do a little negotiating. When a child refuses to eat the dinner that’s served, put it away in the fridge to be eaten later. If the child says ‘I’m not going to eat it,’ the response should be, ‘Fine, just go to bed,’ not ‘O.K., I’ll make you mac and cheese.’
“Children should be allowed to control their bodies, but parents have to provide the guidance and control the environment,” Dr. Ludwig said.
This is the second of two columns on childhood obesity. Read the first: “The Urgency in Fighting Childhood Obesity.”
- Supporting Children Who Serve as Caregivers
- 12 Minutes of Yoga for Bone Health
- The Health Benefits of Knitting
Credit Paul Rogers
Life-threatening ailments like heart disease, cancer, stroke and Type 2 diabetes most often afflict adults. But they are often consequences of childhood obesity.
Two new studies, conducted among more than half a million children in Denmark who were followed for many years, linked a high body mass index in children to an increased risk of developing colon cancer and suffering an early stroke as adults. The studies, presented at the European Obesity Summit in Gothenburg, Sweden, this spring, underscore the importance of preventing and reversing undue weight gain in young children and teenagers.
One study, of more than 257,623 people, by Dr. Britt Wang Jensen and colleagues at the Institute of Preventive Medicine, in Bispebjerg, Denmark, and Frederiksberg Hospital in Copenhagen, grouped children according to standard deviations from a mean B.M.I., adjusted for a child’s age and sex.
They found that each unit of increase in being overweight at age 13, generally corresponding to a two- to three-point increase in B.M.I., increased the risk of developing colon cancer by 9 percent and rectal cancer by 11 percent.
The second study, involving 307,677 Danish people born from 1930 to 1987, used a similar grouping of B.M.I. The risk of developing a clot-related stroke in early adult life increased by 26 percent in women and 21 percent in men for each unit of increase in being overweight at all stages of childhood, but especially at age 13.
Although neither study proves that excess weight in childhood itself, as opposed to being overweight as an adult, is responsible for the higher rates of cancer and stroke, overweight children are much more likely to become overweight adults — unless they adopt and maintain healthier patterns of eating and exercise.
According to the American Academy of Child and Adolescent Psychiatry, obesity most often develops from ages 5 to 6 or during the teen years, and “studies have shown that a child who is obese between the ages of 10 and 13 has an 80 percent chance of becoming an obese adult.”
In a study published in 2014 in The New England Journal of Medicine, Solveig A. Cunningham and colleagues at Emory University found that “overweight 5-year-olds were four times as likely as normal-weight children to become obese by age 14.” The study, which involved a representative sample of 7,738 kindergartners, found that the risk of becoming obese did not differ by socioeconomic status, race or ethnic group, or birth weight. Rather, it showed that excess weight gain early in life is a risk factor for obesity later in childhood across the entire population.
Children are generally considered obese when their B.M.I. is at or above the 95th percentile for others of the same age and sex. Currently, about one-third of American children are overweight or obese. By 2012, the Centers for Disease Control and Prevention reports, 18 percent of children and 21 percent of adolescents were obese.
The adverse effects of excess weight in childhood and adolescence don’t necessarily wait to show up later in life. In a review of complications resulting from youthful obesity, Dr. Stephen R. Daniels, a pediatrician at the University of Colorado School of Medicine and the Children’s Hospital in Denver, found that problems in many organ systems were often apparent long before adulthood. They include high blood pressure; insulin resistance and Type 2 diabetes; high blood levels of heart-damaging triglycerides and low levels of protective high-density lipoprotein (HDL) cholesterol; nonalcoholic fatty liver disease; obstructive sleep apnea; asthma; and excess stress on the musculoskeletal system resulting in abnormal bone development, knee and hip pain, and difficulty walking.
Problems of youthful obesity go beyond physical ones. Obese adolescents have higher rates of depression, which in itself may foster poor eating and exercise patterns that add to their weight problem and result in a poor quality of life that persists into adulthood.
In a study conducted in Singapore, researchers reported that “individuals who were obese in childhood are more likely to have poor body image and low self-esteem and confidence, even more so than those with adult onset obesity.”
Another study by Dr. Jeffrey B. Schwimmer of the University of California, San Diego, and colleagues found that obese children and adolescents reported a diminished quality of life that was comparable to that of children with cancer.
Taken together, the data speak to the critical importance of preventing undue weight gain in young children, a task that depends largely on parents, who are responsible for what and how much children eat and how much physical activity they engage in. As researchers from the University Medical Center Groningen in the Netherlands put it, “Early recognition of overweight or obesity in children by their parents is of utmost importance, allowing interventions to start at a young age.” Yet, they found in a study of the parents of 2,203 5-year-olds, “parents underestimated their overweight child in 85 percent of the cases.”
Though it seems logical that parents who think their children are overweight would make a special effort to assure they would “grow into” their weight as they get older, research has shown the opposite. Such children tend to get even fatter, according to findings from the Longitudinal Study of Australian Children reported in April in the journal Pediatrics by Eric Robinson of the University of Liverpool and Angelina R. Sutin of Florida State University College of Medicine.
Even being labeled overweight can itself be damaging and make it harder for children to avoid bad habits, the authors suggested. A 2014 study of girls aged 10 to 19 found that “regardless of actual weight, adolescents who reported having been labeled ‘too fat’ by a family member or peer were more likely to become obese nearly a decade later.”
“I encourage parents to change the environment at home,” Dr. Daniels of the University of Colorado said in an interview. “Without being authoritarian, they should limit high-calorie-dense foods, keep sugar-sweetened beverages out of the house and assure that kids eat the right amount of fruits and vegetables and fewer calorie-dense snacks. Parents also need to be tuned into opportunities for physical activity and set hard-and-fast rules about television and time spent on electronics.”
Following the “5210” daily program endorsed by the American Academy of Pediatrics can help: Aim for five fruits and vegetables a day; keep recreational screen time to two hours or less; include at least one hour of active play: and skip sugar-sweetened beverages and drink water.
- Supporting Children Who Serve as Caregivers
- 12 Minutes of Yoga for Bone Health
- The Health Benefits of Knitting
Credit Andrew Scrivani for The New York Times
My dad’s face lit up as he placed the engraved linen envelope on the table. We were to be guests at the annual pool party at his boss’s home in East Hampton, N.Y. Not only were we invited for dinner, we were invited to stay for the whole glorious weekend.
Our host was my dad’s boss at the McCann Erickson ad agency, where he was a new creative director. Getting an invitation to his house was more than a polite formality; it was an honor. His family lived on Park Avenue, summered in the Hamptons, and lived by the Emily Post school of etiquette. My family never summered anywhere. We didn’t dress for dinner, we didn’t play golf or tennis, and no one in my family had ever studied Latin or carried a monogrammed bag.
While my dad was flattered, the pressure that accompanied the invitation was huge. His weight had ballooned to almost 400 pounds since landing the job, thanks in part to the decadent three-course client lunches and late-night strategy dinners. In the office, people were focused on my dad’s marketing ideas, but in the Hamptons, my dad said appearances were everything, and there was no hiding behind his creative storyboards and well-thought-out campaigns. He would be presenting my mom, my little sister, April, and me, and showing himself in a more vulnerable setting.
The month leading up to the Hamptons trip was filled with anxiety. My mom and I rushed around shopping for the perfect outfits, and my dad, determined to fit into a bathing suit, starved himself, declaring he was on the “Super Model Diet,” which consisted of hot coffee, cold coffee, coffee shakes, coffee bread, unlimited cigarettes and water.
Even at 10 years old, I knew this was not healthy. I had read the many nutrition and diet books that filled every bookshelf in our house. Each week a new diet, a new promise for miracle results.
“All the actresses and dancers in my commercials swear by this one,” my dad said. “They say substituting a zero-calorie cigarette for lunch helps them stay camera-ready,” he added.
Seeing how worried I was, my dad declared he had never had so much energy, begging my sister and me to try to tag him while he ran up and down the halls of our apartment — not even tempted to take a peek at the diet bread I had just baked for him — adding the required three-quarters of a cup of coffee to my ingredient list.
After successfully losing over 20 pounds on the coffee and cigarette diet in a couple of weeks, my dad headed to Mr. Big & Tall on Eighth Avenue for a couple of items before picking up the Hertz Rent-a-Car. My dad was proud of his new lime-green Bermuda shorts with pictures of palm trees. As we drove to the Hamptons in our beach clothes, my parents argued because my mom, who was in charge of directions, kept navigating us the wrong way. When we finally made it off the highway, my parents became calmer, admiring the quaint churches, old houses and windmills planted on village greens.
Arriving hot and disheveled after our long drive, we were greeted by my father’s boss’s wife, who was wearing a neatly pressed blue Pucci cocktail dress, adorned with a single strand of pearls. Tucking her coiffed blond hair behind her ears, she offered us iced tea with orange slices and led us to the back yard. It was like no pool party I had ever been to, and I wondered if anyone was actually planning to swim.
The tables had crystal candlesticks, and waiters were passing around trays of delicious appetizers that I couldn’t pronounce. Among them were rumaki — chicken livers wrapped with chestnuts — and soufflés — puffy omelets loaded with cream. There were plates stacked on top of plates and more silverware than I had ever seen. For dinner, we each had our own one-and-a-half-pound lobster with a side of mussels and white sweet corn from the local farm stand. The kids and the grown-ups were served the same food, but we were not seated at the same table. Parents and kids sitting together was a no-no, according to our host’s son, whom I was placed next to.
The boy, who was wearing a jacket and a tie, was only a year older than I was but had the demeanor of a grown man. When I asked, “Aren’t you hot in that stuffy outfit?” he said that the men in their family “always wear a tie and a blazer at dinner each and every night.” He motioned to me to unfold my napkin and place it over my bare legs, dangling above the ground.
I tried to follow his lead as I saw my dad covered in melted butter and lobster juice. He seemed to be enjoying himself immensely, not shy about asking for seconds and thirds of potatoes au gratin as he forfeited the salad and green beans. “I need to leave room for the good stuff,” he exclaimed, loosening his belt buckle, as the table howled in laughter, watching my dad joyfully dash to the dessert table.
“Go for the gusto, Lerman!” my dad’s boss bellowed, pleased that all the guests started chanting my dad’s award-winning slogan for Schlitz beer.
“You Only Go Around Once in Life, So Grab the Gusto,” they yelled out, encouraging my father to load and re-load his plate.
While I knew that the next day my dad would have regrets, and his vicious cycle of yo-yo dieting would begin again, that night I relaxed, savoring every bite of the succulent meat — hoping my first lobster dinner would not be my last.
Dawn Lerman is a Manhattan-based nutrition expert and the author of “My Fat Dad: A Memoir of Food, Love and Family, With Recipes,” from which this essay is adapted. Her series on growing up with a fat father appears occasionally on Well. Follow her @DawnLerman.
Credit Shiho Fukada for The New York Times
Should weight loss be prescribed as a treatment for breast cancer?
Scientists are recruiting thousands of women for a large clinical trial to find out. The plan is to put heavy women age 18 and older who were recently given diagnoses of breast cancer on diets to see if losing weight will keep their cancer from coming back.
“We have been telling women to do this for years, but we don’t really have definitive proof,” said Dr. Jennifer Ligibel, the principal investigator of the Breast Cancer Weight Loss study, who is a breast oncologist in the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute in Boston.
“If it shows that losing weight by increasing physical activity and reducing calories improves survival, weight loss and physical activity could become a standard part of treatment for millions of breast cancer patients around the world,” Dr. Ligibel said.
In a sense, the clinical trial is long overdue. Once a woman is given a breast cancer diagnosis, obesity is associated with a higher risk for recurrence and lower likelihood of survival in women of all ages, Dr. Ligibel said.
Studies showing that obese and overweight women are more likely to die of their breast cancer date back decades. Just two years ago, a meta-analysis crunched the numbers from more than 80 studies involving more than 200,000 women with breast cancer, and reported that women who were obese when diagnosed had a 41 percent greater risk of death, while women who were overweight but whose body mass index was under 30 had a 7 percent greater risk.
But while those studies showed an association between weight and breast cancer mortality, they weren’t designed to find out if weight loss after diagnosis improves survival or reduces the chance of a recurrence.
“Nobody understands biologically why that is,” Dr. Ligibel said, adding that researchers will be collecting blood samples throughout the trial to track metabolic changes that occur with weight loss. Exercise is also part of the program, and participants will work with health coaches. Fitbit is donating all the products that will be used to track their activity and weight.
The researchers will look at markers of inflammation and metabolism, including levels of insulin, insulinlike growth factor and hormones that regulate fat storage.
“There’s a physiology of obesity that happens in everybody, but many of the changes we see in obesity actually are factors that influence the growth of cancer,” said Dr. Pamela Goodwin, one of the study’s investigators and a professor of medicine at Mount Sinai Hospital in Toronto.
These changes include higher insulin and glucose levels, inflammation and an increase in certain proteins, all of which appear to fuel cancer growth, Dr. Goodwin said.
Obesity “makes a great environment for cancer to get a foothold and progress,” said Barbara Gower, a professor of nutrition at the University of Alabama at Birmingham, who is running a small short-term trial to see what happens when women with ovarian cancer remove all sugar and starches from their diet. “The hormonal messages getting through to cancer cells are that it’s a good time to grow, and the nutrition they need is there, too.”
While a drug may target one of the factors, Dr. Ligibel said, weight loss and exercise may be a more powerful intervention because they lead to a combination of changes. “You have something that can potentially change all of them to a metabolically healthy low inflammatory state,” Dr. Ligibel said.
The trial, which will get underway this summer, will cost an estimated $15 million to $20 million. It’s sponsored by the National Cancer Institute and the Alliance for Clinical Trials in Oncology.
Researchers are recruiting 3,200 women from across the United States and Canada who have a recent diagnosis of Stage 2 or Stage 3 breast cancer. Participants must be overweight, with a body mass index of at least 27, and have hormone receptor positive or triple negative tumors. (Women with another type of breast cancer, known as HER2-positive, will not be included because their prognosis does not appear to be associated with weight, researchers said.)
Participants must be 18 but there is no upper age limit, though they must be able to walk “a couple of city blocks and have a life expectancy of at least five years for other causes,” Dr. Ligibel said.
Volunteers will be randomly assigned to either a telephone-based weight loss program or to a control group for comparison. The goal for those in the intervention is to lose 10 percent of their body weight over two years. Participants will continue to be followed for 10 years to see whether their cancer progresses or not.
Weight loss is challenging, and some cancer treatments cause weight gain. But an earlier trial that tested a similar telephone-based weight loss intervention on a smaller scale found that women with breast cancer lost 4 to 5 percent of their body weight, Dr. Goodwin said.
“Breast cancer is a teachable moment,” she added.
The new trial might help doctors identify which patients will benefit most from losing weight, and whether even moderate weight loss is helpful, said Dr. Clifford Hudis, the new chief executive officer of the American Society of Clinical Oncology and former chief of Memorial Sloan Kettering Cancer Center’s breast medicine service, who was involved in the design of the Breast Cancer Weight Loss trial.
“If I tell patients they need to lose 20 pounds, they just roll their eyes and say it’s impossible,” Dr. Hudis said. “But if we could say they only need to lose 3 percent of their body weight, that wouldn’t be so scary. That’s more manageable.”
There are many compelling reasons to get up out of your desk chair and stand more at work. But weight control is probably not one of them, according to a new study that precisely measured how many calories people burn during everyday office activities.
The new study’s results suggest that engaging frequently in one type of activity while at work may help many of us avoid weight gain. But that activity is not standing up.
Most of us sit more than we should, and a majority of our sitting time occurs at work, since many modern professions are sedentary. Many of us spend six or seven hours tied to our desks each day.
These long, uninterrupted periods of physical lethargy have been linked with increased risks for diabetes, heart disease, premature mortality and, not least, weight gain.
In response, many people, including me, have begun to look for ways to break up our sitting time. We download smartphone apps that chirp and tell us to stand up several times every hour. Health-minded supervisors organize walking meetings, in which employees discuss business while hoofing along hallways. And standing desks have become so popular that the satirical website The Onion has poked fun at users, declaring “Standing at Work Can Increase Coworkers’ Disdain Up to 70 Percent.”
Recent studies indicate that measures that get us off our seats can help us better regulate blood sugar and lessen the risks for diabetes and chronic disease. But more to the point, many of us are rising from our chairs in the hopes that sitting less will help keep our waistlines and nether quarters from spreading.
Surprisingly few studies, however, have closely tracked how many additional calories we burn if we stand up or walk around our offices.
So for the new experiment, which was published this month in the Journal of Physical Activity and Health, researchers affiliated with the Physical Activity and Weight Management Research Center at the University of Pittsburgh rounded up 74 healthy volunteers. Most were in their mid-20s, of normal weight, and with some acquaintance with office life.
These volunteers were randomly assigned to four different groups. One group was asked to sit and type at a computer for 15 minutes and then stand up for 15 minutes, moving around and fidgeting as little as possible.
Another group also sat for 15 minutes, but watched a television screen and didn’t type. Afterward, they immediately moved to a treadmill and walked for 15 minutes at a gentle, strolling pace.
The third group stood up for 15 minutes and then sat down for 15 minutes.
And the final group walked on the treadmills for 15 minutes and then sat.
Throughout, the volunteers wore masks that precisely measured their energy expenditure, which means how many calories they were using.
Unsurprisingly, sitting was not very taxing. The volunteers generally burned about 20 calories during their 15 minutes of sitting, whether they were typing or staring at a television screen.
More unexpected, standing up was barely more demanding. While standing for 15 minutes, the volunteers burned about 2 additional calories compared to when they sat down. It didn’t matter whether they stood up and then sat down or sat down and then stood up. The total caloric expenditure was about the same and was not sizable.
Over all, in fact, the researchers concluded, someone who stood up while working instead of sitting would burn about 8 or 9 extra calories per hour. (Just for comparison, a single cup of coffee with cream and sugar contains around 50 calories.)
But walking was a different matter. When the volunteers walked for 15 minutes, even at a fairly easy pace, they burned about three times as many calories as when they sat or stood. If they walked for an hour, the researchers calculated, they would incinerate about 130 more calories than if they stayed in their chairs or stood up at their desks, an added energy expenditure that might be sufficient, they write, to help people avoid creeping, yearly weight gain.
The upshot of this experiment is that if your goal is to control your weight at work, then “standing up may not be enough,” said Seth Creasy, a graduate student at the University of Pittsburgh and the lead author of the new study.
You probably need to also incorporate walking into your office routine, he said. Maybe “put the printer at the other end of the hallway, or get up to walk to the water fountain every hour or so” instead of keeping a water bottle at your desk.
“Brief periods of walking can add up to make a big difference” in energy expenditure, he said, while standing barely budges your caloric burn.
Of course, standing up almost certainly has other health benefits apart from weight management, Mr. Creasy said, including better blood sugar control and less back and shoulder pain associated with hunching in a chair all day. So don’t dismantle or abandon your stand-up desk just yet. But don’t expect it to counteract that extra cookie with lunch.
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Should parents talk to an overweight child about weight? Or should they just keep their mouths shut?
Parents in this situation are understandably torn. Say something, and they risk shaming a child or worse, triggering an eating disorder. Say nothing, and they worry they’re missing an opportunity to help their child with what could become a serious long-term health problem.
Now a new study offers some guidance: Don’t make comments about a child’s weight.
The study, published in the journal Eating & Weight Disorders, is one of many finding that parents’ careless — though usually well-meaning — comments about a child’s weight are often predictors of unhealthy dieting behaviors, binge eating and other eating disorders, and may inadvertently reinforce negative stereotypes about weight that children internalize. A parent’s comments on a daughter’s weight can have repercussions for years afterward, contributing to a young woman’s chronic dissatisfaction with her body – even if she is not overweight.
“Parents who have a child who’s identified as having obesity may be worried, but the way those concerns are discussed and communicated can be really damaging,” said Rebecca Puhl, deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. “The longitudinal research shows it can have a lasting impact.”
The impact on girls may be especially destructive, she said, because “girls are exposed to so many messages about thinness and body weight, and oftentimes women’s value is closely linked to their appearance. If parents don’t challenge those messages, they can be internalized.”
The new study included over 500 women in their 20s and early 30s who were asked questions about their body image and also asked to recall how often their parents commented about their weight. Whether the young women were overweight or not, those who recalled parents’ comments were much more likely to think they needed to lose 10 or 20 pounds, even when they weren’t overweight.
The study’s lead author, Dr. Brian Wansink, a professor and the director of Cornell University’s Food and Brand Lab, characterized the parents’ critical comments as having a “scarring influence.”
“We asked the women to recall how frequently parents commented, but the telling thing was that if they recalled it happening at all, it had as bad an influence as if it happened all the time,” said Dr. Wansink, author of the book “Slim by Design.” “A few comments were the same as commenting all the time. It seems to make a profound impression.”
Some studies have actually linked parents’ critical comments to an increased risk of obesity. One large government-funded study that followed thousands of 10-year-old girls found that, at the start of the study, nearly 60 percent of the girls said someone — a parent, sibling, teacher or peer – had told them they were “too fat.” By age 19, those who had been labeled “too fat” were more likely to be obese, regardless of whether they were heavy at age 10 or not.
Comments made by family members had even stronger effects than comments made by unrelated people.
Several studies have found that when parents encourage overweight teenagers to diet, the teenagers are at higher risk of lower self-esteem and depression and of being overweight five years later.
Research by Dianne Neumark-Sztainer, a professor at the University of Minnesota, found that when parents talked to their teens about losing weight, teenagers were more likely to diet, use unhealthy weight-control behaviors and binge eat. Those behaviors are less likely to develop when conversations with parents focused on healthy eating behaviors, rather than weight per se.
Harsh comments about weight can send the message that parents are “tying weight to some kind of perception about how the child is valued,” Dr. Puhl said, and that can trigger negative feelings. “The children are internalizing that, and thinking they’re not O.K. as a person. And that is what’s leading to other outcomes, like disordered eating.”
So what’s a parent to do? Do they just stand by while their child gains weight?
Dr. Neumark-Sztainer was besieged by parents asking her this question, and wondering, “How do I prevent them from getting overweight and still feel good about themselves?”
In her book, called “I’m, Like, SO Fat: Helping Your Teen Make Health Choices About Eating and Exercise in a Weight-Obsessed World,” she notes that parents can influence a child’s eating habits without talking about them. “I try to promote the idea of talking less and doing more — doing more to make your home a place where it’s easy to make healthy eating and physical activity choices, and talking less about weight.”
For parents, that means keeping healthy food in the house and not buying soda. It means sitting down to enjoy family dinners together, and also setting an example by being physically active and rallying the family to go for walks or bike rides together. Modeling also means not carping about your own weight. “Those actions speak louder than words,” Dr. Puhl said.
While your children are young, “there doesn’t need to be a conversation at all – it really is just about what’s being done at home,” Dr. Neumark-Sztainer said.
If an older child is overweight, “wait for your child to bring it up, and be there to support them when they do,” she said. “Say, ‘Look, I love you no matter what size you are, but if you would like, I will support you. I suggest we focus not so much on your weight but on your eating patterns and behaviors. What would be helpful for you?’”
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Neighborhoods designed for walking may decrease the rates of being overweight or obese and having diabetes by more than 10 percent, a new study concludes.
Canadian researchers studied more than three million people in 8,777 neighborhoods in urbanized areas of Ontario, ranking them for “walkability” on a 100-point scale that measures population density, numbers of facilities within walking distance of residences and how well connected their webs of streets are.
The study, published in JAMA, adjusted for age, sex, income and other factors, and found that the prevalence of being overweight and obese was more than 10 percent lower in the one-fifth of neighborhoods rated highest for walkability than in the one-fifth rated lowest. Over the 12-year study period, being obese and overweight increased by as much as 9.2 percent in the three-fifths of neighborhoods rated lowest, with no change in the two-fifths rated highest.
The incidence of diabetes was also lowest in the most walkable neighborhoods, a difference that persisted throughout the study.
The authors acknowledge that this was not a randomized trial and does not prove causation. Still, the senior author, Dr. Gillian L. Booth, a physician at St. Michael’s Hospital in Toronto, said that the healthiest neighborhoods seem to be those where cars are not a necessity.
“Walking, cycling and public transit rates were much higher in walkable neighborhoods,” she said, “and that leads to better health outcomes.”
Drinking diet soda and other artificially sweetened beverages during pregnancy is associated with having overweight 1-year-olds, according to a new report.
Canadian researchers studied 3,003 mothers who delivered healthy singletons between 2009 and 2012 and had completed diet questionnaires during their pregnancies. They then examined the babies when they were a year old. Almost 30 percent of the women drank artificially sweetened beverages during pregnancy.
After controlling for maternal body mass index, age, breastfeeding duration, maternal smoking, maternal diabetes, timing of the introduction of solid foods and other factors, they found that compared with women who drank no diet beverages, those who drank, on average, one can of diet soda a day doubled the risk of having an overweight 1-year-old.
The study, in JAMA Pediatrics, found no association with infant birth weight, suggesting that the effect is on postnatal, not fetal, growth. The mother’s consumption of sugar-sweetened drinks was not associated with increased risk for overweight babies.
“This is an association, and not a causal link,” said the lead author, Meghan B. Azad, an assistant professor at the University of Manitoba. “But it certainly raises the question of whether artificial sweeteners are harmless. It’s not time to ban them or tell everyone not to consume them, but there’s no great benefit to consuming these drinks, so there’s no harm in avoiding them.”
Being “overweight” may not be as bad for you as you thought.
People who have a body mass index of 27 — overweight by current guidelines — have the lowest risk of dying early from any cause, according to a new report. That B.M.I. number is higher than in earlier decades.
Danish researchers used data from three time periods: 1976-78, 1991-94 and 2003-13, to calculate B.M.I. and mortality in more than 120,000 people.
In the earliest group, mortality was lowest among those with a B.M.I. of 23.7, within the normal range. In the 1991-94 group, the lowest mortality was in those with a B.M.I. of 24.6, the high end of normal. But in the 2003-13 cohort, a B.M.I. of 27, well into the overweight range by current standards, was associated with the lowest all-cause mortality. The study was published in JAMA.
“The data are straightforward,” said the senior author, Dr. Borge G. Nordestgaard, a clinical professor at the University of Copenhagen. “Thinking about why is more complicated. It may be that we’ve become better at treating cardiovascular risk factors. But I have no data to support this belief.”
In any case, this does not mean that a person of normal weight should aim to gain weight. “If you’re at 27, then maybe you don’t have to worry as much as you did,” Dr. Nordestgaard said. “But that doesn’t mean ‘now I can eat as much as I want.’”
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I recently wrote about a study showing that one minute of intense interval training, tucked into a workout that was, in total, 10 minutes long, produced comparable health and fitness benefits to 45 minutes of more moderate, uninterrupted endurance training.
Readers posted almost 400 comments to the article and flooded the Internet and my inbox with questions and sentiments about extremely short workouts. Given the extent of the response and the astuteness of the questions, I thought I would address some of the issues that arose over and over.
Q. Are high-intensity interval workouts actually better for you than longer, endurance-style workouts — or just shorter?
A. Better is such a subjective word. At the moment, the two types of workouts appear to be largely equivalent to each other in terms of a wide variety of health and fitness benefits.
In the study that I wrote about, “1 Minute of All-Out Exercise May Equal 45 Minutes of Moderate Exertion,” for instance, three months of high-intensity interval training practiced three times per week led to approximately the same improvements in aerobic endurance, insulin resistance and muscular health as far longer sessions of moderate pedaling on a stationary bicycle.
One type of workout was not more beneficial than the other, in other words, but one required much, much less time.
Other studies have generally produced similar results, although, to be honest, the science related to interval training for health purposes and not simply for athletic performance remains scant. An interesting new review of past research to be published in June did conclude that, for overweight and obese children, short sessions of intense intervals may lead to greater improvements in endurance and blood pressure than longer bouts of moderate exercise, although the authors did not discuss how best to get children to complete frequent interval sessions.
The upshot of the available science is that if you currently have the time and inclination to complete long-ish, moderate workouts — if you enjoy running, cycling, swimming, walking or rowing for 30 minutes or more, for instance — by all means, continue.
If, on the other hand, you frequently skip workouts because you feel that you do not have enough time to exercise, then very brief, high-intensity intervals may be ideal for you. They can robustly improve health and fitness without overcrowding schedules.
What about combining brief high-intensity workouts with longer, endurance workouts?
Alternating high-intensity workouts with endurance-style workouts may yield the greatest health and fitness gains of all.
In a 2014 study, a group of sedentary adults began either a standard endurance-training program, in which they pedaled a bicycle moderately for 30 minutes five times a week, or swapped one of those bike rides for an interval session. All of the participants wound up significantly more aerobically fit after 12 weeks.
But the men and women who had completed one interval session per week had developed slightly more overall endurance than the other volunteers. As a result, they had lowered their risk for premature death by about an additional 18 percent, the study’s authors conclude.
Do I have to use a stationary bicycle for interval training?
Most recent studies of high-intensity intervals have involved computerized stationary bicycles because scientists can easily monitor the riders’ pace and intensity. But there is nothing magical about the equipment. The key to high-intensity interval training is the intensity, which most of us can gauge either with a heart rate monitor or our own honest judgment.
For moderate exercise, your heart rate typically should be between 70 and 85 percent of your maximum. (I recently wrote about how to determine your individual maximum heart rate.) This intensity would feel like about an 8 on an arduousness scale of 1 to 10.
During an intense interval, however, your heart rate should rise to 90 percent of your maximum heart rate, or above. Think of this as feeling like about a 9.5 on the 10-point scale. You maintain that intensity for only 10 or 20 seconds at a time, however, followed by several minutes of very easy exercise before repeating the intense work.
Almost any type of exercise can be used for interval training, including running up the stairs in your office’s stairwell during your lunch hour, said Martin Gibala, a professor of kinesiology at McMaster University in Hamilton, Ontario, and an expert on intervals. (His book about the science and practical implications of high-intensity interval training will be published in early 2017.)
Will high-intensity intervals help me to lose weight?
Few studies have yet looked at the long-term effects on body weight of exercising exclusively with high-intensity intervals, although some experiments do hint that high-intensity interval training can reduce body fat, at least in the short term.
In a 2015 study, for example, overweight, out-of-shape men who began either to jog or otherwise exercise moderately for an hour five days per week for six weeks or to complete intensive interval training for a few minutes per week all dropped body fat and about the same percentages of fat, despite very different amounts of exercise. Likewise, a group of women recovering from breast cancer who were assigned either to moderate exercise or brief interval training for three weeks lost comparable amounts of body fat during the study.
But these were small-scale, brief experiments. Whether interval training helps or hinders long-term weight control is still unknown.
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Young rats prone to obesity are much less likely to fulfill that unhappy destiny if they run during adolescence than if they do not, according to a provocative new animal study of exercise and weight. They also were metabolically healthier, and had different gut microbes, than rats that keep the weight off by cutting back on food, the study found. The experiment was done in rodents, not people, but it does raise interesting questions about just what role exercise may play in keeping obesity at bay.
For some time, many scientists, dieting gurus and I have been pointing out that exercise by itself tends to be ineffective for weight loss. Study after study has found that if overweight people start working out but do not also reduce their caloric intake, they shed little if any poundage and may gain weight.
The problem, most scientists agree, is that exercise increases appetite, especially in people who are overweight, and also can cause compensatory inactivity, meaning that people move less over all on days when they exercise. Consequently, they wind up burning fewer daily calories, while also eating more. You do the math.
But those discouraging studies involved weight loss. There has been much less examination of whether exercise might help to prevent weight gain in the first place and, if it does, how it compares to calorie restriction for that purpose.
So for the new study, which was published last week in Medicine & Science in Sports & Exercise, researchers at the University of Missouri in Columbia and other schools first gathered rats from a strain that has an inborn tendency to become obese, starting in adolescence. (Adolescence is also when many young people begin to add weight.)
These rats were young enough, though, that they were not yet overweight.
After weighing them, the researchers divided the animals into three groups.
One group was allowed to eat as much kibble as they wished and to remain sedentary in their cages. These were the controls.
Another group, the exercise group, also was able to eat at will, but these animals were provided with running wheels in their cages. Rats like to run, and the animals willingly hopped on the wheels, exercising every day.
The final group, the dieting group, was put on a calorie-restricted meal plan. Their daily kibble helpings were about 20 percent smaller than the amount that the runners ate, a portion size designed to keep them at about the same weight as the runners, so that extreme differences in body size would not affect the final results.
After 11 weeks, all of the animals were moved to specialized cages that could measure their metabolisms and how much they moved around. They then returned to their assigned cages for several more weeks, by which time they were effectively middle-aged.
At that point, the control animals were obese, their physiques larded with fat.
The runners and the lower-calorie groups, however, although they also had gained ounces, had put on far less weight than the controls. None were obese.
Both exercise and portion control, in other words, had effectively protected the animals against their fated fatness.
But beneath the skin, the runners and the dieters looked very unalike. By almost all measures, the runners were metabolically healthier, with better insulin sensitivity and lower levels of bad cholesterol than the dieters. They also burned more fat each day for fuel, according to their metabolic readings, and had more cellular markers related to metabolic activity within their brown fat than the dieting group. Brown fat, unlike the white variety, can be quite metabolically active, helping the body to burn additional calories.
Interestingly, the runners also had developed different gut microbes than the dieters, even though they ate the same food. The runners had greater percentages of some bacteria and smaller populations of others than the dieters or the control group; these particular proportions of gut bugs have been associated in a few previous studies with long-term leanness in both animals and people.
Perhaps most striking, “the runners showed no signs of compensatory eating or compensatory inactivity,” said Victoria Vieira-Potter, an assistant professor of nutrition and exercise physiology at the University of Missouri who oversaw the study. They didn’t scarf down more food than the control group, despite running several miles every day and, according to the specialized cages, actually moved around more when not exercising than either of the other groups of rats.
In essence, the runners, while weighing the same as the dieters at the end of the study, seemed better set up to avoid weight gain in the future.
Of course, these were rats, which do not share our human biology or our tangled psychological relationships with food and body fat.
This study also involved young, normal-weight rodents and cannot tell us whether exercise or dieting alone or in combination would aid or hinder weight loss in people (or animals) who already are overweight, Dr. Vieira-Potter said. Metabolisms change once a body contains large amounts of fat, and it becomes increasingly difficult to permanently drop those extra pounds.
So better to avoid weight gain in the first place, if possible. And in that context, she said, “restricting calories can be effective,” but exercise is likely to be more potent in the long term and, of course, as common sense would tell us, doing both—watching what you eat and exercising—is best of all.
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For six weeks after delivering my son, I had postpartum thyroiditis. Every afternoon around the same time, I would shake uncontrollably. Anxiety about night feedings and colic (which my son didn’t have) plagued my thoughts all evening. One night while my husband put our son, Jackson, to sleep, my sister put me to sleep. We watched “Romancing the Stone” and she rubbed my back until I drifted off — as if I were the baby.
Moreover, I lost all the baby weight within weeks. At my two-week checkup with my obstetrician, I had lost over 25 pounds. I left that appointment proud, feeling like I could be on the cover of Us Weekly. It must be the breast-feeding, pumping and healthy eating. But I was kidding myself. I breast-fed for all of three days. Sure, I pumped a few bottles, but Jackson got mostly formula. And I wasn’t eating healthfully. I was eating takeout.
About two months after Jackson’s birth, my thyroid burnt out. I didn’t know it at the time, but I later learned that mild hyperthyroidism had given way to Hashimoto’s disease, a potentially more serious, and chronic, thyroid condition in which the thyroid becomes underactive. Over the next few months, I gained about 30 pounds and became extremely lethargic. When I woke each morning, my first thought was: When can I take a nap today?
My body was just transitioning, I thought. And I had a baby now. Most new moms were tired, right? Still I sensed that something intense was happening: I was a different person.
My husband and I had some traumatic fights during those months. I feared that our marriage, the very foundation for loving this new child, was falling apart. He said things like “you’ve changed” and “I can’t live like this anymore.” And the truth was that we really couldn’t live like this anymore.
To make matters worse, I felt that my internist largely dismissed my concerns. He ran my blood work for virtually everything except my thyroid hormone level. We spent the follow-up appointment discussing my elevated cholesterol (also a symptom of hypothyroidism). He offered me Xanax and suggested I talk to a therapist about postpartum depression. Even most friends and family members chalked up these physical changes to the stresses of being a new mom.
Finally, when Jackson was 6 months old, I saw my O.B. again. She, too, bet on postpartum depression but ran thyroid tests to rule it out. I vividly remember when the doctor called with the results, “I’m surprised you can get out of bed in the morning, much less work full-time and take care of a baby.” When I hung up, I wept. I wasn’t losing my mind. I wasn’t just having a hard time adjusting. My thyroid, this little butterfly-shaped gland in my throat that I last worried about in high school biology, was having a hard time keeping my body up and running.
The synthetic thyroid hormone Synthroid helped with losing weight and energy levels. And ever since, I’ve had routine blood work and sonograms to monitor my hormone levels and the small lumps on my thyroid. During my second pregnancy, I saw an endocrinologist and had blood taken every month. My endocrinologist told me that it was important that I have my medication adjusted every month during the pregnancy since the thyroid helps the body stay pregnant.
I was surprised to find that several of my women friends also turned out to have thyroid problems. They tell the same story about discovering their condition either later in life or surrounding a pregnancy. Toni had three miscarriages in one year because of a mismanaged thyroid. Lisa was diagnosed accidentally at 41 when she saw a doctor for a double ear infection and bronchitis. “He felt my neck and noticed that my thyroid was quite enlarged,” she writes.
All the women had weight troubles. Eat less carbs. Exercise more. Take the baby out for walks. You’re getting older so it’s harder. That was the advice I got, along with speeches about the American diet of processed foods and sedentary lifestyle. But I’ve never been sedentary, and becoming a mother certainly didn’t have me sitting on the couch eating potato chips. My friend Jen remembers being patronized at her doctor’s office. “I was literally patted on the leg and told it’s just going to be hard for you to lose weight, dear,” she said. Her endocrinologist prescribed her a medication for diabetes and told her to eat 1,100 calories a day.
My takeaway from those six months is this: Even amid the huge life change that is motherhood, I knew something was really wrong with my body. And if I had put my health first, I would’ve figured it out much faster and with much less heartache. But prioritizing yourself isn’t something many new moms do very well.
Of course the early weeks with a newborn are exhausting for all parents, but if you don’t start to feel normal once the baby’s sleep schedule stabilizes, it’s worth getting your thyroid checked. A simple blood test can make all the difference.
Kristin Sample is a writer, teacher and dancer. Her novel “North Shore South Shore” is available on Kindle. Follow her on Twitter and Instagram @kristinsample or check out her blog, kristinsample.com.
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There was no reason for Jennifer Morton to move to Utah, except one: It was the place she lost 40 pounds.
In 2009, Ms. Morton was working 90-hour weeks as the director of learning at a large company outside Louisville, Ky. She traveled 80 percent of the time, and her weight shot up. Panicked and exhausted, she quit her job and checked into Fitness Ridge (now called Movara Fitness Resort), a weight-loss and fitness retreat in southern Utah.
She ended up staying a month.
“All of a sudden I was in a place where everybody was like me,” said Ms. Morton, 40. “It felt like home.”
Five weeks later, it really was: She packed up her belongings and settled into a house less than a mile from the resort in the town of St. George. Not long after, she began teaching classes at Movara on emotional eating and food addiction, guiding clients through their own body battles.
“It just made sense to do this,” Ms. Morton said. The low cost of living was appealing, as was the natural beauty. But most importantly, she could continue the healthy lifestyle she had embraced.
“At the resort, the way you feel about who you are is so important to protect that you’re willing to stay in that environment to make sure it sticks,” said Ms. Morton, who began doing triathlons after her stay. “If you find your best self somewhere, you definitely don’t want to leave it.”
People like Ms. Morton are adopting a model familiar to those fighting substance abuse, who are often encouraged to change their environments and relationships post-rehab in order to “stay clean.” (Minnesota, for example, is half-jokingly referred to as “Minnesober” because of the large number of rehab centers there and the many people in various stages of recovery, who often remain in the state after treatment.)
“Addiction is a lifelong problem that people have to deal with, and it’s the same with weight,” said Dr. William Yancy, director of the Duke Diet and Fitness Center in Durham, N.C. “Even if they reach their goal, it’s something they need help and support with.”
“It speaks to the power of the proverbial ‘toxic food environment,’” said David Sarwer, director of the Center for Obesity Research and Education at Temple University’s College of Public Health. “When we’re in our normal day-to-day routines, and those routines have become second nature to us, there are countless negative influences on our eating habits and sedentary behavior that contributes to weight gain.”
Relocating, he said, offers an opportunity to create new habits. “In these cases, people have the opportunity to make a significant commitment to health and well-being to live in a geographical location that promotes health,” he said.
From 2007 to 2012, Marjorie S. Fine went twice a year to the Duke diet and fitness program. She would lose about 30 pounds during her two-month stay, and regain half when she returned home to Miami. “I would chip away at the weight, but never really be anywhere near 99 percent successful,” said Ms. Fine, 69.
Late in 2015, she and her husband moved full-time to Durham (once called the “diet capital of the world” because of the number of weight-loss facilities there). She exercises and eats lunch at Structure House, a residential program in town, six days a week, and attends individual therapy and weekly Overeaters Anonymous meetings there.
“As with any other addiction, you have to work on it on a daily basis,” said Ms. Fine, who has now lost 65 pounds and hopes to lose another 40.
“It’s very important to have that shared experience and problem solve together,” said Catherine J. Metzgar of the University of Illinois at Urbana-Champaign, the lead author of a study that found social support and being accountable to others helped some women lose and maintain weight loss. “Having your family and others in your social circle buy into what you are doing is also important.”
Cindy MacKenzie, 62, a former teacher and self-described yo-yo dieter, retired with her husband in 2015 to southern Utah. The couple purchased a home about a five-minute drive down the road from Movara, where Ms. MacKenzie used to go for annual weight-loss visits.
“We have definitely bought into the program,” said Ms. MacKenzie, who still regularly attends the resort. Back in Silicon Valley, where they used to live, “we would go out to eat all the time, we would drink. Here, there are no threats, no temptations.”
“If you’re living in a community where every single one of your friends and family members is devoted to overeating and an unhealthy lifestyle or to misusing various drugs and alcohol, it’s really hard to change in that environment,” said Maia Szalavitz, a former heroin and cocaine addict and author of the book “Unbroken Brain: A Revolutionary New Way of Understanding Addiction.”
On the other hand, surrounding yourself with too many people with similar issues can be risky. “A lot of people get into a very closed world that’s kind of limited,” she said. “Sometimes you make each other better, and sometimes worse.”
Of course, most of us cannot afford to uproot our families, lives and jobs in the name of healthy living. (Structure House’s base price for new participants, for example, is $10,500 for a four-week stay.) And even if we could, we bring our struggles with us. (In bumper sticker terms: “Wherever you go, there you are.” )
Jean Anspaugh, 62, lost 100 pounds at the Rice House program in Durham, where she stayed for seven years, renting an apartment nearby and taking odd jobs to pay the costs. She figured she would “stay thin forever.” But she didn’t. Work, bills and relationships took their toll, and she got “mainstreamed back into the dominant culture, which eats all the time.”
“Nobody realizes how hard it is to lose weight and keep it off,” said Ms. Anspaugh, a folklorist in Fairfax, Va., and author of “Fat Like Us.” “It’s a full-time job.” She has regained some of the weight but still feels that Durham, “the place where the magic happened,” is home. “I miss the mind-set,” she said. “I miss my tribe.”
Ms. Morton, too, acknowledged that moving to Utah wasn’t a panacea. “You still have to do the same things: build your community, get involved, find the people you like,” she said. And she now is wrestling with “emotional management — meaning, working through the parts of myself that will keep me successful over the long run.”
Still, she has no plans to leave.
“Weight and fitness is definitely on the forefront of my mind, so I think it keeps me accountable because I have to face it every day,” she said. “Also, it helped me realize — we’re all the exact same. We are all dealing with the same set of four or five problems; they just manifest differently in each one of us. It has helped me on my weight management program, and also on my journey to be a good human.”
Credit Robert Ormerod for The New York Times
Many experts believe Type 2 diabetes is an incurable disease that gets worse with time. But new research raises the tantalizing possibility that drastic changes in diet may reverse the disease in some people.
Recently, a small clinical trial in England studied the effects of a strict liquid diet on 30 people who had lived with Type 2 diabetes for up to 23 years. Nearly half of those studied had a remission that lasted six months after the diet was over. While the study was small, the finding offers hope to millions who have been told they must live with the intractable disease.
“This is a radical change in our understanding of Type 2 diabetes,” said Dr. Roy Taylor, a professor at Newcastle University in England and the study’s senior author. “If we can get across the message that ‘yes, this is a reversible disease — that you will have no more diabetes medications, no more sitting in doctors’ rooms, no more excess health charges’ — that is enormously motivating.”
It is not the first time that people have reversed type 2 diabetes by losing a lot of weight shortly after a diagnosis. Studies have also shown that obese individuals who have bariatric surgery frequently see the condition vanish even before they lose very much weight.
But the new study, published in Diabetes Care, proved the reversal after diet can persist for at least half a year as long as patients keep weight off, and can occur in people who have had the disease for many years.
The researchers followed the participants after they had completed an eight-week low-calorie-milkshake diet and returned to normal eating. Six months later, those who had gone into remission immediately after the diet were still diabetes-free. Though most of those who reversed the disease had had it for less than four years, some had been diabetic for more than eight years.
Credit Robert Ormerod for The New York Times
When Allan Tutty, 57, learned five years ago that he had Type 2 diabetes, he asked health care providers if there was a cure. “It was a case of, look, you’ve got it, deal with it, there’s no cure,” said Mr. Tutty, who manages a home for people with brain injuries in Newcastle.
Later, Mr. Tutty spotted a notice recruiting volunteers for a diabetes study that asked, “Would you like the opportunity to reverse your condition?”
Mr. Tutty said he jumped at the chance, becoming one of 30 men and women ages 25 to 80 to sign up. Mr. Tutty was one of 13 participants whose fasting plasma glucose dropped, and during the six-month follow-up remained below the seven millimole per liter (or 126 milligrams per deciliter) that defines diabetes. Although Mr. Tutty completed the study nearly three years ago, his fasting blood sugars continue to range from 5.2 to 5.6 mmol/L, he said.
Type 2 diabetes develops when the body cannot use insulin properly or make enough insulin, so the body cannot properly use or store glucose (a form of sugar) and sugar backs up into the bloodstream, raising blood sugar levels. In the United States, some 8.9 percent of adults 20 and older have been found to have diabetes, and health officials estimate that another 3.5 percent have undiagnosed diabetes.
Although no one knows exactly why the diet appeared to reverse diabetes, Dr. Taylor said the explanation may be related to how the body stores fat. Excess fat in the liver can spill into the pancreas, inhibiting insulin secretion and the liver’s response to insulin, resulting in insulin resistance and diabetes.
Going on a very-low-calorie diet may allow the body to use up fat from the liver, causing fat levels to drop in the pancreas as well. That “wakes up” the insulin-producing cells in the pancreas, normalizing blood glucose levels.
While some previous studies have shown that blood sugars can normalize after significant weight loss, endocrinologists said they were impressed by the persistence of the lower blood sugar levels for months after the diet.
“Decreasing caloric intake for any reason brings with it a rapid improvement in glucose control,” said Dr. Robert Lash, the chairman of the Endocrine Society’s clinical affairs committee and a professor of internal medicine at the University of Michigan. “What’s exciting here is that the improvements in glucose control persisted when the participants went back to eating a diet with a normal number of calories.”
While the research suggests the potential for a cure, questions remain about how long the effect will last and whether it can work for the typical patient with diabetes.
“It’s definitely doable,” said Dr. George King, the chief scientific officer at Joslin Diabetes Center and a professor at Harvard Medical School. The question, he said, is: Can people maintain the weight loss and “continue to have this reversal for many, many years?”
“That is the difficult part,” he added.
Dr. King said that even short-term remission would reduce or put off some of the serious complications associated with diabetes, like nerve damage, kidney damage, loss of vision, heart attacks and strokes. Yet structured weight loss programs are expensive and often not covered by insurance, and physicians — who are often not well-versed in nutrition — may not take the time to counsel patients about diet, Dr. King said.
The participants in the Newcastle trial, who ranged from overweight to extremely obese, were told to stop their diabetes medications and start a 600- to 700-calorie-a-day diet, consisting of three diet milkshakes a day at mealtimes and half a pound of nonstarchy vegetables a day.
Mr. Tutty, who weighed about 213 pounds before the trial, lost a little more than 30 pounds, the average weight loss in the trial. The people in the study most likely to respond to the treatment were in their early 50s on average and younger than the nonresponders, and they had had diabetes for fewer years. The responders were also healthier before the trial: They had been taking fewer medications than nonresponders, had lower fasting glucose and hemoglobin A1c before the trial, and had higher baseline serum insulin levels. Three of those who went into remission had lived with diabetes for more than eight years.
Many of the responders are still in the prediabetes zone and at risk for developing diabetes, Dr. Taylor said. “It’s not fair to say they were completely normalized, but they’re at a level of blood sugar where we don’t expect to see the serious complications associated with diabetes,” he said. “That’s why it’s such good news.”
The big challenge for dieters was returning to normal eating, and trial participants received intensive counseling from a researcher on the team about how to eat after ending the liquid diet, Dr. Taylor said.
“They would describe going back to the kitchen and almost having a panic attack,” he said. “We used that as an opportunity to instill new habits, and were very directive about how much to cook and how much to eat.”
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On Thursday we challenged Well readers to take on the case of a 59-year-old woman who had not been able to stop gaining weight. I presented the case as it was presented to the doctor who made the diagnosis and asked for the final piece of data provided by the patient as well as the correct cause of her symptoms.
I thought the tough part of this case was something that few of my readers would have to contend with – that her complaints and past medical history were quite ordinary. Like many of us, she was overweight and she came to the doctor because she had difficulty losing weight. In the background she also had high blood pressure, obstructive sleep apnea and low back pain, knee pain and leg swelling. These are some of the most common reasons patients seek medical attention. Although her problems were run of the mill, the cause was not. And many of you had no difficulty spotting this zebra.
The correct diagnosis was…
The last piece of data, provided by the patient, was a photograph taken several years before. It was only by seeing the changes in the patient’s face that had occurred over the past few years that the doctor recognized that this patient’s problem was unusual.
The first person to make this diagnosis was Dr. Clare O’Connor, a physician in the second year of her training in internal medicine. She plans to subspecialize in endocrinology. She says it was the swollen legs that didn’t compress that gave her the first clue. Well done.
Acromegaly is a rare disease caused by an excess of growth hormone, usually due to a tumor in the pituitary gland of the brain. The disease’s name, from the Greek, serves as a fitting description of the most obvious symptoms: great (mega) extremity (akron). The tumor secretes a protein called growth hormone that signals the liver to produce a substance called insulin-like growth factor 1, or IGF 1, which in turn tells cells throughout the body to start proliferating.
With the flood of IGF 1, soft tissues throughout the body begin to grow. This becomes visible as hands, feet, cheeks, lips and tongue enlarge. Although these are the changes that can be observed, other structures are similarly affected, causing cardiac problems (usually enlargement of the heart muscle or valves), respiratory problems (usually obstructive sleep apnea), metabolic problems such as diabetes, and excessive sweating and musculoskeletal problems such as carpal tunnel syndrome. The patient had all of these problems except diabetes.
Eventually, usually after years of untreated disease, bone will start to expand as well. This patient’s feet weren’t just swollen, the bones themselves were larger. The difference between the patient’s face in the doctor’s office and that in the picture wasn’t due to the years that had passed but to changes in their very structure. The lips, tongue and nose were broader. The bone of the chin was thicker, the cheeks wider.
Worth a Thousand Words
Once Dr. Donald Smith, the doctor who saw the patient at Mount Sinai Hospital, heard the summary of the case from the doctor in training who saw her first, he turned to the patient. Did she have anything to add?
She thought for a moment and then said, “Let me show you a picture.” She reached over to her purse and pulled out her driver’s license. That’s me just a few years ago, she told him. The picture showed an attractive middle-aged woman who bore little resemblance to the one before him. That’s when Dr. Smith knew that there was something more than simple weight gain at work.
It wasn’t low thyroid hormone causing this, he decided. A patient gaining this much weight due to thyroid disease should have other symptoms typical of thyroid disease as well.
Two other possibilities came to mind. Both were diseases of hormonal excess; both were characterized by rapid weight gain. First was Cushing’s disease, which is caused by an overproduction of one of the fight-or-flight hormones called cortisol; the second was acromegaly, which is caused by too much growth hormone.
How the Diagnosis Was Made
Dr. Smith looked at the patient, seeking clues that suggested either condition. He saw that just below her neck on her upper back was a subtle area of enlargement. This discrete accumulation of fat, known as a buffalo hump, can occur with normal weight gain, but it is also frequently seen in patients with Cushing’s disease.
Do you bruise more easily these days, he asked? Cushing’s makes the skin fragile, and it bruises more easily. No, she hadn’t seen that. Did she have dark purple stretch marks on her stomach from the weight gain? The rapid expansion of the abdomen can cause the fragile skin of these patients to develop stretch lines. No, again. So maybe not Cushing’s.
Have you changed shoe sizes in the past couple of years? the doctor asked. Enlargement of the hands and feet is rare but is the hallmark of acromegaly. Yes, she exclaimed. Just a few years ago she wore a size 8. Now she can barely squeeze into a size 13.
Can I look at your teeth, the doctor asked. He saw that there were gaps between most of her teeth. Was that new? Yes. She had been told that was from gum disease. “You don’t have gum disease. You have acromegaly,” the doctor declared confidently. The new spaces were evidence that her jaw had, like her feet, simply grown larger.
Dr. Smith referred the patient to Dr. Eliza B. Geer, an endocrinologist who specialized in diseases of the pituitary at Mount Sinai Hospital. She measured the level of growth hormone and IGF 1. Both were dramatically elevated. The final test was a glucose tolerance test. A sugary drink would normally suppress IGF 1. The patient’s level was unaffected. That confirmed the diagnosis; she had acromegaly. An M.R.I. scan revealed a tiny tumor on the pituitary, and a few weeks later the patient had surgery to remove the growth.
The Real Mystery
From the first moment I heard of this case I wondered, how could this have been missed? How could a woman go through such dramatic changes and not have her doctor think: acromegaly.
And yet this is a diagnosis that is frequently missed. The average time to diagnosis is five years. And, like this patient, most people with acromegaly are seen by many doctors before the correct diagnosis is made. Indeed, it is said that patients are more likely to be diagnosed by a doctor who has never seen them before than by their longstanding regular doctor – because these changes take place slowly, over years.
But in wondering about this missed diagnosis, I suddenly recalled a missed case of my own just over a decade ago. I was a few years into my practice and had a patient who had the same string of common problems: She was overweight, and she had high blood pressure, obstructive sleep apnea, spinal stenosis and carpal tunnel syndrome. She worked hard to keep all of her medical problems well controlled. She was really a model patient. One week she was seen by one of the trainees in my practice. That doctor took one look at her and saw what I had not. She ordered the test for acromegaly. Like this patient, my hardworking patient had clearly had acromegaly for years.
Missing the Diagnosis
How do we miss this disease? Acromegaly manifests itself in two ways. First, by causing a series of ordinary diseases that are among the most common problems that bring patients to the doctor. Most patients with these medical problems don’t have acromegaly.
It’s the second manifestation that may be the real issue for me and other doctors. The disease clearly causes changes in the face. The picture in my head of what acromegaly looks like is based on two actors affected with the disease: Richard Kiel, who played the murderous character Jaws in the James Bond movies, and Ted Cassidy, who played Lurch in the television series “The Addams Family.”
But those images are misleading. These actors had acromegaly during childhood, before their bones had stopped growing, and so the effect of the disease was profound and permanent. Their bodies were literally shaped by the disease. Mr. Kiel was 7-foot-2. Mr. Cassidy was 6-foot-9. Both had an exaggerated version of the facial changes of bony overgrowth, with prominent brows and massive jaws. Because of these dramatic changes, those who get the excess growth hormone before puberty are said to have gigantism, rather than acromegaly.
In contrast, when the disease strikes during adulthood, the bones have very limited ability to grow. The changes are thus more subtle and so, often enough, the diagnosis is missed.
This patient decided to show her doctor the photograph after a remark made by her sister. What’s happened to your face? she asked. That’s when the patient began to believe that the distressing changes she saw in the mirror weren’t just from getting older.
How the Patient Fared
The patient had surgery to remove the tumor nine months ago and now feels great. She had attributed so many of her symptoms – the fatigue, the sweatiness, the pain in virtually every joint — to getting older and heavier. But it’s clear now that they were caused by the hormonal excess.
The bony changes will be with her forever (goodbye, size 8 feet). But she’s happy that she can see her ankles once more and will finally be able to lose some weight.
The Challenge: Can you figure out why a 59-year-old woman keeps gaining weight?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a woman who has been gaining weight despite years of work to lose it. Was this, as the patient worried, a result of menopause, or was there something else going on? She was frustrated and aggravated, but should she be worried?
Below I provide much of the information available to the doctor who made the diagnosis. Regular readers may assume that this, like so many of my cases, is the zebra. But is it? The first reader to offer the correct diagnosis, along with the missing piece of data that helped the doctor get there, will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real life case.
The Patient’s Story
“I just can’t seem to lose weight,” the 59-year-old woman said quietly. She’d done everything, she told the young doctor. Weight Watchers. Exercise. She drank more water. She ate more vegetables. She tried eating less fat, then only “good” fat. She kept food diaries, downloaded calorie counters. She’d done it all.
And not only was she not losing weight, these past few years she just kept on gaining. Despite all of her hard work, she’d put on maybe 50 pounds in the past year.
More Than Skin Deep?
She decided to go to Dr. Donald Smith, an endocrinologist at Mount Sinai Hospital in New York. She’d seen the doctor years earlier in a documentary on weight loss surgery on TV. The fact that he was an endocrinologist made him a doubly good choice for her because she worried that the real cause of her weight gain was hormonal.
She first met with the doctor in training who was working with Dr. Smith as part of her endocrinology fellowship. She’d never been skinny, she told the young doctor. But she’d never been heavy like this before, either. She was 5-foot-4, and throughout her 20s and 30s she’d weighed 170 to 180 pounds. It was a comfortable weight for her, easy to maintain. Then, in her mid-40s, weight maintenance was no longer easy and the pounds started to accumulate, slowly at first, then rapidly.
She was considering bariatric surgery, but first she wanted to know, was this just a consequence of menopause? She had thyroid disease and had been on the same dose of medication for years. Could something have happened to her body so that the drug was no longer working for her?
The Patient’s History
Did she have any of the symptoms associated with a low thyroid hormone level, the young doctor queried? Fatigue? Oh yes, these days she always seemed to be tired. Had she seen any changes in her hair or skin? No. Any constipation? No. Do you get cold more easily these days? Never. Indeed, these days she usually felt hot and sweaty.
Any other medical problems, the doctor asked?
Oh sure, she replied promptly. She had high blood pressure and high cholesterol — both well controlled with medications. She also had obstructive sleep apnea, a disorder in which the trachea, the breathing tube connecting the lungs with the nose and mouth, collapses during sleep, causing the sufferer to stop breathing and awaken many times throughout the night. But she had a machine that helped keep her trachea open and used it every night.
In addition, she had low back pain from a place where her spine had become narrow. She had knee pain and carpal tunnel syndrome. She didn’t smoke or drink and had worked as a nurse until the pain in her back, legs and hands forced her to retire early.
Big, Bigger, Biggest
After a quick examination, the young doctor stepped out of the exam room. She returned a few minutes later with Dr. Smith. He looked to be in his mid-60s and had a kind face and friendly smile, just as the patient recalled from the TV show she’d seen him on. The young doctor briefly summarized what she and the patient had talked about. When she finished, Dr. Smith turned to the patient and asked if there was anything she’d like to add.
She thought for a moment. All she could say, really, was that she didn’t understand why she was getting so much bigger. She was gaining weight, but it wasn’t just that. Her legs and feet were huge. She used to have nice ankles, but now you could hardly see them. Her regular doctor, a cardiologist, gave her a diuretic, but it really hadn’t done a thing, she told him.
Not Just the Legs
Dr. Smith leaned over to look at her lower legs a little more closely. They were quite swollen. And yet when he pressed his thumb against the skin there was none of the give he would have expected in such bloated-looking limbs. Usually with swelling from edema, which occurs when extra fluid leaks from the blood vessels into the soft tissues, any firm pressure will leave a deep impression.
The presence of apparent engorgement that doesn’t compress suggested that the patient may have a condition called lymphedema, an accumulation of fluid rich in white blood cells that is normally collected from the tissues and then drained through the tiny vessels of the lymph system. If these vessels somehow become blocked, the fluid backs up and the skin around them becomes thick, inflamed and eventually scarred.
It’s not just my legs, the woman added. It was everything. Maybe this sounded crazy, she told him, but she didn’t feel like she was living in her own body. She’d explained this to many doctors. They’d just encouraged her to lose weight.
Over the years, the patient had been to many doctors. You can review some of the lab results her various doctors had ordered in the two years before she’d come to see Dr. Smith.
Review the patient’s lab results from 2013 here.
The patient’s labs.
Review the patient’s lab results from 2015 here.
The patient’s labs.
You can also review the note from her last visit to her regular doctor, a cardiologist, here.
The patient’s visit with a cardiologist.
Solving the Mystery
There was one more piece of data that led Dr. Smith — eventually — to the answer. Can you figure out what that missing piece of information might be? And the diagnosis it led to?
Post your answers in the comments section. The first reader to figure out both parts of the puzzle will get a signed copy of my book and that special satisfaction of solving a mystery that my readers know so well.
I’ll post the answer tomorrow.
Rules and Regulations: Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.
Most Americans know that a heart-healthy lifestyle includes eating a healthful diet, not smoking, being physically active and keeping weight and body fat down. But a new study found that fewer than 3 percent of American adults could claim all four healthy elements.
Only 2.7 percent of the Americans in the study were nonsmokers who ate a reasonably good diet, including eating plenty of vegetables and whole grains and avoiding saturated fat; got at least 150 minutes of moderate exercise a week; and had a healthy percentage of body fat, defined as up to 20 percent for men and 30 percent for women.
The results were “shocking,” said Ellen Smit, an associate professor at Oregon State University College of Public Health and Human Sciences and the senior author of the report. “I think it’s a wake-up call.”
The study, published in Mayo Clinic Proceedings, was based on data gathered from the National Health and Nutrition Examination Survey from 2003 to 2006 and included a nationally representative sample of 4,745 Americans.
Eating habits were self-reported, which can be unreliable, but other measures were based on objective tests, including blood samples to verify smoking status, a sophisticated X-ray test to determine body fat, and accelerometers to measure physical activity.
Credit David Maurice Smith for The New York Times
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Credit Gary Taxali
Mark Mattson, a neuroscientist at the National Institute on Aging in Maryland, has not had breakfast in 35 years. Most days he practices a form of fasting — skipping lunch, taking a midafternoon run, and then eating all of his daily calories (about 2,000) in a six-hour window starting in the afternoon.
“Once you get used to it, it’s not a big deal,” said Dr. Mattson, chief of the institute’s laboratory of neurosciences. “I’m not hungry at all in the morning, and this is other people’s experience as well. It’s just a matter of getting adapted to it.”
In a culture in which it’s customary to eat three large meals a day while snacking from morning to midnight, the idea of regularly skipping meals may sound extreme. But in recent years intermittent fasting has been gaining popular attention and scientific endorsement.
It has been promoted in best-selling books and endorsed by celebrities like the actors Hugh Jackman and Benedict Cumberbatch. The late-night talk show host Jimmy Kimmel claims that for the past two years he has followed an intermittent fasting program known as the 5:2 diet, which entails normal eating for five days and fasting for two — a practice Mr. Kimmel credits for his significant weight loss.
Credit Gary Taxali
Fasting to improve health dates back thousands of years, with Hippocrates and Plato among its earliest proponents. Dr. Mattson argues that humans are well suited for it: For much of human history, sporadic access to food was likely the norm, especially for hunter-gatherers. As a result, we’ve evolved with livers and muscles that store quickly accessible carbohydrates in the form of glycogen, and our fat tissue holds long-lasting energy reserves that can sustain the body for weeks when food is not available.
“From an evolutionary perspective, it’s pretty clear that our ancestors did not eat three meals a day plus snacks,” Dr. Mattson said.
Across the world, millions of people fast periodically for religious and spiritual reasons. But some are now looking at the practice as a source of health and longevity.
Valter Longo, the director of the Longevity Institute at the University of Southern California, initially studied fasting in mice that showed that two to five days of fasting each month reduced biomarkers for diabetes, cancer and heart disease. The research has since been expanded to people, and scientists saw a similar reduction in disease risk factors.
Dr. Longo said the health benefits of fasting might result from the fact that fasting lowers insulin and another hormone called insulinlike growth factor, or IGF-1, which is linked to cancer and diabetes. Lowering these hormones may slow cell growth and development, which in turn helps slow the aging process and reduces risk factors for disease.
“When you have low insulin and low IGF-1, the body goes into a state of maintenance, a state of standby,” Dr. Longo said. “There is not a lot of push for cells to grow, and in general the cells enter a protected mode.”
Critics say that health benefits or not, various forms of intermittent fasting are too impractical for most people.
The 5:2 diet, for example, advocates eating without restrictions for five days and then consuming just 500 calories — roughly the equivalent of a light meal — on each of the other two days of the week. Another regimen, called alternate-day fasting, involves eating no more than 500 calories every other day.
A third regimen, which Dr. Mattson follows, is known as time-restricted feeding. The idea is to consume all of the day’s calories in a narrow window, typically six to eight hours, and fasting for the remaining 16 to 18 hours in a day. Studies of time-restricted feeding practices in both animals and humans have suggested that the practice may lower cancer risk and help people maintain their weight.
The scientific community remains divided about the value of intermittent fasting. Critics say that the science is not yet strong enough to justify widespread recommendations for fasting as a way to lose weight or boost health, and that most of the evidence supporting it comes from animal research. Advocates say the body of research on intermittent fasting is growing rapidly and indicates that the health benefits are striking.
The 5:2 diet, in particular, is backed by “promising” studies that show that it lowers weight and improves blood sugar, inflammation and other aspects of metabolic health, said Joy Dubost, a registered dietitian and a spokeswoman for the Academy of Nutrition and Dietetics, the country’s largest organization of dietitians. She noted that fasting isn’t appropriate for pregnant women, people with diabetes and people on medications.
“Most people who do this understand that it’s not about binge eating,” Dr. Dubost said. “But they like that it gives them the freedom not to worry about calories, carbs and other restrictions on days when they’re not fasting.”
Krista Varady, an associate professor of nutrition at the University of Illinois at Chicago, has studied the effects of alternate-day fasting on hundreds of obese adults. In trials lasting eight to 10 weeks, she has found that people lose on average about 13 pounds and experience marked reductions in LDL cholesterol, blood pressure, triglycerides and insulin, the fat-storage hormone.
Dr. Varady found in her research that intermittent fasting was easiest when people ate a moderately high-fat diet and were allowed to consume up to 500 calories on their fasting days. In her studies, 10 percent to 20 percent of people usually find the diet too difficult and quickly stop. Those who stick with it typically adjust after a rocky first few weeks.
“We’ve run close to 700 people through various trials,” Dr. Varady said. “We thought people would overeat on their feast days to compensate. But people for some reason, regardless of their body weight, can only eat about 10 or 15 percent more than usual. They don’t really overeat, and I think that’s why this works.”
In 2011, Dr. Mattson and his colleagues reported a study of the 5:2 program that followed 107 overweight and obese women. Half of the subjects were assigned to eat no more than 500 calories each on two consecutive days each week. A control group was assigned to follow a low-calorie diet.
After six months, both groups had lost weight. But the intermittent fasting group lost slightly more — about 14 pounds on average — and had greater reductions in belly fat. They also retained more muscle and had greater improvements in blood sugar regulation.
Dr. Mattson’s interest in intermittent fasting grew out of work on animals that showed that alternate-day fasting protected mice from strokes, Alzheimer’s and Parkinson’s disease, and consistently extended their life spans by 30 percent. Dr. Mattson and his colleagues found that alternate-day fasting increased the production of proteins that protect brain cells, enhancing their ability to repair damaged DNA. Fasting, he said, acts as a mild stress that makes cells throughout the body stronger, shoring up their ability to adapt to later insults.
In this way, intermittent fasting is like exercise, which causes immediate stress and inflammation, but protects against chronic disease in the long run. Eating fruits and vegetables may have a similar effect. While very large doses of antioxidants can cause cancer in humans, moderate amounts of exposure can make cells more resilient, Dr. Mattson said.
“There is overlap between the way cells respond to exercise, to fasting, and even to exposure to some of the chemicals in fruits and vegetables,” he added.
Dr. Mattson is now starting a rigorous clinical trial of people 55 to 70 years old who are prediabetic and at high risk for developing Alzheimer’s disease. He plans to study whether intermittent fasting may slow cognitive decline.
Dr. David Ludwig, a professor of nutrition at the Harvard T. H. Chan School of Public Health, said one benefit of fasting is that it forces the body to shift from using glucose for fuel to using fat. During this process, the fat is converted to compounds known as ketones, a “clean” energy source that burns more efficiently than glucose, like high-octane gasoline, Dr. Ludwig said.
The same process, known as ketosis, occurs when people go on extremely low-carb, high-fat diets. Dr. Ludwig said ketones seem to have unique effects on the brain. High-fat diets, for example, have been used for years to treat people who suffer from epileptic seizures.
“There are extensive reports of children who had debilitating seizures who were cured on ketogenic diets,” Dr. Ludwig said. “If it benefits the brain to prevent seizures, then maybe it benefits the brain in other ways.”
Dr. Ludwig noted that the long-term effectiveness of fasting had not been well studied. He cautioned that for many people, fasting is simply too difficult and may slow metabolism. A potentially more practical approach is to limit sugar and other processed carbohydrates, replacing them with natural fats, protein and unrefined carbohydrates, he said.
“It takes a very disciplined person to skip a couple meals every day,” he added.
But Dr. Mattson, who has been skipping meals for decades, said the adjustment to skipping breakfast and lunch was a lot like the change that occurs when a couch potato starts exercising.
“If you’ve been sedentary for years and then you go out and try to run five miles, you’re not going to feel very good until you get in shape,” he said. “ It’s not going to be a smooth transition right away. It takes two weeks to a month to adapt.”
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Credit Mark Hyman
For years Dr. Mark Hyman was a vegetarian who kept his intake of dietary fat to a minimum. Whole-wheat bread, grains, beans, pasta and fruits and vegetables made up the bulk of his diet, just as the federal government’s dietary guidelines had long recommended. But as he got older, Dr. Hyman noticed something that bothered him: Despite plenty of exercise and a seemingly healthy diet, he was gaining weight and getting flabby.
At first he wrote it off as a normal part of aging. But then he made a shift in his diet, deciding to eat more fat, not less – and the changes he saw surprised him.
He lost weight, his love handles disappeared, and he had more energy. He encouraged his patients to consume more fat as well, and many of them lost weight and improved their cholesterol. Some even reversed their Type 2 diabetes.
Today, as the director of the Cleveland Clinic’s Center for Functional Medicine, Dr. Hyman has become an outspoken advocate about the health benefits of eating fat. He promotes it on talk shows, educates other doctors, and has even managed to wean his close friend Bill Clinton off of his previously prescribed low-fat vegan diet.
Now in a new book called “Eat Fat, Get Thin,” Dr. Hyman takes a deep dive into the science behind dietary fat, making sense of decades of confusing health recommendations and building a case for why even saturated fats, which have long been vilified, belong in a healthy diet. Dr. Hyman argues that Americans have been misled about the benefits of fat because of a disconnect between nutrition science and food policy. In the book he challenges the nutrition orthodoxy while also exploring the food industry’s outsize influence on official health recommendations.
Recently, we sat down with Dr. Hyman to discuss his thoughts on the gap between nutrition science and health recommendations, the reason you should always plan your meals, and why he never leaves home without a stash of “emergency foods” in his backpack. Here are edited excerpts from our conversation:
Why did you write “Eat Fat, Get Thin”?
I wrote it because we’ve been suffering from 40 years of bad advice about fat that’s led to the biggest obesity and diabetes epidemic in history. The myth that fat makes you fat and causes heart disease has led to a total breakdown in our nutritional framework. I felt it was important to tell the story of how fat makes you thin and how it prevents heart disease and can reverse diabetes. I think people are still very confused about fat.
In the book you argue that nutrition recommendations are often contradictory. How so?
This year, for example, the U.S. Dietary Guidelines for the first time removed their longstanding restrictions on dietary fat. But they still have recommendations to eat low-fat foods. They say total fat is not an issue, but you should drink low-fat milk and eat low-fat dairy and other low-fat foods. It’s a schizophrenic recommendation from the government, and it’s the same with other professional organizations such as the American College of Cardiology and the American Heart Association. There’s a mismatch between the science and the government and professional recommendations.
What’s driving this disconnect?
I think the government based its recommendations on some very flawed science, which took hold. It became policy that was turned into the dietary guidelines and the food pyramid that told us to eat six to 11 servings of bread, rice, cereal and pasta a day and to eat fats and oils sparingly. It’s very hard to overturn dogma like that. It’s embedded in our culture now. It’s embedded in food products. The food industry jumped on the low-fat bandwagon, and the professional associations kept driving the message. Unfortunately the science takes decades to catch up into policy and into practice. And I’m trying to close that gap by bringing awareness to the latest science on how fats and carbs work in your body.
You reviewed hundreds of studies while writing this book. What is your conclusion on saturated fat?
It’s a huge area of controversy. But large reviews of randomized trials, observational research and blood-level data have all found no link between saturated fat or total fat and heart disease. Yet there are still recommendations to limit saturated fat because it raises total cholesterol and LDL cholesterol. But it also raises HDL, and it increases cholesterol particle size, so you actually get a net benefit.
What do you say to scientists who argue that saturated fat does in fact cause heart disease?
I think the challenge with the research is that a lot of the data combines saturated fat in the context of a high-carbohydrate diet. The real danger is sweet fat. If you eat fat with sweets – so sugar and fat, or refined carbohydrates and fat – then insulin will rise and it’ll make you fat. But if you eliminate the refined carbs and sugar, that doesn’t happen. I think saturated fats can be bad in the context of a high-carbohydrate diet. But in the absence of that, they’re not.
What foods do you eat and recommend to your patients?
What I eat is a cross between paleo and vegan diets. It combines elements of the two, so I call it a “pegan” diet. It’s low in sugars and refined carbs, and it’s very high in plant foods. About 70 to 80 percent of your diet should be plant foods. It should also include good-quality fats like nuts and seeds, olive oil, avocado, coconut oil and fatty fish. It should basically include whole, fresh food that’s unprocessed and high in fiber and phytonutrients. I always say that vegetables should make up 50 to 75 percent of your plate.
In a world where fast food is everywhere, wouldn’t that be fairly difficult for most people?
It’s actually very easy to eat well if you just know what to do. The reason most people don’t succeed is they don’t plan their food. They plan their vacations, they plan their kitchen redesign, but they don’t plan out what they’re eating, and that’s a recipe for failure. I always think through how and where I’m going to get my food every day of every week. I also carry with me a set of emergency food so that I’m never in a food emergency.
What are the “emergency foods” that you carry?
I have to protect myself from myself because I’ll eat whatever if I’m hungry in an airport. So I always carry packets of almond butter, cashew butter, an Evolution bar, a Bulletproof bar, a Tanka bar and a KIND bar. I basically have fat and protein as my snacks, and I have enough food in my bag to last an entire day so I don’t make bad choices.
We talked a lot about fat. But what is one overarching message you would most like people to understand?
I think we have to get rid of the prevailing dogma that all calories are the same, and that we just need to exercise more and eat less, which is what the food industry and the government promote. The truth is that you can’t exercise your way out of a bad diet. Metabolism is not a math problem. It’s a hormonal problem. Food is not just energy. It’s information. It’s instructions that turn on or off different switches in your body that regulate hunger and metabolism. Obesity is not about how much you eat. It’s about what you eat. If you just focus on quality, not calories, then the quantity takes care of itself.