The Guevedoces: How An Intersex Genetic Defect Led To A Blockbuster Class Of Medicines

Blog #46   Andrew Siegel, M.D.

In the early 1970’s, a Cornell endocrinologist by the name of Julianne Imperato conducted an expedition to the Dominican Republic to investigate reports of a community where children who were thought to be “girls” at birth turned into “boys” at puberty.  In this remote area, these intersex children—biological males with a normal male chromosomal make-up (46 XY) who have female-appearing genitals—surprisingly develop male genital anatomy at the time of puberty. The very interesting tale of the guevedoces (literally, “penis at 12 years”) and how an understanding of their genetic defect led to the development of a commonly used medication is the subject of this week’s blog.

In Salinas, an isolated village of the southwestern Dominican Republic, 2% of the live births in the 1970′s were guevedoces.  These children who appeared to be girls at birth, developed a penis, testicles and all of the typical male physical characteristics at the time of puberty.  Most guevedoces were found to be descendants of a single common ancestor, Altagracia Carrusco.  Their underlying pathology was shown to be deficiency of an enzyme known as 5- alpha reductase (5AR).  This enzyme is responsible for converting the male hormone testosterone into dihydrotestosterone (DHT), the more potent, active form of testosterone.

During uterine gestation, DHT is essential for the development of normal male external genitals.  In the absence of DHT in utero, the external genitals develop as female.  However, internally the gonadal tissue is that of the male.  The guevedoces have feminized external genitals, a short “vagina,” undescended testicles and an absent uterus.  With the testosterone surge at puberty, the tiny penis– that was thought to be a clitoris–develops into a normal-size, functional penis; at the same time, the testicles, previously not within the scrotal sac, descend into the scrotum, and other usual male characteristics develop in terms of libido, musculature, voice change, etc.  For the duration of their lives, the guevedoces resemble other Dominican men in all respects except that they have scanty beard growth, never develop acne, their prostate glands remain small and they never develop baldness.

The discovery of this congenital 5-alpha reductase (5AR) deficiency in this small enclave of the Dominican Republic helped transform my field of urology from a largely surgical specialty into a discipline that became enabled to offer effective drug treatments and minimally invasive procedures for prostate and urinary conditions.  The clinical findings of the guevedoces led Merck researchers in the 1970’s to work on the development of a drug that would replicate the effects that the 5AR deficiency had on the adult guevedoces population. Pharmaceutical scientists reasoned that if 5AR could be inhibited after the external genitalia were fully formed and mature, then a medication to shrink the prostate, relieve urinary symptoms and treat baldness and acne might be developed.  The legacy of the guevedoces became a class of drugs known as 5 alpha-reductase inhibitors (5ARIs), the “prostate pills.”  Finasteride, the original 5ARI, was approved in 1992.  Dutasteride followed, and the treatment approach to prostatic obstruction was forevermore changed.  Aside from prostate shrinkage and symptomatic relief of urinary symptoms, this class of drugs is an effective treatment for male pattern baldness.

I do not believe in medications unless there is a compelling reason to use them and the benefits outweigh the potential side effects. The 5ARIs are genuine winners with a terrific reward/risk ratio and not only do I endorse them and prescribe them liberally, but I personally start my mornings with a dose of Finasteride.   The 5ARIs cause prostate atrophy and alter the natural history of benign prostate hyperplasia, BPH (prostate enlargement), improving the typical urinary symptoms that the aging male is prone to.  They help prevent a situation where a male cannot urinate (acute urinary retention) and requires emergency placement of a catheter and also help prevent the need for prostate surgery.  The 5ARIs are very useful to control blood in the urine that is of prostatic origin, a not uncommon manifestation of BPH.  Studies have shown that these medications confer a risk reduction for prostate cancer, so urologists often employ the 5ARIs for men at high risk: those with a family history; those with very elevated PSA levels; and those with prior prostate biopsies showing pre-malignant findings.   Men on 5ARIs will have a decrease in prostate specific antigen (PSA) to about 50% of baseline and this is factored into ongoing PSA testing.  Another utility is that if the PSA does not drop to 50% of baseline, it is suspicious that an underlying prostate cancer may be an issue.  Additionally, the shrinkage of the BPH as a result of these medications will make the digital rectal exam more sensitive to finding abnormalities that can help make an early diagnosis of prostate cancer.  Most recently, the 5ARIs have been shown to delay prostate cancer progression in men with low-risk, localized prostate cancer. Finally, the 5ARIs promote hair growth, particularly for men with hair loss at the crown of their heads.

The safety record of the 5ARIs deserves mention, as they are intended for long-term use. Aside from a relatively low incidence of sexual dysfunction—difficult to distinguish from the declining erectile capabilities that occur with aging—the 5ARIs are among the most benign treatments for any chronic condition.  Another rather inconsequential result of 5ARIs is that they cause a decrease in ejaculate volume as a result of the prostate atrophy.  5ARIs do not cause major side effects while still depriving the prostate of stimulation because inhibiting 5AR results only in lowering the concentration of DHT within the prostate gland, leaving serum testosterone levels normal or even slightly elevated.

My own tale:

A number of years ago, within a few day period of time, both my wife and father independently noticed and related to me that I had sunburn on the crown of my head.  This did not appeal to my sense of vanity!   I tried topical Minoxidil (Rogaine) but it was ineffective, so I started Propecia (Finasteride 1mg) every morning.  Lo and behold, about six months later, I was startled to find that my exposed scalp was not so exposed any more. It worked slowly, but within a couple of years after starting the Propecia, the vertex of my head had a full regrowth of hair.  No kidding!

When the Veterans Administration report came out demonstrating that the risk of prostate cancer diminished 25% with Finasteride use, this cinched it—particularly insofar as my father had been diagnosed with prostate cancer at age 65.  This is a drug that fixes my bald spot, shrinks my prostate, and helps prevent prostate cancer for which I have a positive family history. This was truly a win-win situation, a real no- brainer.  I will share with you a little insider information—a significant number of urologists and other physicians avail themselves of this class of medications for all of the reasons just stated.  It is truly a medication worth taking.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Now available on Amazon Kindle

www.PromiscuousEating.com

Refined Foods: Not So Fine For Us

Blog # 45   Andrew Siegel, M.D.

 

                        Wheat Chaff                                            Wheat Kernel

 

Nature is ever so clever—look at our human species—amazingly engineered, evolved and adapted not only to survive, but also to thrive on this planet.

Whenever nature provides us with a nutrient that is potentially unhealthy, it protects us does by limiting our access to that nutrient.  Take, for example, sugar—also known as sucrose or alternatively, 50% glucose/50% fructose—clearly unhealthy and a key contributor to the obesity epidemic.  The major sources are sugar cane and sugar beets.  Did you ever try to get the sugar out of a sugar cane or sugar beet plant?  They are fibrous and unyielding and if we want to derive calories from these, it will require great effort and we will likely end up frustrated.  It’s like chewing on a stick of bamboo!

 However, because of the collective intelligence of mankind—standing on the shoulders of giants, if you will—we are now able to easily remove the protective fiber matrix and process the sugar cane or sugar beet into a pure, refined and powdery product.   This process enables unrestricted access to the sugar and allows many “naked” calories to be easily consumed in a short time period. That is NOT the way nature intended, but humankind has prevailed over nature. Processing has allowed us to cheat nature by refining sugar, permitting consumption in immoderate and unhealthy amounts, contrary to nature’s design. 

 Now lets move on to a discussion about the processing of grains—specifically wheat, since these amber waves of grain are one of the staples of the American diet. However, this same line of thought is relevant to other grains including rice, corn, rye, oats, barley, etc.  The bottom line is that processing leaves us with a very refined product—not unlike sugar—again cheating nature’s “natural” protective mechanisms.  Unfortunately, when we cheat nature, we ultimately cheat ourselves.

Wheat needs to be processed to make it available and accessible to us. Threshing is the means whereby the chaff  (the wheat husk) is separated from the wheat kernel, the diamond of wheat.  Highly efficient milling enables the wheat kernel to be separated into the following three components—the bran: the outer covering of the wheat kernel; the germ: the embryo or sprouting section; and the endosperm: the source of the white flour that contains starch and protein.

 White flour has the bran and germ removed, resulting in a pure, highly refined powder as opposed to whole-wheat flour that contains the bran and germ. By removing the fiber-rich bran and germ, the resulting product has a longer shelf life and makes for lighter and fluffier breads, as opposed to the darker, coarser, heavier breads made from the whole-grain wheat.

The removed bran and germ—the wholesome and healthy components of the wheat kernel—are often used to produce animal and poultry feed.   Interestingly, the farm animals are fed the wholesome, slow-digesting grain components and us humans end up with the refined and unhealthy component!  Go figure!  In fact, the nutritionally depleted and deficient processed white flour needs to be fortified with vitamins and minerals to replace those that were lost with refining, hence the term “enriched” wheat flour.

 What is the problem with enriched wheat flour?  Simply, wheat grain that is hulled and stripped of the bran and germ results in a pulverized, super-fine, silky-white powder. This highly refined substance is very similar in appearance to cocaine or heroin. This pre-chewed, pre-digested, melts-in-your-mouth, adult baby food equivalent is absorbed extremely rapidly and is promptly transformed into glucose; it is not unlike getting an injection of intravenous glucose into one’s bloodstream.  Insulin levels (remember that insulin is our “fat” hormone) surge in response and any glucose that does not need to be immediately used as fuel gets stored as glycogen in our muscles and liver and when that is maximized, any excess glucose gets stored as fat.

 This quick fix of sugar is not particularly filling because of the absence of fiber; it is a short-lived satisfaction that begs for more consumption, establishing a vicious cycle. The result is a push in the direction of weight gain, insulin-resistance, obesity, diabetes and heart disease. Furthermore, the refined product does not induce the “thermic effect” that many more substantive foods do, in which the body’s metabolism increases because of the energy expenditure it takes to digest a wholesome, fiber-rich product.

 In contrast to the refined, enriched wheat flour product, whole-wheat flour is made by grinding up the entire wheat kernel. “Whole” refers to all three grain components used—bran, germ, and endosperm.  Whole-wheat flour is brown in color and textured, as opposed to the silky-white enriched wheat product. Whole wheat is very nutritious because the bran and germ components contain abundant fiber, protein, calcium, iron and other minerals. Because of the fiber, absorption and glucose transformation occur in a slow, gradual and well-regulated fashion. Whole wheat is filling, satisfying and substantive and literally sticks to your ribs.  Whole-wheat adds heaviness to breads or to whatever recipe it is used for and requires more flour to obtain the same volume of bread as white flour. Whole-wheat has a shorter shelf life than white flour because of its higher oil content—the source of the oil being the wheat bran, and the oil being a healthy one.  Products containing oil will go rancid faster than products that do not contain oil.  Whole-wheat flour is more expensive than white or enriched wheat flour.  It is easy to understand why the Industrial Food Complex is enamored with enriched wheat flour.

 Now let’s go way beyond mere processing and separation of a natural product into its components and get into a real chemistry experiment—high fructose corn syrup (HFCS).  HFCS is a sugar substitute that is derived from corn via a complicated chemical process. Corn is milled to produce cornstarch, a powdery derivative. The cornstarch is processed into corn syrup, which contains glucose. Glucose is converted to fructose by using a process developed in the 1970’s by food scientists in Japan. Glucose is then added back in differing percentages to the fructose to achieve the desired sweetness. 55% fructose HFCS is used to sweeten soft drinks and a 42% fructose HFCS is used in baked goods. HFCS is abundant in processed foods and drinks.

Why does the Industrial Food Complex adore HFCS?  It is less costly than sugar because of corn subsidies and sugar tariffs. It is easy to transport as the viscous syrup lends itself to huge storage vats within trucks.  Fructose is the sweetest of all naturally occurring carbohydrates and does not crystallize or turn grainy when cold, as sugar can do in cold drinks such as iced tea. Because HFCS is highly soluble, its use makes for softer products and its ability to retain moisture allows for moister and better textured baked goods. Finally, it acts as a preservative to help prevent freezer burn as well as maintain the freshness and extend the shelf life of processed foods.

While HFCS may help preserve processed foods, it does not help preserve us; in fact, I would describe HFCS as killer sweetener.  It’s not just about the “naked” calories of the refined, fiber-less carbohydrate but is all about the fructose, which can be thought of as “poisonous” carbohydrate that has unique and distinct properties.  Fructose is remarkably similar to a carbohydrate that is very familiar to all of us—ethanol, a fermented sugar that is an acute toxin to the brain. However, fructose can only be metabolized by the liver and not by the brain, so in the words of Dr. Robert Lustig, fructose is “alcohol without the buzz.”   While ethanol is an acute toxin, fructose can be thought of as a chronic toxin. The “beer belly” from alcohol is not unlike the “soda belly” seen in those who overindulge in products containing HFCS.

Fructose is metabolized entirely differently from the way glucose is.  Every cell in our body can metabolize glucose, but only the liver can metabolize fructose. Fructose does not stimulate insulin release, as does glucose.  Fructose does not stimulate the secretion of our satiety hormone leptin, nor suppress our hunger hormone ghrelin, so that foods containing fructose, unless couched in fiber, do not fill us up and curb our appetites. Fructose much more readily than glucose replenishes liver glycogen, and once the liver is saturated with glycogen, triglycerides (fats) are made and stored. Thus, HFCS ingestion can readily lead to obesity, elevated cholesterol, fatty liver, hypertension, insulin resistance and metabolic syndrome. The bottom line is that excessive HFCS ingestion pushes our metabolism towards fat production, and it doesn’t take eating that much processed food to cross the excessive HFCS threshold.

Fructose is the predominant sugar in many fruits, hence the name fructose. The difference between this sugar contained within a piece of fruit as opposed to that within a bottle of cola is that fruit fructose is natural (not created in a chemistry lab) and the amount is significantly less than the load contained within the soft drink. Additionally, the fruit fructose is accompanied by a substantial amount of fiber, anti-oxidants, and other phyto-nutrients, all health-promoting ingredients not present in the cola.

 

Bottom line:  Resonate with nature and literally think “outside the box,” can, package, bottle, etc., by eating whole, natural foods and not their refined by-products. Whole and real foods do not require a label because what you see is what you get. Leave the chemistry experiments to the chemistry lab and not for our consumption. Processing is a necessity to make some foods accessible to us, so read food and nutritional labels as carefully as you would read the ingredients in a medication, because when it comes down to it, food is medicine. The best diet is the “anti-processed-atarian” diet.  Your body will thank you.

 

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Gluttony, Sloth, & Cardiac Care or Healthy Lifestyle & Wellness

Blog # 44   Andrew Siegel, M.D.

February is American Heart Month, so I put my heart into this narrative about this amazingly engineered, all-important organ that serves us tirelessly and relentlessly. Like our pet canines, this organ requires to be  well fed, to be exercised, and to be given tender loving care.  Be kind to it and it will return the favor big time.

Two hundred years ago, the following words on angina pectoris (chest pain from coronary artery occlusion) from John Warren, M.D. were published in the very first issue of the New England Journal of Medicine and Surgery:

The disease itself is excited more especially upon walking up hill,

and after a meal; that thus excited, it is accompanied with a sensation,

which threatens instant death if the motion is persisted in;

and that on stopping, the distress immediately abates, or altogether subsides.

 

Two centuries later, we are infinitely wiser regarding the diagnosis and management of heart disease, yet unfortunately this illness is more prevalent than ever.  The saddest aspect of this is that coronary artery disease is largely a preventable and avoidable problem.  Every day, many hearts are broken because of the premature and unnecessary demise of loved ones who succumb to cardiac disease. It is my heart’s desire that we become better caretakers of ourselves and avoid the 600,000 deaths to heart disease and 130,000 deaths to strokes that occur every year in the USA.

Cardiovascular disease (CVD), including heart disease and stroke, is the number one cause of death in the USA and other industrial countries.  The only year since 1900 in which CVD was not the leading cause of death was in 1918, the year of the influenza pandemic.  CVD is also the leading cause of death in every region of the world except for sub-Saharan Africa.  The burden of CVD is increasing because of our longer life spans, continued tobacco use, physical inactivity, unhealthy food consumption, obesity, high blood pressure, elevated LDL cholesterol and prevalence of type 2-diabetes.

The following paragraph is a brief historical perspective of some of the important medical advances with respect to the management of heart disease.  The 50-year cardiovascular Framingham study (1948-1998) linked high blood pressure and high cholesterol with angina and heart attacks and originated the novel concept that coronary artery disease and its complications could be prevented.  The advent of the coronary care unit (CCU) vastly decreased the death rate of patients admitted with acute heart attacks by provided sophisticated monitoring with electrocardiograms, closed chest cardiac massage, and external defibrillation (using electric paddles to shock the heart back into a normal rhythm).   Cardiac catheterization and coronary arteriography lead to the birth of cardiac surgery and coronary revascularization (coronary artery bypass).  The field of interventional cardiology enabled balloon angioplasty revascularization of occluded coronary arteries without the need for cracking one’s chest open, using access through a thigh artery.  Cardiac stents, initially metal and currently drug eluting, were developed to prevent coronary re-occlusion.  Statin medications to lower LDL-cholesterol levels and many new and potent cardiac drugs have provided significant advances.  Implantable pacemakers and implantable pacemaker-ventricular defibrillators have further improved the prognosis of those suffering with cardiovascular disease. Sophisticated tests including echocardiograms, treadmill tests, isotope stress tests, Holter monitoring, and computerized tomography of the heart are readily available to help pinpoint the precise cardiac diagnosis.

Despite all of the aforementioned incredible technological advances, coronary artery disease remains highly prevalent and is a major widow-maker and widower-maker.  Why?  It’s really very simple—those all-important, tiny blood vessels that provide the lifeline of blood flow of oxygen and nutrients to that vital organ that pumps our blood 24/7/365 get blocked with fatty plaques.  With clogged coronary arteries, when increased demand is placed on our life-sustaining pump, not enough oxygen can get delivered through the compromised coronary arteries and we develop angina and possibly sustain damage to the heart muscle (a myocardial infarction or heart attack) or its electrical conduction system (an arrhythmia).  Tragically, this compromise to our heart and blood vessels is too often self-induced through bad eating habits, physical inactivity, and the use of tobacco.

To quote the insightful and poetic Dr. David Katz who says it all:

“We are all offspring of predecessors who lived in a world where calories were relatively scarce and hard to get, and physical activity constant, arduous and unavoidable. We now live in a world where physical activity is scarce and hard  to get, and calories constant, effortless and unavoidable.

Atherosclerosis is the process that gives rise to the fatty plaques in our arterial walls that compromise blood flow to our organs.  Atherosclerosis is a chronic arterial inflammation that develops slowly, gradually and progressively over many years.  It happens in response to the biological effects of risk factors.  It begins with changes in the endothelial cells, the unique cells that line arteries.  When subjected to these risk factors, endothelial cells change their permeability and allow white blood cells and LDL cholesterol entrance into the cells.  The risk factors include the following:

• high blood pressure within the arteries
• oxidative stress from free radicals (highly reactive molecules known as free radicals are created as a consequence of how our body reacts with oxygen; these interact with other molecules within cells and cause oxidative damage)
• biochemical stimuli (chemicals from tobacco, high levels of bad fats like LDL cholesterol in the blood, food toxins)
• inflammatory factors

The presence of white blood cells and LDL cholesterol within the endothelial cells gives rise to a cascade of chemical reactions that causes proliferation of both endothelial and smooth muscle cells and the formation of plaques.  Plaques lead to symptoms by restricting flow through the arteries involved, or alternatively, by provoking clotting that interrupts blood flow.  If the plaque ruptures, more clotting will occur at the site of the disruption, perpetuating the restricted flow, and additionally, the ruptured plaque can travel and jam other blood vessels.  LDL cholesterol is clearly a major culprit and atherosclerosis occurs in direct proportion to LDL levels.

Occlusion of the coronary arteries is a big deal because damage of the blood flow to the heart—the most important organ in our body—is a major concern.  However, it is important to know that the process of atherosclerosis is by no means unique to the heart—it is just that the effects of atherosclerosis on the heart—including angina, heart attacks, arrhythmias and death—are ever so dramatic.  It is critical to realize that if you have atherosclerosis in your coronary arteries, you can bet you have it in every artery in the body—including the aorta and those arteries providing blood to the brain, kidneys, intestines, legs, genitals, etc.  This can give rise to strokes or transient ischemic attacks, kidney disease, pain in the abdomen after meals, pain in the legs when walking, sexual dysfunction, etc.  Suffice it to say that intact blood flow to transport oxygen and nutrients to every cell in our body is our lifeline and we don’t want it compromised.

It is nothing short of wonderful that the medical fields of cardiology and cardiovascular surgery have become so evolved and sophisticated and that we have the medical and surgical resources to manage CVD so well.  Countless lives and loved ones have been saved from premature deaths.  That being the case, I must make an appeal from the bottom of my heart for preventive and pre-emptive measures that can keep the disease away and the cardiac team at bay.  Nature and nurture have roles in CVD and we can’t do a thing about the genetic blueprint that we inherited from our parents that can predispose us to CVD, but we do have incredible power to shape our health destiny with our lifestyle.  In my heart of hearts, I can assure you the truth and the validity of the following statement: Genes load the gun, but lifestyle pulls the trigger.  Even if genetics has been unkind to you, you have the authority and choice to pull the trigger, keep your finger on the trigger, or withdraw your finger from the trigger.

Prostate cancer is the number one cancer in men and one that I spend a great deal of my time managing and treating. Can you guess what the leading cause of death is in prostate cancer patients?  If your answer was prostate cancer, you are wrong.  The leading cause of death in men with prostate cancer is CVD.  After CVD, cancer happens to be the second leading cause of death in the USA and in most developed countries.  Most of our knowledge regarding lifestyle and dietary change for CVD prevention applies to cancer prevention as well.  One of the most dramatic reductions in both CVD and cancer has been through smoking cessation.   A heart-healthy diet and lifestyle will contribute to health improvements in every part of our human anatomy, whether it is the heart, colon, prostate or genitals.

As individuals, we must take responsibility for our health and make every effort towards maximizing our fitness and well-being.  We are the stewards of our own health destiny—no one else is.  Yes, we have physicians, sophisticated diagnostic tests, medications and surgery to help us when things go south, but simply by being smart and living a healthy lifestyle, we can avoid personal grief and the grief of our families.

Please take the following advice to heart:

Pearls to keep your heart ** healthy:

1.  No smoking or tobacco
2.  Maintain a healthy weight
3.  Eat a healthy diet: nutrient-dense, non-processed, whole foods; lean protein including seafood which is abundant in heart-healthy omega-3 fats; eat meat and dairy sparingly (use fat-free dairy products); fruits, vegetables and legumes; nuts and seeds; whole-grain carbohydrates
   
4.  Exercise daily: walking is great, but try to get some exercise that makes you sweat, breathe hard and gets your heart pumping. Exercise is all about adaptation. Our hearts and bodies are remarkably adaptable to the “stresses” that we place upon them, whether they be vigorous exercise or sitting on the couch.   
5.  See a medical doctor for periodic health check-ups: don’t take better care of your car than you do of yourself!
6.  Minimize and manage stress
7.  Know your blood pressure and cholesterol levels and maintain them at healthy levels

 ** And every other organ in your body as well.

 

Heartfully Yours,

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Where’s Your 6-Pack?

Blog # 43 written by Andrew Siegel, M.D.

I posed this question to my nurse friend Jen and she replied “in the fridge.”  She made me laugh with that reply, but in reality she has a pretty hard body, especially for a woman who has given birth to several children.  However, if your answer to the question truly is “in the fridge,” then you might just want to read on!

If you would like the short version, skip to the end of this blog where you can read “10 pearls to help your washboard abdomen emerge”—it provides nuggets of information that if heeded, will allow your to firm up your abdomen and start the process of unveiling the 2-pack, 4-pack or 6-pack that lies obscured within.  Read the full blog if you would like to know the more detailed science.  Although vanity may be an important driving force for wanting to develop that 6-pack, it’s really about living a healthy lifestyle—in brief, the aesthetics will follow a healthy existence and our internal health often mirrors our external physiques.

Sporting a six-pack is a badge of honor emblematic of one’s discipline, restraint and tenacity.   A “hard core” can only be earned through the combined efforts of healthy eating and vigorous exercise.  Chances are if you’re wearing a 6-pack, then you are fit and healthy and that in all probability you have rejected the Western diet of processed foods, lots of added fats, sugars and loads of refined grains and instead have chosen a healthy diet consisting of real food that comes from nature, rather than from a chemistry lab.

We all have 6-packs hidden beneath our winter-weighted physiques.  We may be flabbier and less toned than desirable, but somewhere within is a sinewy, tight, and lean torso.  The question is: what can we do to bring out this svelte body?  How do we reduce our shapeless stockpile of stored energy that is shrouding our underlying sculpted physique?

Michelangelo’s “David” was at one time a mere solid block of marble.  The master artist crafted this magnificent sculpture by knowing exactly what to carve away—what did not belong. In the words of Antoine de Saint-Exupery (author of Le Petit Prince): “Perfection is not when there is no more to add, but when there is no more to take away.”  The late Steve Jobs was a grand master at removing the unnecessary and superfluous to reveal the elegant simplicity that remains. In the words that follow, I will offer sound advice on how to peel away the nonessential to reveal your own magnficence that lies obscured.

Having some fat on our bodies is not a bad thing, as long as it is not excessive. Fat actually serves a number of useful purposes.  It functions to cushion our internal organs and as insulation to conserve heat.  Fat provides a means of storing energy and fat-soluble vitamins.  During periods of decreased caloric intake, fat reserves are broken down to release energy.  Fats are important parts of the structure of the brain and cell membranes and are used in the manufacture of several important hormones.  Fat has more than twice as many calories per gram than carbohydrates or protein.   Anybody who has barbecued any kind of meat with a high fat content and has witnessed their would-be dinner engulfed in flames realizes what a concentrated form of fuel that fats are.

As we age, many of us tend to slowly and insidiously gain weight.  A collection of fat often becomes apparent on our abdomens, particularly around our waistlines.  An accumulation of fat in our midsections not only is unattractive from a cosmetic standpoint, but also can have dire metabolic consequences.  It is important to distinguish between visceral fat and subcutaneous fat.  Visceral fat—also referred to as a “pot belly,” “beer belly,” or “Buddha belly”—is internal fat deep within the abdominal cavity.  Subcutaneous fat—also known as “love handles,” “spare tires,” “muffin top,” or “middle-age spread”—is present between the skin and the abdominal wall.  Although neither type is pretty, visceral fat is much more hazardous than subcutaneous fat since it increases the risk of diabetes, cardiac issues, and metabolic disturbances.  Subcutaneous fat is inactive and relatively harmless and does not contribute to the health problems that visceral fat does.

The good news is that by losing abdominal fat, the potentially bad health repercussions can be reversed and the six-pack within can become more unveiled.  The dangerous visceral fat submits relatively easily to diet and exercise whereas the less harmful subcutaneous fat at the waist is more stubborn and resistant to reversal measures.  It is this accumulation of belly fat that masks the underlying rectus abdominis muscle that is our 6-pack muscle.

And now a few necessary paragraphs on metabolism: Dietary carbohydrates are broken down to the simple sugar glucose, which is the “energy of life” and the fuel source of every cell in our body. When it is not used immediately for energy, it is stored as glycogen. The pancreatic hormone insulin is responsible for converting glucose into glycogen. Glycogen is present in our liver and muscles; when a state of saturation has been achieved and no more glycogen can be stored in our liver and muscles, the excess glucose is converted to fat.  There is a finite limit to the amount of carbohydrate stored in the muscles and liver—it amounts to about 1600-1800 calories.

When talking metabolism, it is helpful to think of our glycogen as our “small fuel tank.”  Once the fuel in the liver and muscles is exhausted, our “large fuel tank”—our fat—needs to be tapped to provide energy.  In contrast to the limited carbohydrate storage in our liver and muscles, our bodies abundantly store fat.  Depending on how much fat we have, many days to weeks of energy can be provided.  To reveal your 6-pack, you need to have as small a “large fuel tank” as possible, since it is these stored energy reserves that are obscuring the glorious sculpted abdominal musculature that lies beneath.

There are a few important facts that are fundamental to our understanding of the science of fat. First off, our fat stores are not static, but are dynamic.  In other words, there is continuous mobilization of our fat (as fatty acids) and storage (as triglycerides).  Secondly, fat storage is largely under hormonal control.  Hormones are chemical messengers that cause specific actions in our body.  The hormones involved in fat metabolism are insulin, cortisol, estrogen, and testosterone.  Thirdly, fat is not just fat—it is a metabolically active endocrine organ that does not just protrude from our abdomens in an inert state, but has a life of its own.  Fat produces pro-inflammatory factors, hormones and immune cells.  Fat has an abundance of the hormone aromatase, which converts testosterone to the female hormone estrogen.  One consequence of too much fat in men is excessive conversion of testosterone to estrogen, creating the potential for male breast enlargement.

Insulin is the principal regulator of fat metabolism. After a sugar and carbohydrate load, insulin is released to get the fuel into our cells. When we go without food, as happens when we sleep, insulin levels decrease and fat is released to be used as fuel.  Insulin levels are determined primarily in response to our carbohydrate intake in order to keep our blood sugar regulated.

Insulin has much to do with the way our bodies store or burn fat. You can think of insulin as our fat hormone. When insulin levels are elevated, we accumulate fat; when levels are low, we burn fat for fuel.  Insulin is all about increasing fat storage and decreasing fat burning—this is why diabetics on insulin injections typically get fat.  If we have a substantial amount of belly fat, then by definition we have insulin-resistance, a condition in which our pancreas works overtime to make more and more insulin to get fuel into our cells.  This is a precursor to diabetes, cardiovascular disease and all the havoc they can wreak.

Our insulin levels are determined by the carbohydrates we eat—the more carbs we eat, the sweeter they are, the easier they are to digest, the greater the insulin levels and the more that fat accumulation is driven.  Insulin secretion caused by eating carb-rich foods—flour and cereal grains, starchy vegetables like potatoes and rice, sugars and high-fructose corn syrup—is what makes us fat.  The sweeter the food, and the easier it is to digest, the fatter it will make us, and liquid carbs such as sodas, fruit juices and beer are the biggest culprits.

If we want to get leaner and reveal the 6-pack within, we must lower our insulin levels.   To lower our insulin levels requires carbohydrate restriction, meaning decreased consumption of sweets and starchy carbs.  Even if we don’t reduce our quantity of carb intake, we can improve the quality of our carb intake by eating healthier carbs—whole grains, fruits, vegetables, legumes, etc.  Aside from shrinking our waistlines, there are numerous other health benefits that accrue from a lower carb diet.  If we replace a high carb diet with a diet lower in carbs and higher in healthy protein and healthy fat, the consequences are the following: weight loss; HDL (good) cholesterol rises; triglycerides decrease; glucose levels stabilize; blood pressure decreases; heart disease risk decreases; body fat reduces; energy levels surge.

The adrenal gland hormone cortisol—released in response to stress—can stimulate our appetites and cravings for sugar, causing fat storage and promoting weight gain and obesity. This is the very reason people on corticosteroid medications tend to have enormous appetites, gain weight and have a central distribution of body fat known as centripetal obesity, even if they were very thin prior to starting on the cortisol.  Chronic stress literally can make us soft and flabby and sabotage our efforts to achieve that chiseled 6-pack.  So what can we do about stress, because we all have it, and it’s not going away anytime soon?  Stress busters include exercise, yoga, meditation, massages, getting into a Jacuzzi, aromatherapy, chamomile or other herbal teas, sex, etc.  Sounds nice…relax to help bring forth that 6-pack!

The sex hormones estrogen and testosterone play a key role in fat regulation. One of the key reasons that women have a different physical appearance and body fat distribution than men is because of the different levels of these two hormones in each gender.  Around the time of menopause, when the ovaries stop producing estrogen, central fat deposition is promoted and many women start packing on pounds in their mid-section.  Similarly, as men age, testosterone levels often drop, contributing to a loss of muscle mass and an increase in body fat. Low testosterone is present in about half of obese men.

Believe it or not, a good night’s sleep will help us on our mission for that elusive 6-pack.  When we sleep poorly and become sleep-deprived, we are often driven to eat. Sleep deprivation results in decreased levels of leptin, our chemical appetite suppressant, and increased levels of ghrelin, our appetite stimulant, in addition to increased levels of the stress hormone cortisol.  Furthermore, being exhausted can sabotage our exercise regimen.

Six-pack diet

Lean sources of protein including egg whites, wild salmon (or any other wild fish that is grilled or broiled), skinless chicken, turkey breast, fat-free yogurt and soy products such as tofu and edamame are money.  We need to be sparing with meat and dairy intake since they are rich in saturated fats and high in calories.  Vegetables—including nuts, avocados and olives—are a much healthier source of fat.

High fiber foods—vegetables, fruits, legumes (lentils, peas and beans) and whole-grain cereals and breads—are very filling and the fiber regulates the rate of carbohydrate absorption. Intake of a variety of brightly colored fruits and vegetables will ensure getting ample doses of phyto-nutrients and anti-oxidants. Dietary fiber (roughage) refers to the indigestible part of a carbohydrate.  Insoluble fiber, e.g., cellulose from plant foods, serves as plants’ armor against predatory pests and serves as humans protection against obesity.  Since we do not have the enzymes necessary to dissolve insoluble fiber, it increases stool bulk, decreases intestinal transit time, increases our satiety, reduces the rate of carbohydrate absorption and the conversion of complex carbohydrates to simple sugars, and decreases the absorption of some fats.  Soluble fiber binds cholesterol in the intestinal tract; for example, oatmeal can help lower serum cholesterol levels.

It is very important to minimize refined carbohydrates, substituting whole grain products for white bread, white pasta, white rice, etc.  Curtailing sugar intake is equally important since sucrose is a 50% fructose/50% glucose combination and fructose gets metabolized completely differently from glucose, pushing our bodies towards fat deposition.  The same is especially true for high fructose corn syrup (HFCS), that gooey liquefied sweetener abundant in processed foods and beverages in a 55% fructose/45% glucose ratio. Every cell in our body can metabolize glucose, but it is primarily the liver that metabolizes fructose. Fructose, more readily than glucose, replenishes liver glycogen, and once the liver is saturated with glycogen, fats are made and stored. So, HFCS gives us a fatty liver, a fatty body and a masked 6-pack.  Fructose does not suppress ghrelin (our hunger hormone), does not stimulate insulin, and is truly a toxin to our body in immoderate doses. Let fruits be the source of fructose for our bodies, not refined sugars and HFCS.

Nature is very clever—whenever it provides us with a nutrient that is potentially bad for our health, it limits access to that nutrient by adding lots of fiber to it.  So when nature has given us fructose, it has also included the antidote.  Did you ever try to get the sugar out of a sugar cane plant?  It is literally like gnawing on a piece of bamboo stick—you can’t chew it and have to suck it out!  Processing has allowed us to cheat nature by refining sugar, permitting consumption in unrestrained, unhealthy amounts, contrary to nature’s design.  For example, it is very easy to drink 12 ounces of orange juice, to the tune of about 170 calories of fiber-free sugar.  To get that kind of caloric load from nature’s whole product—the orange—you would have to eat almost 3 of them.  Can you imagine sitting down and eating three oranges?  I sure can’t.  So go easy on anything that comes in a bottle, box, carton or can…think whole foods that resonate with nature, not refined foods that are unfaithful to nature.

While at the dinner table the other evening, I found myself staring at a colorful salad on my left and a basketful of white Italian bread (not whole grain) on the right.  I pondered the “order” of eating in terms of insulin release—would there any difference if I had salad first followed by bread vs. bread first followed by salad, vs. eating them together and would the order of eating play a role in the way calories are burned or stored?

Salad first followed by bread (bulky, fiber-rich carbs then fiber-less carbs): This gives us a gradual, low-level insulin spike followed by rapid, high-level insulin spike.  It is likely that the bolus of salad slowly digesting in the gut will modulate (regulate) the insulin spike from the bread’s fiber-less carbs, resulting in less of a tendency for fat deposition.

Bread first followed by salad: (fiber-less carbs then fiber-rich carbs):  This gives us a rapid, intense insulin spike followed by gradual, lower-level insulin spike.  It is likely that this order will result in fat deposition, since by the time the salad gets to the gut, the bread has already been digested and absorbed.

Together: The salad mixing in the gut with the bread will modulate the insulin spike from the fiber-less carbohydrate load of the bread, resulting in less of a tendency for fat deposition.

Bottom line: If you are going to eat white carbs, you can minimize the intensity of the insulin spike and thus the tendency for fat deposition by mixing in some fiber-rich foods; better yet is to ditch the white carbs completely and eat the whole-grain product. If you are going to use the strategy of using the powers of fiber-rich food like salad to lessen the “damage” from fiber-less white carbs, be sure to go easy on the croutons, cheese and excessive amounts of salad dressing that can sabotage the strategy.

A very important principle in the acquisition of a 6-pack is not to drink calories, so avoid liquid calories such as soda, juices, processed iced tea, lemonade, etc.  These are particularly bad since they are essentially pre-digested, fiber-less carbohydrates that get “mainlined” into our bodies causing a massive insulin spike and caloric storage as fat.  A “beer belly” resulting from the carbohydrate alcohol and a “soda belly” resulting from the carbohydrate fructose are substantially equivalent. The best drink is water or seltzer—it can be jazzed up with a squeeze of lemon or lime.  Water keeps us well hydrated, dampens our appetite and will quell our thirst that is sometimes confused for hunger.

It is important to be careful not to overdo sodium intake as it can cause fluid retention, high blood pressure, bloating, weight gain and a number of potential cardiac issues, aside from thwarting the emergence of our 6-packs.

Six-pack exercise regimen:

A general rule of thumb is to think “athletics” and the “aesthetics” will follow.   The key to exercise is diligence—carving out the time—and variety—strength  (resistance) training, cardiovascular (aerobic) training and core (abdominal and torso) conditioning, and perseverance.  A core synergistic exercise regimen, which is a combination of the aforementioned three types of exercise, provides a terrific overall workout. Pilates, yoga, and martial arts are three great means of obtaining a hard core, although there are many other effective exercises as well.  Pilates, in particular, is an awesome means of developing core strength.  I have been taking Pilates lessons weekly for over a year from an amazing instructor, Catherine Byron, who has been instrumental in helping me achieve a toned abdomen, core strength, better balance, posture and muscle symmetry (www.cbperformancepilates.com).  My friend and yoga instructor Ben Wisch, has also helped whip my core into shape (www.homeyogaexperience.com).  I  enjoy and have derived great benefit from home exercise DVDs from beachbody.com:  the P90x “ab ripper,” “core synergistic,” and “yoga” workouts and the P90x plus “abs-core” workout can’t be beat.

Muscles play a key role in our metabolism: they are extremely metabolically active, each pound of lean muscle burning about 50 calories/day.  With a sedentary existence and aging, there is a gradual loss of muscle mass and a resultant slowing in our resting metabolism.  By building and maintaining our muscle mass with strength training, we will raise our resting metabolic rate and burn more calories.  Additionally, exercise serves to increase the “insulin sensitivity” of muscle, which means that are muscles become more efficient at burning off carbohydrates as fuel. Exercise is also our endogenous stress reducer, lowering cortisol levels, suppressing our appetites and helping us burn carbs before they have a chance to be stored to fats.

We can measure our maximal heart rates by doing an aerobic activity, such as swimming, running or cycling full throttle until we can’t go on, and then taking our pulses.  In our workouts, if we can achieve a heart rate of 75% of our maximum rate and sustain that for 30-60 minutes daily, it is easily conceivable to burn 600 or more calories per day.   High intensity interval training—alternating between extremely intense exertion and regular “normal” exertion—can rapidly help propel us towards that sculpted body that lies within.
10 pearls to help your washboard abdomen emerge:

 1.    If you want a hard waist, you must incorporate exercise into your lifestyle, achieving balance between aerobic, resistance and core workouts.

2.    Eat high-quality, whole-grain, high-fiber carbs, lean protein sources (easy on meat and dairy) and healthy fats (vegetable and seafood-origin).

3.    Eat in accordance with nature’s design—meaning whole foods.  Avoid processed foods.  The best diet is an “anti-processed-atarian” diet.

4.    If you want to look good naked, don’t eat “naked” calories (stripped of fiber), so restrict sugar, simple white carbs, and liquid calories.  Aggressively steer clear of high fructose corn syrup.

5.    Soft foods (sugared drinks, white pasta, white rice, white bread, doughnuts, bagels, potatoes, etc., will earn you a soft core; hard foods (whole grain pasta, brown rice, whole grain breads, legumes, whole fruits and vegetables) will help earn you a hard core.

6.    Avoid giant meals in which the caloric load will be stored as fat; substitute with multiple smaller meals in which the calories will be used for immediate energy.

7.    Limit after dinner snacking since unnecessary calories at a time of minimal physical activity will be stored as fat.  If you restrict your evening snacking to one piece of fruit, you will wake up in the morning with less to pinch on your waistline.

8.    Drink plenty of water; use salt sparingly.

9.    Minimize stress; if you can’t eliminate it, manage it.

10. Get adequate amounts of quality sleep.

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

The 80-20 Diet

Blog #42    Andrew Siegel, M.D.

The Pareto Principle (also known as the “80–20 rule”) states that, for many circumstances, approximately 80% of the effects come from 20% of the causes.

Italian economist Vilfredo Pareto observed in 1906 that 80% of the land in Italy was owned by 20% of the population.  He also observed that 20% of the pea pods in his garden contained 80% of the peas.  It is a common precept that 80% of sales come from 20% of clients.  In my urology practice, 80% of my challenges come from 20% of my patients.

I have adapted the 80-20 rule as a general recommendation as to how to eat: essentially this means 80% healthy and the other 20% not so healthy.  By healthy, I am talking about a balanced diet with sufficient intake of quality macronutrients (protein, fats and carbohydrates) and micronutrients (vitamins and minerals) and avoidance of excessive calories.  This means real food: fruits, vegetables, whole grains, lean protein sources, etc.  By non-healthy, I mean…well, you know what is not healthy…fast food, junk food, processed food, French fries, pizza, cheeseburgers, candy, sweetened beverages, Cinnabon’s, doughnuts, pepperoni and salami, etc., etc.

Truth be told, my diet is probably closer to 90-10 or 85-15.  But if you can do an 80-20, then you are doing well.   My diet has a strong Mediterranean accent to it, so, for example, my dinner might consist of wild salmon on top of whole-grain pasta with a large, colorful salad and a piece of whole grain bread (although I must admit that some of the time it is not whole grain).  As a beverage I may just have one glass of wine or beer or, alternatively, plain or sparkling water with a piece of lemon or lime squeezed in.  For dessert, perhaps a dark chocolate-covered biscotti with a cup of herbal tea.

I love my carbs and sweets just as much as anyone else.  I just don’t like to drink calories, so I gave up sodas a few years ago and have never looked back.  I used to be a big fan of diet sodas, but gave them up as well…who needs artificial color, flavor and sweetener?  Most of the time, I drink good old water.  If I am going to drink calories, it is usually in the form of alcohol, in moderate amounts.

An occasional cookie, brownie, ice cream, piece of cake, pecan pie, etc., is not going to kill you or me, and does feel really good. There are certain foods that I find simply irresistible: prune hamentashen, crumb cake from B & W bakery, Carvel chocolate ice cream cake with crunchies, and a black raspberry “strong man” sundae (homemade black raspberry ice cream, hot fudge, shaved chocolate and whipped cream) at Baumgarten’s café.  These are all “20% foods” that I do eat, on occasion.  When I indulge, I do not feel good about my health, but the pleasure factor balances that out and knowing that it is just a small deviation and that I will get right back on track makes it okay.

Avoiding all unhealthy foods requires amazing discipline and the deprivation often will backfire, resulting in over-indulgence at a later time.  So I like to use a tactic that I refer to as vaccination/inoculation.  Many of us are accustomed to getting vaccinated and inoculated with a small dose of virus or bacteria to prevent an infection at a later date. The same concept can apply to eating.   Indulge with a small piece, a modest but satisfying and gratifying taste—a vaccination if you will—a small dose that will avoid depriving ourselves and prevent us from coming down with the disease—the obesity disease.  Just exercise moderation and don’t overdo it.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

FYI: One of my favorite “power snacks” that I sometimes eat mid-morning and which keeps me well-fueled until lunch:  6 ounces or so of non-fat yogurt (Greek yogurt is the best); add one ounce of raw oatmeal, a few raw almonds, (7 for purposes of the nutritional count that follows), sweeten with one pack of stevia, mix together and you have one awesomely delicious snack, moderate in calories, protein-packed, chock full of good fats and fiber and best of all, it is downright healthy for you, definitely in the “80% foods”!

Calories: 180, Protein: 12.5 grams, Unsaturated fat: 4 grams,  Saturated Fat: 0.4 grams, Carbs: 23 grams, Fiber: 2 grams

Losing Weight: Hard…Maintaining Weight Loss: Grueling!

 Blog #41  written by Andrew Siegel

Kudos to Tara Parker-Popes for her NY Times Magazine article entitled “The Fat Trap.” http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?_r=1&pagewanted=all

Bottom line: As we lose weight, our bodies change in terms of hormones and metabolism.  This biochemically-altered state persists after weight loss, spurring our appetite and ultimate renewed weight gain.  Thus, maintaining weight loss is an intense struggle in which we have to combat not only hunger and cravings, but also our body’s powerful internal drives.

After weight loss, ghrelin  (the hunger hormone that drives eating) rises from pre-weight loss levels, and leptin (the satiety hormone that suppresses hunger and increases metabolism) decreases from pre-weight loss levels.  Additionally, a number of other hormones associated with appetite and metabolism change and remain altered from pre-weight loss levels.  In essence, weight loss induces a unique metabolic state that causes a biochemical imperative to eat and regain weight.

Essentially, the body rebels against the weight loss long after the dieting has stopped.  This helps explain the sobering truth that once we become fat, most of us will remain fat. That stated, there are those who, in spite of biochemical forces that are obstacles, successfully achieve and maintain a normal weight after weight loss.

In addition to the internal biochemical imperative for weight gain after weight loss, our external environment aggravates the problem. We live in a culture where eating plays an enormously prominent role.  In our food-obsessed and food-centric society, it is very difficult, if not impossible, to avoid food cues and eating opportunities over the course of the day.  Our culture has reinforced using food for reasons that have no relationship to nutrition and energy, particularly when we eat for emotional reasons, ranging the gamut from reward-eating to stress-eating to boredom-eating.

Weight loss is not an easy task—we all know that pounds go on easily, but come off with great effort that involves fewer calories in and more calories out through exercise.  Many people are not successful at losing weight, although those who are truly disciplined can succeed.  Of those who do lose weight, most will ultimately regain the weight because of this combination of internal and external factors that conspire to thwart our best efforts.  These factors are so powerful that in order to overcome them to allow the weight loss to be permanent, a lifelong modification in our relationship with food must occur.  It is possible, but demands a dramatic change in mindset in order to resist our own internal biochemical imperative and the external “hostile” food environment.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

The Mind-Body Connection: How it Relates to Our Eating Behaviors

 Blog # 40

(Much of the following first paragraph is excerpted from the December 29, 2011 obituary of Dr. Robert Ader, written by Paul Vitello and published in The New York Times.)

Dr. Ader was an experimental psychologist who was among the first scientists to show how mental processes influence the body’s immune system, a seminal discovery that changed modern medicine.  You might say that he was the father of the “mind-body” connection.  His research was a touchstone for studies that have shown the communication network among immune cells, hormones, and neurotransmitters.  This field—psychoneuroimmunology—provides the science behind notions too often considered “magical thinking”:  that meditation helps reduce arterial plaque; that social bonds improve cancer survival; that people under stress catch more colds; and that placebos work not only on the human mind, but also on cells themselves.  Dr. Ader demonstrated that stress worsens illnesses, sometimes even setting them off, and that stress reduction is essential to health care.  To summarize Dr. Ader’s work in one phrase: Stop worrying or you’ll make yourself sick.

The fact that mental processes affect the immune system, hormones, and neurotransmitters has a profound influence on our eating behaviors.  An understanding of our mind-body relationship is fundamental in the effort to conquer eating issues.

Carly, age 40: “When I am stressed or have things on my mind or I am really tired, I eat sweets, like cakes and cookies. I don’t even give it any thought. I feel bad after and think about eating better or exercising, but I don’t act on these thoughts.”

Although it is convenient to think of our minds and bodies as separate and discrete entities, our emotional and cognitive sides do not exist independently of our flesh and physical beings. Our minds and bodies are very much commingled, and our mind-body connection is extensive. Our bodies house our minds, and our minds control our bodies, but our minds are made of matter just as our bodies are, and our bodies have a vast array of neural networks running through them that essentially are peripheral extensions of our minds. When our minds are unhealthy, often our bodies become unhealthy, and vice-versa. Optimal human functioning and performance requires a coordinated and harmonious relationship between our minds and bodies.

The following are a few examples of the mind-body connection:

When you become embarrassed your cheeks get a crimson flush.

When you are driving and the car in front of you comes to a sudden and unexpected stop, you respond by slamming on your brakes and just miss a rear-ending collision, your heart races, your pupils dilate and your breathing pattern is rapid and deep. 

When you are fatigued after a hard day of work but can muster up the fortitude for a workout, you can emerge physically and emotionally invigorated, stress relieved, fatigue washed away—refreshed with a wonderful feeling of well-being.

The above examples show how our minds can affect our bodies—blood flowing to our face in the blush response and the classic physiological stress response; and how the body can affect the mind—physical exercise transforming an emotional state. The essence of the mind-body connection is that our thoughts, feelings and emotions can affect our body chemistries and cause a physical response, and conversely, our physical actions, like exercise or laughter, can influence our brain chemistries and affect our thoughts, feelings and emotions.

How is the mind-body connection relevant to eating?

We are highly emotional creatures and it these feelings that are one of the key features that separate us from other members of the animal kingdom. We bring our emotions to every situation, and on a certain level we are all emotional eaters since we all bring our emotions “to the table” in this sense. It is impossible to separate emotions from eating and, with this in mind, it becomes easier to understand how our emotions can cause unhealthy eating patterns.

There are wide ranges of emotions that can trigger eating. Exhaustion, stress, boredom, anxiety, anger, loneliness, sadness, depression, frustration, resentment, disappointment, issues of self-esteem, and interpersonal conflicts are some of the negative emotions that can drive eating. Positive emotions including hopefulness, happiness and confidence can also spark emotional eating. In general, it appears that negative emotions demand neutralizing and positive emotions fuel our passion for eating. There are many among us who use food as a refuge from negative emotions, and for whom food serves as both a “friend” and “therapist”; however, there are certainly, some of us who turn off from eating under the same circumstances. Thus, there is a wide range of eating responses to emotions and all of us “metabolize” our feelings differently.

Stress seems to be our most compelling emotional drive to eat, second only to hunger as a motivation to eat. It is the rare person who does not lead a stressful existence. Stress seems to pummel our souls and eating serves as a mechanism to sooth our beaten-up inner beings— a means of distracting us from our troubles and escaping from the real-life problems and unpleasant aspects of our daily lives.  Life can oftentimes be very tough and food can provide an immediate source of comfort and relief, just as a cigarette can to a smoker or alcohol to a drinker. Many of us, particularly after a very stressful day, head straight for the refrigerator after arriving home from work, seeking solace, refuge and sanctuary.

Interestingly, it seems that when we eat for negative emotional reasons we tend to gravitate to unhealthy foods—it would appear that we desire the kind of foods that will match the emotion driving the eating. Self-destructive emotions beg for self-destructive eating behaviors and self-destructive foods.

In accordance with the work of Dr. Ader, there is a biochemical explanation for stress eating. The adrenal gland hormone cortisol—released in response to stress—can stimulate our appetites and cravings for sugar.  This is the very reason people on corticosteroid medications tend to have enormous appetites, gain weight, and have a tendency for obesity. Cortisol also functions to reduce the satiety hormone leptin, further stimulating our appetites. Additionally, the consumption of certain foods, especially those containing sugar and fat, can cause release of endorphins that are powerful morphine-like chemicals with pain-relieving properties. Is it any wonder that food serves a role as a sedative?  It is of great interest to note that exercise can also release large amounts of these endorphins, so better to head to the gym than the fridge when stressed!

In summary, our emotional state—in a constant state of flux—affects our neurotransmitters, hormones and immune cells.  The variable state of our internal biochemical environment that occurs in response to our emotional state is capable of profoundly influencing our behaviors, including eating. In spite of the biochemical imperative to eat driven by certain emotions, understanding the influence of the mind-body connection is one of the first steps towards overcoming unhealthy eating patterns.

A healthy and sunny 2012 to all!

Andrew Siegel, M.D.

www.PromiscuousEating.com for more info on my book: Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship With Food

Harmonize (Like Simon and Garfunkel) with Good Eating and Physical Activity

Blog #38 by Andrew Siegel, M.D.

Harmonizing is combining simultaneously sounded musical notes to produce chords having a blended, soothing and pleasant effect. In my opinion, Simon and Garfunkel harmonize like no other two singers—each alone have amazing voices but together they combine with a powerful chemistry to create a really special sound—think Scarborough Fair: http://www.youtube.com/watch?v=BYQaD2CAi9A

The mathematical metaphor for harmonizing (synergy) is 1 + 1 = 3.  I am reminded of one of my favorite sci-fi movies, The Fifth Element, directed by Luc Besson, in which a climactic scene shows the harmonizing of the four elements earth, wind, water and fire with the fifth element (a character played by the actress Milla Jovovich) to create a unique and memorable synergy.

I borrow these music, mathematical and cinema metaphors and apply them to the wellness arena.  Here, the two players are healthy eating and exercise.  There are four permutations of these two players:

Healthy eating + exercise

Healthy eating + no exercise

Unhealthy eating + exercise

Unhealthy eating + no exercise

On the wellness index, the top combination reigns supreme; the middle two, less so; and the bottom clearly ranks as a bad duo.

To put it another way, if Paul Simon’s voice represents healthy eating, Art Garfunkel’s voice represents exercise, my tonally challenged voice represents unhealthy eating and my wife’s tonally challenged voice represents no exercise, then we have the following combos:

Paul Simon + Art Garfunkel = Simon and Garfunkel

Paul Simon + my wife = not so good, as my wife will poison Paul Simon’s sound

Me + Art Garfunkel = not so good, as I will poison Art Garfunkel’s sound

Me + my wife = disaster (lol)!

The foundations of wellness are the combination of healthy eating and exercise.  Healthy eating means the right quality and quantity of the food that we consume.  Healthy eating and maintaining a healthy weight are very important, but are simply not enough to achieve wellness, in the absence of exercise.  By the same token, subjecting our bodies to exercise on a regular basis is fundamental to our good health, but not sufficient to maintain wellness.  Physical fitness has everything to do with how much we exercise and does not bear a direct correlation with our weight. (Of course, if we are obese, there is no way that we can be fit since fitness demands a reasonable weight.) There are very lean individuals who eat well but never exercise and are clearly in a poor state of physical fitness; if they had to run a couple of miles, they would likely end up incredibly winded. By the same token, there are very athletic and physically fit individuals who exercise daily but do not eat well, consuming excessive calories and carrying too many pounds. So, wellness demands healthy eating, maintaining a reasonable weight AND exercising to achieve cardiovascular health (endurance) and strength (involving our core and skeletal muscles).

A human body is far better engineered than the most expensive Mercedes Benz.  Both the costly vehicle and our bodies need to be cared for.  They both require high quality fuel in their tanks.  They both need to be used regularly—the way they were designed to—not sitting idle in the garage or couch, respectively, wasting away and gathering dust.  They both thrive on being taken out on the road for sprints as well as long rides.  They both demand being cared for and not abused.  If their engines and their bodies are kept clean, shiny, bright and humming, they will both last a very long time. Both the car and our bodies may have a lot of miles and years on them, but if attended to properly, they can run like new for many more miles and years.

It makes sense to fuel up with premium fuel so that our engines run as efficiently as possible.  We are most fortunate to be alive and only go through life once, so it behooves us to eat quality, nutritious foods that will provide us with energy and the proper balance of carbohydrates, proteins, fats, vitamins, and minerals to allow us to live a healthy and long existence.  Unlike our vehicles, our bodies are in a constant state of flux—tissues are continually being destroyed and remade.  The building blocks for the repair process come from the makeup of our diets.  So we literally are what we eat.  Furthermore, we are what we eat eats, and what we eat eats eats as well.  In other words, if your salmon dinner last night originated from the Pacific Northwest and dined on krill and other natural foods, its composition was very much different from the farmed salmon brought up on corn products and processed salmon feed.  The point is to have your building blocks be high quality components, just as you would use if you were replacing vital parts in your car.

Our food choices go a long way in terms of forming the foundation of our wellness destiny. Healthy eating is a lifelong experiment that should continue to evolve if one eats mindfully.  It is not so much what we choose to eat, but what we elect not to eat—essentially, by avoiding the “bad,” by default we will be fueling ourselves with the “good.”  In other words, there are a great variety of quality, healthy foods that can nourish us, and it is not that important what our specific choices are as long as there is balance, sufficient intake of macro-nutrients (protein, fats and carbohydrates) and micro-nutrients (vitamins and minerals), and avoidance of excessive calories. The key is to stay away from processed, reconstituted, unhealthy, mystery, fake foods. Processed food is real food that has been altered in order to lower its cost, lengthen its shelf life, make it look more appealing and make us want to eat more of it, resulting in a reduction of nutritional content and an increase in chemicals, dyes, preservatives and toxins.

Like our vehicles, our bodies also need to be used the way they were meant to be.  We were not designed to be sedentary creatures, but were given the gift of motion to help us survive.  Whether this motion is organized into exercise, sports or fitness pursuits, or is integrated into our lifestyles matters not; what matters is that we keep on moving.  Exercise burns calories, improves our strength and fitness and makes us feel energized.  The short-term positive effects of exercise are the psychological and physical benefits of stress busting, improvement of mood, fatigue reduction, and increase of energy. Long-term benefits include reduction in risk for diabetes, cardiovascular diseases, stroke, hypertension, some cancers, osteoporosis, chronic medical problems, falls, and physical disability. An exercise regimen is also useful for increasing muscular strength and tone, reducing body fat, and helping with weight control. Exercise will help lower blood pressure and our “bad” cholesterol (LDL) as well as raise our “good” cholesterol (HDL). Biological aging is thought to be partly on the basis of oxidative stress, which is reduced by exercise, so exercise can keep us looking and acting youthful.

When our physical fitness improves, it seems to help inspire good eating habits. Equally so, good eating habits seem to motivate many of us to exercise. So, there seems to be a harmony between exercise and healthy eating—healthy habits engender more healthy habits and unhealthy habits promote unhealthy habits. Many of those I interviewed for Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship With Food reported that if they were actively engaged in some sort of exercise regimen, they were less likely to binge or eat poorly, and if they were not exercising, they were more likely to succumb to unhealthy eating behaviors. The military term cascading system failure refers to a failure in one area causing a failure in a different area that would not ordinarily fail. That is precisely what often happens to our eating habits when we fail to maintain our exercise regimen and what often happens to our exercise regimen when we are not vigilant about our eating. Hopefully, the cognitive dissonance that occurs when healthy eating occurs without exercise or exercise occurs with out healthy eating will act to promote the harmonious incorporation of both into our daily routines.

Why do exercise and healthy eating harmonize so nicely together?

Many of those who have the self-restraint to eat a healthy diet and maintain a good weight come to an understanding that adding exercise improves the way they feel and their overall well being.  Those who are ardent exercisers usually come to the realization that they need to fuel up with quality nutrition to maximize their performance and keep their weight steady.  Additionally, those with the discipline and perseverance to put in the hours and the effort to exercise on a regular basis simply do not want to spoil their hard work by poor eating.

Bottom line: healthy eating and exercise harmonize in a way that will make your heart sing!

George, age 53

“When I exercise, I am more careful about eating.”

Justin, age 35

“Exercise drives my healthy eating; when I fall off my exercise regimen, I start eating pizza, burgers and deli sandwiches. The combination of exercise and healthy eating creates great rhythm.”

A wonderful Christmas and Hanukkah to all!

Andrew Siegel, M.D.

www.PromiscuousEating.com

“Health and wellness sure beats wealth and hellness.”

Why Should You Bother to Read My Blog?

Blog # 38

Let me start with a true story: Twenty-three years ago, I saved a person’s life.

I was moonlighting in a Kaiser-Permanente emergency room in Los Angeles when a young man was rushed in with a gunshot wound.   He happened to be a receptionist who worked in that very emergency room. He had sustained a chest wound and his blood pressure remained dangerously low despite having received many liters of intravenous fluid. At that time, I was a resident working the graveyard shift in the emergency room, covering surgical “emergencies,” most of which were rather minor; this, however, was major as he was at imminent risk of dying.   I entertained the possibility of a condition in which there is bleeding into the tissues around the heart, which compresses the heart and will not allow it to beat normally—cardiac tamponade.  There was simply no time as the patient was rapidly going downhill, and as there was no chest surgeon around, I—never previously having had done this, having only read about it—took a syringe and needle, carefully penetrated his chest wall, passed the needle into his pericardial space and was able to suck out a syringe of blood.  His blood pressure instantaneously rose and as he stabilized, I accompanied him on the elevator to the operating room, leaning over him and holding the syringe that was impaled in his chest, continuing to suck out blood.  As soon as the thoracic surgery team arrived, the patient had his chest cracked, the tear in the pericardium repaired, and the tamponade corrected.  He was discharged from the hospital within a few days, stopping down in the ER and offering me a profusion of thanks before he went home.

What a delightful and rewarding feeling it was to be able to save a person’s life!  I will never forget that unusual day, because for us urologists, absolute life-and-death emergencies are few and far between, and we are in the habit of saving lives “slowly.”  I believe (hope!) that a blog about health and wellness issues is also capable of saving lives, not acutely like the intervention for a cardiac tamponade, but slowly, gradually and meaningfully by the process of education and instilling a sense of the importance of proactive, preventative, pre-emptive measures.

The original intent of my blogging efforts was a means of marketing my Promiscuous Eating book.  That stated, the blog writing evolved into an enjoyable weekly process that I relish and look forward to creating.  I guess this shouldn’t be surprising as I have always been rather fond of writing, wellness advocacy, and education and communication with respect to public health issues.  To date, I have written almost 40 blogs (listed below), and plan on continuing to do so weekly.  I find the topics stimulating to work on and I am provided with a great sense of gratification in that I am “trying to make a dent in the universe,” in the words of Steve Jobs.  In the future, I intend to expand into broader general health issues, going beyond the diet and exercise arena. There clearly exists a communication gap between physicians and patients and my blog attempts to bridge that gap and provide a free service that will help educate, inform and engage. Hopefully, the information provided—in some way—will help readers obtain and maintain both quality and quantity of life.

You can subscribe to the blog (no charge for this, of course) at the following site: www.PromiscuousEating.wordpress.com

Feel free to recommend the blog to friends, colleagues or relatives who may be interested.  I welcome constructive criticism and recommendations for topics.

My background: I grew up in Teaneck, New Jersey and after attending Middlebury College and Syracuse University, attended Chicago Medical School.  I did surgery training at North Shore Hospital and urology at U. Penn followed by a fellowship at UCLA.  I have been in urology practice in Northern New Jersey since 1988.  I have been an active writer throughout my career, contributing chapters to several textbooks and numerous articles in an array of medical journals. I have presented papers at professional meetings for many medical societies both nationally and internationally. I am actively involved in medical student and resident education at Hackensack University Medical Center.

I am an avid believer in remaining young, healthy and fit through the practice of exercise, nutritional conscientiousness and intelligent lifestyle choices. I have written FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity, published in 2008. My second book, PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food, was published in 2011. I am passionate and enthusiastic about public health issues and wellness advocacy and my goal is educating the community about healthy lifestyles and preventative measures that help ensure maximum fitness, nutrition, disease avoidance and longevity.  I have done over thirty educational videos on a variety of health subjects, all accessible on my YouTube channel at: www.youtube.com/incontinencedoc and have written many patient education monographs, all available online at: www. BergenUrological.com

I live in Ridgewood, New Jersey, with my wife, Leslie, and 12 year-old daughter, Isabelle and English Springer Spaniel puppy, Charley Morgan.  My oldest child, Jeff, graduated New York University Film School in 2006 and my 19 year-old daughter, Alexa, attends Tulane University. I am an avid reader and enjoy photography, movies, tennis, cycling, golf, yoga, Pilates and fitness training.

Andrew Siegel, M.D.

www.PromiscuousEating.com

My Blogs:

1)   FATigue Eating

2)   Seasonal Eating and Weight Gain

3)   Food Perspectives

4)   Strategies for Combating Opportunistic and Temptation Eating

5)   My Own Promiscuous Eating: Fatigue Eating Redux

6)   So you want to drop a few pounds: what’s more efficient…eating less or exercising more?

7)   Have a Very Sweet Mother’s Day…But Not With Too Much Fructose

8)   Maximizing Our Beach Body Appearance

9)   Is Processed Food Really Any Different From Tobacco?

10)                  Does Weight Gain Influence Urinary Control Issues?

11)                  A Synopsis of Gary Taubes’ “Why We Get Fat And What To Do About It”

12)                  Elective Male Sexual Dysfunction: How We Are Eating Ourselves Limp

13)                  100 Pearls excerpted from Promiscuous Eating Book

14)                  Hydration for Health

15)                  Questionable Cuisine

16)                  A Synopsis of Brian Wansink’s: “Mindless Eating: Why We Eat More Than We Think”

17)                  E. Coli Contamination Of Our Food

18)                  Scary Stuff: Our Drinking Water

19)                  Male Obesity Causes Low Testosterone With Potentially Dire Medical Consequences

20)                  What is the best diet for us?

21)                  My Freshman Fifteen

22)                  To Vitamin Supplement or Not…That is the question

23)                  Tempus Fugit (Time is flying)

24)                  Wealth is Health: Your Exercise Savings Account

25)                  Aging Young

26)                  Psych 101 as it relates to eating

27)                  Prostate Cancer: Can Diet and Lifestyle Make a Difference?

28)                  Until Apple Invents the iFinger, PSA Is The Next Best Thing

29)                  Boredom Eating

30)                  Prelude to Excess—Strategies to Deal With Eating Orgies

31)                  I’m Your Doc, Not Your Provider!

32)                  Eating Mantra

33)                  Exercise to Exorcise

34)                  My Favorite Quotes: Health, Wellness and Miscellany

35)                  Promiscuous Eating: Food Naughty Behavior

36)                  Is There a Best Exercise?

37)                  S.A.D. (Seasonal Affective Disorder) Makes Me F.A.T.

S.A.D. (Seasonal Affective Disorder) Makes Me F.A.T.

If we had no winter, the spring would not be so pleasant; if we did not sometimes taste adversity, prosperity would not be so welcome.

Anne Bradstreet (17^th century poet)

Like many others, I adore the spring and summer—relishing the sunshine, the vibrant blues and greens that dominate the outside palette, and the long hours of summer daylight.  One of the greatest thrills I have ever experienced was to be in Northern Europe in June where it stayed light until near midnight.  I feel most alive when exposed to sunlight, warmth, vibrant natural colors, scents such as honeysuckle and lilacs, and the background white noise of cicadas.  How delightful it is to be outdoors scantily clad in shorts and a short-sleeved shirt—cycling, playing tennis or golf, or just throwing a Frisbee for my English Springer Spaniel, Charley Morgan.

Light profoundly affects my mood.  Sitting in my living room on one of those days when the sun is in and out behind a cover of clouds, I am made acutely aware of how a sudden darkening of my environment makes me gloomy and a sudden lightening makes me happy.  I can virtually dial up my mood when the brightness of the lighting in my basement or living room is controlled with a rheostat.

I am among the 5-10% of the population that suffer with an affliction known as Seasonal Affective Disorder (S.A.D.). The prevalence of S.A.D. is highest towards the north and south poles and lowest at the equator.  It is quite common in the Scandinavian countries, where light is in limited supply during the winter.  Due to the very short winter days, these winter blues are characterized by variable degrees of melancholy brought on by the dark, cold and colorless external environment. The feelings of hibernation and stagnancy are distinctly unpleasant for any of us who are afflicted with S.A.D.  I am fortunate to be affected in only a mild way, much less so than many who suffer with depression, concentration issues, loss of energy and sexual drive, sleep disturbances, exhaustion, and withdrawal from friends, family and social activities. Various theories have been proposed to explain S.A.D., including a biochemical basis involving the chemicals serotonin and melatonin, but the jury is still out on the precise underlying basis.

Cold weather and darkness also directly affect our eating behaviors; they seem to conspire against healthy and disciplined consumption patterns and beg for relief by means of comfort foods.  For many of us, winter fosters a type of foraging activity that causes us to satisfy carbohydrate cravings and seek solace in rich, heavy foods including stews, creamy soups and starches.  Additionally, being more housebound in the winter leaves abundant opportunities for “boredom” eating, providing fewer distractions from eating that are possible in the warmer times of the year. The sleep disturbance that many with S.A.D. experience can lead to “fatigue” eating. During winter, outdoor exercise/activities dramatically decline; at the same time, there is less availability of healthy fresh fruits and vegetables that are abundant in summer.  There is less opportunity for grilling, a healthier form of cooking than many other alternatives. Unfortunately, all of the forces discussed above can work together and lead to winter weight gain.

So what to do to cope with S.A.D. causing the winter doldrums and the potential for unhealthy weight gain?  Options include melatonin supplements (a naturally-occurring hormone that maintains our circadian rhythms); anti-depressant medications; and cognitive-behavioral therapy or occupational therapy (both of which can help S.A.D. sufferers function at more optimal levels during their “dark” times).  My preference is to use exercise as an effective means of keeping the blues at bay.  It nudges the pharmacy within to release a cocktail of “happy” chemicals including serotonin (which modulates mood, emotion, sleep and appetite). A daily dose of exercise will not only help release the natural anti-depressants within, but will burn calories and help prevent the weight gain.  I wholeheartedly recommend tapping into our own pharmacy within before reaching for the products of Big Pharma.

If you can swing it, a winter vacation to a nice sun-drenched Caribbean island can be just what the doctor ordered.  If this is not feasible, a therapeutic bright light box is an alternative that can provide the much-needed daily dose of light.  Another tonic to soothe the blues is music, capable of producing a steep rise in a listener’s serotonin levels.  Ultimately, having purpose and remaining busy, productive and engaged in meaningful activities is one of the best means of staying focused and keeping the effects of S.A.D. at bay.  So whatever it is you choose to do to chase those blues away, do it with passion and gusto.

 In the depth of winter, I finally learned that within me there lay an invincible summer.

Albert Camus

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship With Food

Available at www.PromiscuousEating.com; e-book available on Amazon.