Bladder Infections In Women

 Bladder infections (cystitis) are relatively common occurrences among females.  Acute uncomplicated bacterial cystitis is an infection of the bladder that can cause burning, frequency, urgency, bleeding, urinating small volumes, incontinence, and pain (abdominal, pelvic, or lower back).  Lab studies usually show bacteria, white blood cells and red blood cells in the urine. 80-90% of cystitis is caused by Escherichia coli, 5-15% by Staphylococcus and the remainder by less common pathogens including Klebsiella, Proteus, and Enterococcus.

 Cystitis occurs when bacteria that normally inhabit the colon gain access to the urinary bladder. While cystitis is common among the female population, it is rare among the male population.  Anatomical differences that promote cystitis in women are the short female urethra and the close proximity of the urethra to the vagina and anus, areas that are normally colonized with bacteria.  The occasional occurrence of cystitis—while a nuisance and oftentimes uncomfortable—is usually easily treated with a short course of antibiotics.   When bladder infections recur time and again, it becomes a major source of inconvenience and suffering for the patient, and it becomes important to fully investigate the source of the recurrence.

 A urinary infection is considered complicated under the following conditions:  if it involves the kidneys; if it occurs during pregnancy; if the bacteria are highly resistant to antibiotics; if there is a structural abnormality of the urinary tract; if it occurs in immune-compromised patients, including diabetics; in the presence of a “foreign body” such as an indwelling urinary catheter, urinary stent or urinary tract stone.

 For an infection to develop, there has to be vaginal colonization with pathogenic bacteria (bacteria that can cause an infection and not the normal healthy bacteria that reside in the vagina); movement of these bacteria into the bladder; and finally, attachment of the bacteria to the cells that line the bladder.  Whether or not an infection develops is based upon the interaction of female protective mechanisms (“defense”) and bacterial virulence factors (“offense”). “Defense” factors include an acidic vagina, which inhibits the growth of the type of bacteria that cause infections while promoting the growth of “good” bacteria such as lactobacilli; the presence of a mucopolysaccharide layer that protects the bladder lining; and immune cells present in the urine that block the adherence of bacteria to the bladder cells.  Additionally, the dilution action of urine production and the flushing effect of urinating can wash out bacteria before they have a chance to latch on to the lining of the bladder.  Bacterial “offense” factors include fimbriae, tentacle-like structures that promote attachment to the bladder lining cells and the capability of bacteria to evolve and develop resistance to antibiotics.

  Women aged 18-24 years old have the greatest prevalence of acute uncomplicated bacterial cystitis and sexual activity often is a factor in bacteria finding their way into the urethra and bladder, hence the term “honeymoon cystitis.”  The following are risk factors for cystitis: a new sexual partner; recent sexual intercourse; the use of spermicides, diaphragms or spermicide-coated condoms. Spermicides can change the vaginal “environment” and promote the presence of different bacteria from the normal flora. Being overweight can play a role in promoting cystitis because it is more difficult to maintain good hygiene under these circumstances.

  Cystitis also occurs with increased prevalence in the post-menopausal population, based upon changes that happen because of estrogen deficiency.  As a result of low levels of estrogen, there is a change in the normal bacteria (flora) of the vagina in which E. Coli replaces lactobacilli.  Topical estrogen cream has been shown to reverse vaginal colonization with E. Coli and helps prevent cystitis.  Other factors are an age-related decline in immunity; incomplete bladder emptying; and the not uncommon occurrence of urinary and fecal incontinence often managed with pads, which remain moist and contaminated and can promote movement of bacteria from the anal area towards the urethra.  The presence of diabetes (particularly when poorly controlled, with high levels of glucose in the urine that can be thought of as “fertilizer” for bacteria), neurological diseases, pelvic organ prolapse, obesity and poor hygiene further increase the prevalence of cystitis among older women

 It is important to distinguish a symptomatic urinary infection from asymptomatic bacteriuria, urethritis, vaginitis, and Painful Bladder Syndrome (PBS)/Interstitial Cystitis (IC).  Asymptomatic bacteriuria is the presence of bacteria within the bladder without causing an infection.  Asymptomatic bacteriuria does not require treatment, since treatment is most often futile and achieves nothing but selection of a resistant organism—in other words, by unnecessarily exposing bacteria to an antibiotic environment, bacteria can evolve and adapt to become modified in such a way that the antibiotic is no longer effective. Asymptomatic bacteriuria needs only to be treated in pregnant women and in patients undergoing urological-gynecological surgical procedures.  Urethritis is an infection in the urethra; vaginitis is a vaginal infection; and PBS/IC (Painful Bladder Syndrome/Interstitial Cystitis) is a chronic inflammatory condition of the bladder that can mimic the symptoms of cystitis.

 The diagnosis of cystitis is on the basis of urinalysis and culture.  A urine specimen is obtained after cleansing of the vaginal area with an antibacterial wipe and collection of a mid-stream voided specimen. At times, catheterization is necessary to obtain a specimen.  Dipstick is the fastest and least expensive means of screening for an infection, but it is not very accurate and fraught with false positives and negatives.  Microscopy is much more accurate, seeking the presence of bacteria, white blood cells and red blood cells.  The definitive test is urine culture and sensitivity, which will demonstrate the bacteria responsible for the infection, the quantitative bacterial count, and those antibiotics that are most likely to be effective.

    Treatment of cystitis is based upon antibiotics to eradicate the bacteria. In the case of recurrent cystitis, it is important to do an evaluation to rule out a structural cause. This generally involves imaging—often an ultrasound (using sound waves to obtain an image of the urinary tract)—and a cystoscopy (a visual inspection of the urethra and bladder with a flexible scope).  This will check the entire urinary tract, including the kidneys and bladder.  Findings may be a (cystocele) dropped bladder, a stone within the urinary tract, a urethral stricture (a narrowing in the channel leading out of the bladder that causes an obstruction), a urethral diverticulum (a pocket connected to the urethra), or a fistula (abnormal connection between the colon and bladder).

    After treatment of the acute infection, it is important to make changes in order to help minimize recurrent episodes of cystitis.  After urination or a bowel movement, it is important to wipe in a top-to-bottom direction to avoid bringing bacteria from the anus up towards the urethra.  It is also important to remain well hydrated to keep the urine from becoming very concentrated:  “The solution to pollution is dilution” applies well to urinary infections.  It is important to urinate on a regular basis over the course of the day, utilizing the natural flushing effect of urination to wash out the bladder and keep it from becoming over-distended.  Many workers such as nurses and teachers do not have the time to empty their bladders during the course of their days, and they often end up predisposed to cystitis.  It is very important to urinate after sexual activity to help flush out any bacteria that may have been introduced into the urethra and the bladder.

   One option for the management of recurrent cystitis is the self-administration of a short course of antibiotics when the cystitis symptoms first occur.  It is useful to first test your urine using a dipstick (although not perfect, it is great for home screening) when the symptoms of cystitis arise. This has proven to be safe, economical and effective.  Alternatively, a single dose of antibiotic can be administered just before or after sexual activity if the infections are clearly sexually related.  Another possibility is a single dose of antibiotic administered on a prophylactic basis every evening or every other evening to prevent recurrent cystitis.  Methenamine is converted to formaldehyde in the urine and can help prevent recurrent infections. Cranberries, lingonberries, and blueberries contain proanthocyanidins that inhibit the adherence of bacteria fimbriae to the bladder cells, acting as anti-adhesives and helping to prevent bacteria from attaching onto bladder cells and causing an infection.  There are formulations of cranberry extract available to avoid the high carbohydrate load of cranberry juice.  Estrogen cream applied vaginally can help restore the normal vaginal flora and thus help prevent cystitis.  Probiotics promote healthy bacteria colonization of the vagina, production of hydrogen peroxide that is toxic to bacteria, maintenance of acidic urine, induction of an anti-inflammatory response in bladder cells, and inhibition of attachment between bacteria and the bladder cells.

   In summary, bladder infections in females are common, annoying, but rarely serious.  They are very treatable, and those who suffer with recurrent infections can be nicely managed.

                      Pearls To Help Keep Cystitis Away

• Wipe in a top-to-bottom motion after using the bathroom
• Stay well hydrated to keep the urine dilute
• At minimum, urinate every four hours while awake to avoid an over-distended bladder
• Maintain a healthy weight
• Urinate after sexual activity
• If infections are clearly sexual related, an antibiotic taken pre or post-sexually can usually preempt the cystitis
• If you are diabetic, maintain the best control possible
• Topical estrogen can be helpful for the post-menopausal female
• Seek urological consultation for recurrent infections to check for an underlying and correctable structural cause; if none are found, there are a number of means of managing recurrences, including self-diagnosis/self-treatment; daily antibiotic prophylaxis; daily methenamine; cranberry extract; probiotics

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Now available on Amazon Kindle

To view my educational video on bladder infections:

http://www.youtube.com/watch?v=awvKBc0WRo4

 

Low Caloric Density Diet: A Healthy Means Of Shedding Pounds

Blog #49     Andrew Siegel, M.D

Bottom line: Eating too much high caloric-density food has contributed to the obesity epidemic.  A diet consisting of low-caloric density foods will allow us to eat more food, but with fewer intake of calories.  This will keep us satisfied and limit the intake of excessive calories, promoting the maintenance of a healthy weight and general well being.

Density is defined as mass per unit volume.   For example, New Jersey is the densest state in the nation in terms of population, with the highest number of people per square mile.  All foods have a property called caloric density (energy density), which is defined as food calories divided by food weight.  Weight can be used as a substitute for volume since it is easier and more precise to weigh a food item than measure its volume.    

A major factor in high caloric vs. low caloric density is water content. Water serves to increase the volume of a food without adding any calories.  Another factor is fat content since fat packs a whopping 9 calories/gram as opposed to carbohydrates and proteins that are 4 calories/gram.  Thus, the less fat and more water content a food has, the lower its caloric density and the less amount of calories per unit weight it provides. For example, a given weight of vegetables has a lower caloric density than the same given weight of pizza.  Most fruits and vegetables have a very low calorie per weight measure.  On the other hand, many meats are high in caloric density.

One reason that we get fat is because we consume too many foods that have a high caloric density. One goal of a healthy eating plan is to eat foods that have a relatively low ratio of calories to weight–this will serve to keep our calorie count under control, yet the weight of the food consumed will keep us satisfied, if not full.  Dropping a few pounds simply becomes a matter of avoiding or minimizing high caloric density foods and replacing them with foods with low caloric density.  Additionally, combining low caloric density foods with high caloric density foods can lower the overall caloric density of a meal, making it healthier.  A classic example is raisins as opposed to grapes.  Twenty grapes have the same amount of calories as twenty raisins, but much more volume and weight.  It would be easy to hold twenty raisins in your palm and pop them into your mouth; doing the same with the identical number of grapes would be virtually impossible.  The difference is the presence of the increased water content of the grapes as opposed to the minimal water content of the dried fruit.  The water content of the grapes makes them occupy a much greater volume in your hand as well as in your stomach, which makes them much more satisfying than raisins in terms of quelling hunger as well as thirst.  It is difficult to get full on raisins since they are so dense, but easy to do so on grapes because they have so much volume.  It is therefore very easy to consume excessive calories munching on a box of raisins, but much more difficult to do so with a bowl full of grapes.  The greater volume lends itself to not only feeling satisfied, but also to built-in portion control.

As another example, let us compare fruit juices to whole fruit.  It is very easy to drink 12 ounces of orange juice, what in essence amounts to about 170 calories of less-than-healthy 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.  I can’t begin to imagine eating three oranges—the bulk and weight from the fiber is just too filling, plus the work involved in peeling the orange would certainly be a deterrent.  Additionally, the orange is a discrete unit that naturally lends itself to a defined volume of consumption, while there is absolutely no such clear-cut unit with the juiced by-product.

Most people eat a more-or-less consistent volume (weight) of food on a daily basis.  So, by choosing foods of less caloric density, one will feel fuller on a diet of fewer calories.  That is the principle behind a low-density, high-volume diet.  This is essentially the same concept behind drinking a glass or two of water before every meal.  This will not only quench thirst that can be confused with hunger, but can serve to stimulate the receptors in the stomach that trigger fullness. A low caloric-dense diet achieves the same endpoint by having the water content within the food itself.  Water adds weight and volume to foods, but adds no calories.

The same applies to air—it adds volume without calories.  When you froth up a smoothie in the blender, air is folded into the concoction, which increases volume without changing the weight or calories, and this extra volume will stimulate the fullness receptors in the stomach.

Calorie density counts of selected foods (Adapted from The Ultimate Volumetrics Diet by Barbara Rolls)

Food     /    Calorie density

Water 0.0

Celery 0.1

Salad greens 0.2

Cantaloupe 0.3

Peach 0.4

Apple 0.5

Lentil soup 0.6

Grapes 0.7

Cooked peas 0.8

Baked potato 0.9

Banana 1.1

Cooked whole wheat pasta   1.2

Avocado 1.6

Hummus 1.8

Lean broiled ground beef      2.2

Bread 2.7

Ice cream 2.8

French fries 2.9

Raisins 3.1

Hard pretzels 3.5

Brownie 4.1

Trail mix 4.3

Cooked bacon 5.2

Dark chocolate 5.7

Peanut butter 6.3

Olive oil 8.8

 

Pearls:

• Beware of caloric-dense foods like dried fruit as it is much easier to overdo caloric consumption: raisins vs. grapes, prunes vs. plums, dried figs vs. whole figs, etc.
• Start meals with soup, salad or cut up fresh fruit—this low-density caloric consumption will fill you up and minimize the chances of over-eating caloric dense entrees
• Drink low caloric density beverages including water, seltzer or herbal teas instead of high caloric density, liquid calories from sodas, sweetened beverages or juices
• Dilute juices with seltzer to decrease their calorie density
• Drink light beer instead of full beers
• Dilute thick soups with water to decrease the caloric density
• Add chopped vegetables to pizza, pasta, casseroles, stews, meat loaf, macaroni and cheese and soups
• Add pureed vegetables to sauces and toppings
• Add extra carrots to carrot cake, extra zucchini to zucchini bread, etc.
• Instead of ice cream as a dessert, have an assortment of fruits and add a small scoop of ice cream as a topping
• Use less caloric-dense toppings on potatoes such as Greek yogurt as an alternative to sour cream
• Use less caloric-dense bases for dips such as Greek yogurt instead of sour cream
• Use less caloric-dense bases for salad dressings such as Greek yogurt instead of mayonnaise
• Eat less caloric-dense snacks such as baked chips instead of fried chips
• An apple is much less calorie dense than a piece of apple pie
• Enjoy natural caloric-dense foods as an alternative to processed caloric-dense foods, e.g., a refrigerated dried fig or two as an alternative to candy for a sweet

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Now available on Amazon Kindle

Testosterone Replacement Therapy Vs. Performance Enhancing Drugs: A Whole Different Ball Game

Recently, an appeals court ruled that Alberto Contador, the three-time winner of the Tour de France, was guilty of “doping,” the use of anabolic steroids to gain an athletic advantage.  This was an additional blow to a sport that has been repeatedly tarnished by doping scandals involving the most elite cyclists in the world.  The court ordered Contador to be stripped of his victory in the 2010 Tour de France as well as twelve subsequent victories.

Doping is by no means unique to cycling, as professional athletes in many different sports—weightlifting, bodybuilding, baseball, football, martial arts, etc.—have tested positive for performance-enhancing substances in the last few years. Doping is banned by all of the major sporting governing bodies.  Not limited to professional athletes, many amateur athletes and bodybuilders have used anabolic steroids to try to improve their game and gain a competitive edge.

Many years before Barry Bonds became involved with doping, it was recognized that the male sex hormone testosterone played a major role in muscle mass and strength.  In the early 1950’s, Soviet Union and other Eastern Bloc Olympic weightlifting teams made use of such androgens, isolated from the testicles of animals, in order to enhance their performance in Olympic events.  Over the subsequent 60 years, the use of synthetic anabolic steroids increased substantially.  Anabolic steroids mimic the effects of testosterone, increasing protein synthesis in cells, causing muscle growth and an increase in lean body mass that results in a gain in muscle strength and thus, a competitive edge.

Anabolic steroids have two different types of effects—anabolic and androgenic.  Anabolic refers to the promotion of cell growth and includes the following effects: increased appetite, increased muscle and bone growth and increased production of red blood cells by the bone marrow, all of which result in increased strength. Androgenic refers to the development of masculine characteristics including oil gland production, libido and sexuality, deep voice and male-pattern hair growth.  Many effects and side effects of anabolic steroids are dose-dependent, in other words, in proportion to the doses used.

Along with the escalating use of synthetic androgens in athletes, there has been a parallel increasing awareness of testosterone deficiency and its treatment, particularly over the last couple of years.  Since testosterone (T) and performance enhancing drugs (PEDs) are both classified as anabolic steroids and each increases muscle mass and strength, they are often incorrectly thought to be one and the same.

T and PEDs differ in structure, biochemistry and use.  The medical use of T is for men with testosterone deficiency, usually manifested by fatigue, diminished sex drive and a constellation of other symptoms.  The goal of treatment is to improve symptoms by getting the testosterone into a normal range.  There are a variety of means of testosterone replacement including gels, creams, trans-dermal patches, pellets and injections.  All of these formulations are FDA approved and provide testosterone that is identical to that of the testosterone that is present in our bodies under normal circumstances.  Testosterone levels are checked periodically to ensure that the testosterone is in the normal range.

PEDs are most often manufactured clandestinely at small labs to avoid FDA scrutiny; they are sometimes obtained through veterinarians, pharmacists or physicians, and are often procured on the black market.  They are intended solely to build muscle mass, strength and improve athletic performance, so their use is beyond the domain of standard medical practice.  PEDs favor anabolic (muscle building) over androgenic (pertaining to the development of male characteristics) effects.

The vast majority of the time, PEDs are provided illicitly by a trainer without special expertise in this area.  The goal is a super-high testosterone level, often ten times or more than normal levels.  Dopers often use the equivalent of 1000 mg or greater of T per week.  PEDs are not the chemical equivalent of T and there is no medical monitoring of users.   Popular PEDs include nandrolone and stanozolol, which were FDA approved years ago, but now have no medical indications.  “Designer” PEDs are often concocted by modifying T; their advantage is that monitoring organizations lack the wherewithal to detect them because of their unique chemical formulations.   The two common patterns of PED usage are stacking and cycling.  Stacking is using two or more PEDs simultaneously whereas cycling is an on—off schedule of use.

PEDs have no medical indications and a risk profile that includes the following: elevated blood pressure; abnormal cholesterol and lipid profiles; altered blood glucose; cardiac muscle enlargement; mood disorders including aggression and violence (“steroid rage”); increased rates of homicide and suicide; liver dysfunction; spontaneous tendon rupture; and endocrine issues including severe and irreversible testicular dysfunction. This contrasts with the use of T, which provides medical benefits and a relatively benign safety profile.  Adverse effects of testosterone may include the following: acne; male breast growth; high red blood cell counts; testicular atrophy; prostate enlargement; decreased sperm production; ankle swelling.

In summary, testosterone deficiency is a genuine problem that can cause a myriad of quality of life as well as quantity of life issues.  When deficiency symptoms are apparent and blood testing confirms the deficiency, testosterone replacement with careful physician monitoring is capable of improving or resolving these issues.  On the other hand, the use of performance enhancing drugs for purposes of achieving anabolic benefits and thus conferring a sports advantage or edge is a very risky business and is not recommended.

Andrew Siegel, M.D.

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

www.PromiscuousEating.com

Now available on Amazon Kindle

To view my ten-minute video on testosterone deficiency, go to the following link:

Credit to Dr. Abraham Morgentaler, Harvard Urologist and author of a good little book entitled Testosterone For Life, for providing much of the factual info for this blog.

Tobacco Keeps Me Way Too Busy As A Urologist

 

 

Blog # 47       Andrew Siegel, M.D.

 To paraphrase Dr. David Katz—the master levers of our medical destiny are our fingers, forks and feet: fingers that may or may not bring cigarettes to our lips; forks that may or may not bring healthy food to our mouths; feet that may or may not participate in exercise and fitness pursuits.  The negligent use of our fingers, forks and feet is the leading causes of premature death and conversely, the appropriate use of them is capable of preventing 90% of diabetes, 80% of cardiovascular disease and 60% of cancers.

Bottom line:  Most everyone is knowledgeable about the role of tobacco in contributing to cardiovascular disease, stroke, lung cancer and emphysema.  However, the complications of tobacco abuse go way beyond the heart and the lungs; physicians in every medical and surgical specialty bear witness to the havoc that tobacco wreaks on every system in our body.  As a urologist, I am on the front lines of the deleterious and deadly effects of tobacco. Tobacco has clearly been linked to several urological cancers as well as numerous other non-malignant conditions. Tobacco is a major factor in the occurrence of bladder cancer, kidney cancer, sexual dysfunction, and infertility in both men and women.  Smoking cessation can help reverse these serious issues.             

Bladder cancer is an incredibly prevalent cancer.  It is the 4^th most common cancer in men and the 8^th most common cancer in females.  It is highly correlated—hugely so—with the use of tobacco.  Cigarette smoking is the number one environmental cause and greatest risk factor for bladder cancer.  Cancer-causing chemicals known as carcinogens get inhaled into the smoker’s lungs, are absorbed into the bloodstream and are filtered by the kidneys, from where they pass into the urinary bladder.  In the bladder, these carcinogens have prolonged, direct contact time with the bladder lining, where they induce changes that ultimately can become malignant.  There is a many-year “latency period” from the time of exposure of the carcinogens to the actual occurrence of cancer—often several decades.  So the smoking that you did in your teens and twenties can come back to haunt you in your forties and fifties.  

 Continuing to smoke leads to worse bladder cancer outcomes compared to patients who discontinue tobacco use. Ongoing smoking after the diagnosis of bladder cancer greatly increases the risk of morbidity and mortality, treatment-related complications, recurrence of the cancer and the development of a second malignancy.  Smoking cessation will diminish all of the aforementioned consequences.  It is estimated that elimination of smoking could decrease the overall incidence of bladder cancer by 50%.

Prostate cancer is the most prevalent cancer in men and keeps our office bustling with patients.  Although smoking does not increase the risk of being diagnosed with prostate cancer, men who smoke at the time of prostate cancer diagnosis have an increased risk of recurrence and death from prostate cancer and also face an increased overall mortality from cardiovascular disease. Conversely, those who quit smoking at least a decade before the diagnosis of prostate cancer was made have mortality similar to those who never smoked.   

Smoking is also strongly correlated with both male and female sexual dysfunction.  Anything that compromises blood flow to the genitals is going to interfere with sexual function, and the chemicals in tobacco do a marvelous job at constricting blood flow.  Approximately 40% of men with erectile dysfunction are smokers.  There is a direct relationship between the quantity of smoking and the extent of sexual dysfunction. Smoking cessation will help restore lost function, but tobacco takes its toll as former smokers have been shown to be at an increased risk of developing sexual dysfunction later in life.   

Smoking adversely affects the reproductive system in both sexes.  As compared to non-smokers, the semen of smokers demonstrates poorer parameters, particularly sperm motility. Thus, sperm from smokers has reduced potential for fertilizing an egg.   Females who smoke have a higher prevalence of fertility issues including an increased risk of ectopic pregnancy and fare poorer than non-smokers when assisted reproductive techniques are needed.  Women who smoke during pregnancy increase their risk for bearing male children born with undescended testicles. Smoking has also been associated with increased risk of acquiring HIV infection, HPV infection, invasive cervical cancer, and pelvic inflammatory disease.

An estimated six trillion cigarettes are smoked worldwide every year.   It is not only the smokers who suffer the ill effects of tobacco use.  The health of individuals exposed to smokers is also at risk due to second-hand smoke. Second-hand smoke is a mixture of the smoke given off by a cigarette, pipe or cigar and the smoke exhaled into the air we breathe from the lungs of smokers.   Second-hand smoke is involuntarily inhaled by non-smokers and can linger in the air for hours after tobacco products have been extinguished.  There is no safe level of second-hand smoke, and even brief exposure can be harmful. Second-hand smoke clearly is associated with serious diseases and is responsible for shortening life spans. Second-hand smoke has been classified by the Environmental Protection Agency as a cause of cancer in human beings, causing approximately 3,000 lung cancer deaths and about 50,000 cardiac deaths in non-smokers in the United States annually.  Second-hand smoke is particularly harmful to young children, being responsible for hundreds of thousands of respiratory tract infections in those under 18 months of age.

There at least 43 carcinogens and more than 300 polycyclic aromatic hydrocarbons in second-hand smoke, as well as many other toxins including arsenic, carbon monoxide, lead, cyanide, DDT, formaldehyde and polonium 210. Polonium 210—a highly toxic radioactive poison that was brought to the attention of the public because of its use in the poisoning of a former KGB agent—is inhaled along with the tar, nicotine, cyanide, and other chemicals.

Smoking is a vile, incredibly harmful, self-destructive and miserable habit and addiction.  It is the single greatest cause of illness and premature death in modern society.  Every cigarette that is smoked can be thought of as another nail in one’s coffin.

Years ago, smoking was an excusable habit simply because we didn’t know any better.  It was thought of as a sophisticated, glamorous and sexually alluring and was so glorified on television, in magazines, and in Hollywood on the silver screen.   Magazine advertisements depicted physicians smoking and one slogan went so far as to state: “More doctors smoke Camels than any other cigarette.”   Even my father, a physician, smoked; however, as soon as he caught wind of the fact that smoking was dangerous to his health, he stopped immediately. 

The greatest irony is that there are many smokers who have a pervasive fear of terrorism and potentially pandemic bacterial and viral illnesses such as avian bird flu, mad cow disease, SARS, anthrax, West Nile virus, etc.  What they fail to realize is that the cocktail of carcinogenic chemicals entering their lungs and bloodstream via smoking and being delivered to every single cell in their body can be thought of as little terrorists—suicide bombers if you will, that can and certainly will ultimately wreak havoc on their health and their lives.  Smoking really is just a form of slow, voluntary suicide.  While we do not have a great deal of control over terrorist acts or deadly pandemics, we certainly have the ability to live a smart lifestyle that avoids self-destructive behavior such as smoking.

What truly is a source of amazement to me are the smoking lounges in the airports.  Glassed in like fish in an aquarium, these ridiculous-appearing humans are puffing away in unison, garnering not only the ill benefits of first-hand smoke, but also second-hand, third-hand, and every other permutation imaginable!  A motley group of men and women collectively inhaling and exhaling, hacking and choking within this absurd observatory, with plumes of smoke floating around like clouds—this glass menagerie is a showcase for the folly of humankind.

This folly is certainly aided and abetted by Big Tobacco. In 2006, a federal judge named Gladys Kessler ordered strict new limitations on tobacco marketing, sticking it to the cigarette manufacturing companies for their disingenuous behavior and forcing them to stop labeling cigarettes with deceptive descriptors including “low tar,” “light,” or “natural.”  The tobacco industry was shown to have “marketed their lethal product with zeal, with deception, with a single-minded focus on their financial success and without regard for the human tragedy or social costs that success exacted.”  She further stated that “cigarette makers profit from selling a highly addictive product that causes diseases leading to a staggering number of deaths per year, an immeasurable amount of human suffering and economic loss, and a profound burden on our national health care system.”

The WHO (World Health Organization) estimates that by the year 2020, cigarettes will be responsible for the deaths of 10 million people annually.   Cigarettes killed 100 million people in the period between 1900 and 2000, and we’re on track for nearly a billion tobacco-related deaths for the 21^st century.  About half of all smokers will die of smoking-related diseases. Habitual smoking decreases general life expectancy by an average of 8-12 years. Many smoking-related deaths are not pleasant and quick deaths, but are often protracted and associated with significant suffering.  

There is a magic pill—inexpensive, readily available, free of side effects and safe for all ages—that taken daily will reduce the risk of getting any major chronic disease by 80% or so. This pill is called healthy lifestyle, and if you don’t have it in your medicine cabinet yet, it would make all the sense in the world to acquire it. 

 

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

 

For my educational video on bladder cancer:

http://www.youtube.com/watch?v=WvEOcCzw2gQ

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