Weight Loss Success: Make New Habits or Break the Old?

Which works better for weight loss: creating new healthy habits or getting rid of bad ones? 

A small but clinically significant study was recently published in the International Journal of Obesity that addressed this question. The good news is that BOTH interventions produced sustained weight loss at one year, with the 21 adults who created new habits having a 6.2% weight loss (roughly 12.5 lbs) and the 22 adults who worked on breaking unhealthy habits having a 4.8% (10.1 lbs) weight loss. 


The intervention group that tried new habits followed the researcher's "Top Ten Tips" which included fairly predictable weight loss strategies such as walking 10,000 steps/day; reading labels, watching portion size and reducing fat content; packing snacks and sticking to a meal routine; choose water over other drinks; slow down and be mindful while eating; and of course, my standard preach of at LEAST 5 servings of fruits and veggies per day.

Interestingly, the bad habit breaking group was called "Do Something Different" (DSD). The concept was to "increase behavioral flexibility" by being assigned a different task to perform each day during the 9 week initial intervention. Tasks could include choosing a different route to work or wearing a new outfit, or even writing a short story.

I love the focus on all-around behavioral flexibility that includes new healthy habits. Consider challenging yourself (or better yet, share a challenge with a friend or family member to increase your accountability) to "Do Something Different" each day on your path to a healthier you. My challenge today? Substitute water for my recently "snuck back in" habit of having a soda with my lunch. 

Should You Be Gluten-Free?

I LOVE when patients ask me if they should be GLUTEN-FREE. Why? Because the gluten-free diet is inherently healthy (if you do it without searching out the elusive gluten-free twinkies) and because I have been following a GF diet for about seven years, so I have far more personal opinions and advice about this diet than your average non-GF doc.

Who NEEDS to be Gluten-Free? People with Celiac Disease. Anyone with this autoimmune disorder needs to COMPLETELY avoid gluten, which is a protein found in wheat, barley and rye. If they do eat gluten, their body basically overreacts and the inflammatory response in their gut damages the gut lining, which blocks absorption of important minerals and vitamins. Untreated celiac disease can lead to multiple complications, including anemia, a skin disorder called dermatitis herpetiformis, autoimmune disorders, neurological problems and some cancers.

Who MIGHT be helped from a gluten-free diet? People with autoimmune disorders. Gluten is pro-inflammatory, which means that it can stir up an overactive immune system by irritating the gut lining and triggering a whole body response, sort of poking the giant. With autoimmune diseases, the problem comes from too much immune response (too much inflammation) creating swollen joints, rashes, etc. The general concept is that if you remove gluten, that is one less thing to provoke your overactive system.

My most important advice about the GF diet: emphasize the natural foods that are gluten free- fruits, vegetables and protein sources (nuts, meats, fish, eggs, etc). If all you do is substitute the GF version of every bread, pasta, pizza, cookie, cake and twinkie for those things in your diet now, then yes, you will be GF but not necessarily healthy. And from the mental/emotional aspect, sometimes that's the easiest way to start GF without feeling deprived. But why not have those GF alternatives in moderation, while emphasizing the healthy wonder that is the colorful world of veggies and fruits? Your body will thank you for it.

Do I still seek out the best GF treats like pizza, calamari and brownies? You bet! Am I excited to find Udi's newest delicious GF multigrain bread? Of course! But my dietary GOAL remains focusing on more vegetables and fruits, always paired with a protein source.

BOTTOM LINE: Gluten-free diets are necessary for people with celiac disease, probably good for those with autoimmune disorders, and healthy for all of us as long as we "go natural". 

Sunscreen 101

See that shot glass? BURN that image into your memory, because believe it or not, that's how much you should use every time you apply sunscreen! What else do you need to know? Here's my Sunscreen 101.

Let's start with SPF. What does it mean? Sun Protection Factor is a measure of a sunscreen's ability to protect the wearer against UV radiation from UVB. Note that the sun produces both UVA and UVB, and BOTH cause damage that can lead to skin cancers. Right now, though, the SPF only addresses the UVB protection. So, SPF means that compared to bare skin, the sunscreen keeps you from burning X times longer. If it takes you a half hour to turn red with bare skin, a sunscreen with an SPF of 30 should in theory keep you from burning 30 times longer, which would be 900 minutes- 15 hours. Unfortunately, no sunscreen stays fully effective beyond two hours without re-application. Additionally, sunscreens with an SPF of 15 block roughly 93% of UVB rays, SPF 30 ~ 97%, and SPF 50 is 98%. Therefore, even with perfect application, no sunscreen blocks all UVB rays, and many block no UVA rays.

How much should you use to be effective? See above- an OUNCE of prevention here for sure, and that same amount should be REAPPLIED every two hours. This means you will use roughly half of an 8 ounce bottle on ONE PERSON during a full day outdoors. (And no, I don't own stock or have financial interests in sunscreens.)

Which ingredients are important? Most dermatologists recommend combining the physical barrier ingredients that protect against the deep penetrating UVA rays, such as ZINC OXIDE and TITANIUM DIOXIDE (the ones that leave the white residue) along with the chemical barrier agents known to block UVBs, such as PABA, salicylates, cinnamates and benzophenones. Since nearly all sunscreens contain mixes of the chemical barriers, I scan the ingredients to be sure it also contains zinc oxide or titanium dioxide. Note that some people are sensitive to PABA or other ingredients, and may do best with purely barrier sunscreens and clothing (such as surf shirts.) Ask your doctor for more specifics if you are concerned about allergens.

Easy Sprays...NOT my first choice. Why? Few have either zinc oxide or titanium dioxide, and those that do are very expensive and have these minerals broken down into "nanoparticles" to allow them to be in a light enough liquid to spray. In the medical literature, some debate exists as to whether these nano-sized minerals can potentially cause cancer, which is of course, the opposite of our intent. Regardless of these issues, probably the biggest issue with sprays is that people use TINY portions- picture that less than 10 second total body spray- and so they are not obtaining anywhere near the listed SPF. Would I prefer that over skipping sunscreen all together? Yes...which means I do keep some on hand.

What do I usually buy? Our family's current favorites are Banana Boat's Sport or "Baby" lotions. To sunscreen's credit, my kids complain that their skin is "way too white" because I never let them tan. I take that as a compliment! Probably more importantly, for extended sun exposure we all use swim shirts, and try to consistently wear hats and sunglasses.

BOTTOM LINE: Get a sunscreen that contains both chemical and barrier agents (think titanium dioxide) and realize an 8 oz tube should be used up by a family of four in ONE morning OR afternoon since each person needs ONE OZ every TWO HOURS.

Yesterday's tragic accident has no doubt magnified the fear of flying for many people (and let me add prayers of sympathy for those directly affected, as well as kudos to the brave pilot, Tammie Jo Shults, and flight attendants who helped save the rest of the passengers.) Despite the fact that this type of accident has not happened before, and is very unlikely to happen again, hearing and reading the horrific details add fuel to any anxiety surrounding flying. If you suffer from this fear, know that you are not alone- and that your family physician can offer you a few different medications that may reduce your stress. Many patients have told me they were afraid to ask for any medication, because they did not realize these drugs could be used situationally for a single event such as a flight. Of course our wonderful colleagues in psychiatry can also offer Cognitive Behavioral Therapy (CBT)- talk therapy that has excellent success for social phobias such as aviophobia, but if you have an upcoming flight next week, the medications might be more accessible before this trip.

Medication options include:

• Beta-blockers- this class of medication simply keeps your heart from racing, and lowers your blood pressure. When the physical symptoms of anxiety are reduced, the brain feels calmer too. (We also prescribe this drug for public speaking.)
• Sedatives- although when used frequently these medications are definitely addictive, taking a short-acting sedative for a flight is a very reasonable option. Alprazolam (trade name xanax) is commonly prescribed in small doses (and very small quantities). Note that these pills should never be combined with alcohol. 
• Sleep aids-these are longer acting sedatives indicated for treatment of insomnia; physicians consider prescribing these for flights longer than 6 hours, such as fully across the country or overseas.

Behavioral modifications are also key to help the time "fly" by; consider:

• Noise-cancelling headphones make a world of difference, especially if you can use them to engross yourself in a visual media as well, such as your favorite television series or movie. 
• Music by itself, particularly a very familiar whole album or musical 
• Crazily addictive games on your phone or iPad 
• Puzzles or word searches

Avoid stimulants like caffeine and decongestants- no need to ramp up your heart rate before you even get on the plane!

If you have the luxury of time before you travel, consider CBT with a trained clinician, biofeedback, hypnosis, or meditation training.

Bottom Line: Fear of flying is common- plan ahead and talk to your doctor if you would like to consider a medication to lesson your stress.

Getting ANXIOUS for FINALS? Try This!

INTENSE TEST ANXIETY affects up to 20% of college students, and this time of year is the worst. Finals are approaching, projects and papers are due, and added pressure from mistakes earlier in the semester can push students over the edge. What's the difference between appropriate "nerves" and serious test anxiety?

With a typical student, test day adrenaline might cause extra bathroom trips up until the test starts, a racing heart and anxious anticipation, but once she starts answering questions, the physical symptoms subside enough for the student to focus effectively.

The student with intense test anxiety, however, accelerates symptoms rather than settling down as the exam begins. Sweat pours down his neck and slicks his palms, his racing heart tries to leap out of his chest, meanwhile his lips and fingertips tingle and he feels short of breath (from hyperventilation) and his brain sputters or completely blanks out.

Is there anything that can be done at this point in the semester? YES! Both behavioral and medicinal options are available to reduce or eliminate test anxiety.

·     Breathing exercises- Stop rolling your eyes...breathing exercises really do work, and since this is free and simple, start here. Take one full minute to focus on your breathing before you enter the testing room, and again just before you start the exam. Breathe in for a slow count of four and then breathe out for a slow count of ten. Repeat this sequence three or four times till you feel your body relaxing.  

·     Cognitive behavioral therapy (CBT)-either individual or group –is highly effective in treating social phobias such as test anxiety. This “talk therapy” helps people recognize how they are unconsciously MAGNIFYING and catastrophizing potential negative outcomes, which triggers the physical anxiety responses. "I'm going to fail and flunk out of school" becomes "I may not do great on this test, but  I've done well on other assignments."

•       Will one CBT session be enough? Even one session helps people recognize harmful thought patterns and begin to reverse negative thinking. 
•       Can ALL students get appointments the last few weeks of the semester? Resources vary, so if you cannot get in this semester, start with online resources like AnxietyBC.

·     Medications-

o  The most common prescription medication used is actually a blood pressure medication (a beta-blocker called metoprolol) that is used in low doses primarily for the side effect of slowing the heart rate and reducing tremors. 

o  Interestingly, when the physical sensations of racing heart and tremor are stopped, the brain “hears” that the body is not stressed, and frequently this is enough to lower the test anxiety down to an expected, manageable level. This type of medication is not addictive, and in my clinical experience, there are very few side effects. In fact, students often end up only using these pills for a handful of tests, at which point they have broken the negative test anxiety cycle and no longer need the medication. 

o  Other social phobias such as fear of flying may be medically managed with sedatives called benzodiazepines, such as alprazolam (brand name Xanax). Note that these medications are very addictive, often misused, and sedating, so they are NOT a good option for test anxiety. 

Untreated test anxiety leads students to a swirling vortex of stomach pains, headaches, insomnia, fatigue, anxiety and depression. Then self-medication with too much caffeine leads to less sleep, more fatigue, more caffeine, more headaches, irritated stomach lining...and worsening test anxiety. BREAK THE CYCLE before you hit your final round of exams this semester!

BOTTOM LINE: Intense test anxiety is a common, real problem that can be dramatically improved with a few interventions. Schedule an appointment today and get help.

What's the BUZZ? Caffeine vs. Alcohol

We all know that caffeine is a stimulant, and most of us have a daily dose to fight fatigue and pep us up. So why create caffeinated ALCOHOLIC drinks? Doesn't that seem counter intuitive to put a stimulant (caffeine) with a sedative (alcohol)? A recent interesting high quality study, Acute impact of caffeinated alcoholic beverages on cognition: A systematic review points out a few facts you might want to share with your favorite college student...

• Energy drinks combined with alcohol DO decrease fatigue and "PERCEPTION of intoxication"
• However, despite FEELING unimpaired, complex tasks such as driving definitely ARE impaired.
• Additionally, caffeinated alcoholic beverages INCREASE impulsivity- which can obviously lead to drinking too much (further decreasing judgment and increasing impulsive choices).
• Finally, with this cycle of feeling less buzz and drinking more, ALCOHOL ADDICTION may increase.

I find this study particularly interesting in light of the "pre-gaming" with Attention Deficit Disorder (ADD) meds and alcohol that has become increasingly common on college campuses. Same concept- the ADD med stimulant taken before drinking alcohol blunts the "buzz" response from alcohol...at least for the first few drinks. Unfortunately, these stimulants do not blunt the other effects of alcohol toxicity such as decreased gag reflex, poor muscle coordination, feeling off-balance, nausea, vomiting, and ultimately impaired breathing. So what happens is you feel "fine" till suddenly you are unpleasantly drunk, then you risk vomiting with impaired consciousness and/or gag reflex...allowing you to choke and aspirate your own vomit-which, by the way, can be lethal. Or worse, you feel "fine" and choose to drive because you have no idea that your judgment and motor skills are significantly decreased, leading to a wreck that hurts not only you but potentially others...because you are driving a one ton weapon. 

BOTTOM LINE: Combining caffeinated energy drinks (or ADD meds) with alcohol is a potentially very dangerous choice because you blunt the "buzz" of alcohol without decreasing the other negative effects of rising blood alcohol levels. Just say NO.

Can't (cough) Stop (cough) COUGHING?

COUGHS often seem to hang around FOREVER, and this year's flu season has been a prime culprit.
Allergies certainly can cause coughs as well, but typically allergy coughs are more the dry, annoying, clear-your-throat variety, rather than the wet sounding coughing fits (that worsen every evening and prevent sleep) which come from viral respiratory infections. Typically there are a few days of headaches, fever, body aches, sore throats and stuffy nose,  but then the cough itself may persist for up to SIX WEEKS after the initial illness.

Is there anything that can be done for a cough that wont go away? Yes, absolutely.

Will an antibiotic fix a cough? Especially is there is green mucus? Probably NOT, because the vast majority of respiratory infections are viral. Green mucus does not equal bacterial infection.

So you NEVER need an antibiotic for a cough? No, that is not true- sometimes a cough IS being caused by a bacterial infection (possibly a pneumonia), but this is the exception, not the rule.  If you are a week into your symptoms, slowly getting better, and then suddenly you feel a ton worse and develop a fever, this might be a bacterial infection setting up shop AFTER the virus cleared the way past your body's defenses. For this scenario, yes, you need an antibiotic.

If antibiotics don't help, why see your doctor for a cough? 
Certainly not every cough NEEDS to be evaluated by a physician. Over-the-counter cough products include DM (dextromethorphan) (which works at the brain level, decreasing the drive to cough) plus expectorants like guaifenisen (ex. trade name Mucinex) to thin up the mucus. Combinations of these ingredients (along with decongestants to help stuffy noses) make up the cough/cold/flu products like Dayquil/Nyquil/Robitussin/etc. and may be helpful in alleviating cough and cold symptoms in adults.

Cool mist humidifiers next to the bed often bring relief, and honey (either taken as a straight teaspoon or in a hot tea) has been objectively shown to help improve coughs (though never for children younger than one year).

However, often after a viral respiratory infection, the lungs' defenses become overly reactive, creating too much mucus and then subsequent spasm of the airways- we call this "reactive airway disease" and this is the same process we see with asthma. Subsequently, persistent coughs often resolve more quickly when treated with prescription asthma inhalers or other oral medications (possibly anti-inflammatory steroids).

Additionally, there are other prescription cough medications that might help.
Benzonatate (trade name Tessalon) is a non-addictive, non-sedating medication that works in the lungs to decrease the cough reflex by numbing the stretch receptors in the respiratory tract. (In my clinical experience, this drug either works like a dream or has little impact, but its low side effect profile makes it an attractive choice.)

Finally, a cough that is keeping you (and/or your bed partner) up all night despite OTC medications may require a sedating prescription cough syrup. With our current opioid crisis, know that conscientious physicians are appropriately limiting the quantities of these potentially addictive medications, and this is not a long term solution.

Finally,  a cough may come from other sources, such as acid reflux or sinus drainage or a medication side effect (such as from one class of blood pressure medications), which require different treatments.

BOTTOM LINE: See your doctor to evaluate coughs that get worse after a respiratory illness, or that wont go away- please don't expect antibiotics, but know there are other treatment options.