Improving Dementia Diagnosis With a Sleep Marker

Dementia presents a growing challenge for clinicians both in the assessment as well as treatment domains.  Autopsy remains the only definitive diagnostic intervention that can confirm Alzheimer's disease and the other forms of senile dementia including vascular dementia, dementia with Lewy bodies, frontotemporal dementia and other dementia variants.

Since autopsy studies do not provide clinicians or their patients any direct benefits during the patient's lifetime, better diagnostic tests and clinical predictors are needed.

A recent study from a team of neurologists, psychiatrists, sleep medicine specialists and pathologists from the Mayo Clinic supports the potential of a sleep disorder to aid in the diagnosis of dementia with Lewy bodies.  Lewy bodies are distinct accumulations of proteins found in the brains of individuals with parkinsonism and Lewy body dementia.  They are identified at autopsy by special stains viewed under a microscope.

Dementia with Lewy bodies is often considered the second most common type of dementia.  The clinical diagnostic criteria were revised in 2005 and include core and suggestive features.  The core features include: fluctuations in cognitive abilities, parkinsonism and visual hallucinations.  The suggestive features include: sensitivity to antipsychotic drugs, reduced brain dopamine uptake on functional brain imaging and presence of the sleep disorder known as REM sleep behavior disorder (RBD).

The 2005 diagnostic guidelines for dementia with Lewy bodies can be made when patients have two of the core criteria or one of the core criteria and at least one suggestive criteria.

REM sleep behavior disorder (RBD) is a sleep disorder characterized by violent (or other dangerous) behavior during the REM or dream or nightmare phase of sleep.  This behavior can include punching, kicking, yelling, jumping out of bed often in response to specific content of the dream that is being experienced.  Individuals with RBD can physically injure themselves or their bed partners with their violent behaviors.

In normal individuals, REM sleep includes temporary muscle paralysis preventing individuals from physically responding to dreams or nightmares.  Loss of this REM sleep paralysis can lead to development of RBD.  RBD is felt to indicate disregulation of several brain neurotransmitter systems including dopamine, serotonin and acetylcholine.  This dysregulation may explain extreme sensitivity of patients with RBD to adverse effects of a variety of psychotropic drugs including antidepressants and antipsychotics.

The Mayo Clinic study included a prospective longitudinal study of a group of patients with dementia who were seen four times per year until their deaths.  Postmortem autopsies were conducted on 234 patients.  Seventy seven (33%) of the sample met pathological criteria for diffuse Lewy body disease.

The authors looked specifically at RBD as a predictor of true diagnosis of dementia with Lewy body disease.  They found that RBD was three times more powerful as a predictor of Lewy body dementia than any of the the core criteria of Lewy body dementia.

This study confirms the value of RBD in diagnosing Lewy body dementia--in fact it supports moving RBD up to a core feature rather than a suggestive feature.  A second multicenter study by Bliwise and colleagues has confirmed the high rates of RBD in Lewy body dementia compared to those with Alzheimer's disease.

These findings should encourage clinicians to aggressively look for RBD in patients with dementia to aid differential diagnosis and the treatment planning in this challenging population.

Photo of typical Santa Fe home architecture taken during sunset in Santa Fe, New Mexico from the author's collection.

Ferman TJ, Boeve BF, Smith GE, Lin SC, Silber MH, Pedraza O, Wszolek Z, Graff-Radford NR, Uitti R, Van Gerpen J, Pao W, Knopman D, Pankratz VS, Kantarci K, Boot B, Parisi JE, Dugger BN, Fujishiro H, Petersen RC, & Dickson DW (2011). Inclusion of RBD improves the diagnostic classification of dementia with Lewy bodies. Neurology, 77 (9), 875-82 PMID: 21849645

Bliwise, D., Mercaldo, N., Avidan, A., Boeve, B., Greer, S., & Kukull, W. (2011). Sleep Disturbance in Dementia with Lewy Bodies and Alzheimer’s Disease: A Multicenter Analysis Dementia and Geriatric Cognitive Disorders, 31 (3), 239-246 DOI: 10.1159/000326238

The Holy Grail of Weight Loss III

...CONTINUED FROM THE LAST POST

ME: This ties in to one of my strongest philosophies on money - it's better to make a little bit of money doing what you love than making a ton of money doing what you hate. The same could be said of living a "healthy lifestyle." A pound lost doing something enjoyable is worth more than 10 pounds lost doing something excruciatingly difficult - like starving yourself or doing unwanted exercise. The word 'sustainable' is sheer poetry - up there with 'unprocessed.' And this concept is really important when you consider the fact that you have been losing weight consistently for almost 2 years steady. Who could do unwanted exercise and deprive themselves of food for 2 years? Not me. And as you know, the metabolic consequences of doing so can be quite severe.


Now I'm sure everyone is curious... Could you tell us what kind of foods that you enjoy and were able to eat? What did a typical day of eating look like for you?

SASHA:  You are absolutely right. Chronic dieters have this imaginary wagon or track that they like to talk about being on and there are always a myriad of reasons for them to "fall off the wagon" or "go off-track." I've seen a lot of this in the past two years of associating with people who diet, which to me is very different from people who heal their bodies. A lot of this has to do with food. I love talking about the way I eat because I love food and both my husband and I love cooking and looking for new sources of whole food. At first it was difficult, we had to spend a little time and research to suss out our sources for the right kinds of foods. I wanted to stay away from grocery store foods for the bulk of our shopping, so this meant the local farmer's market, local produce sellers, people who sell pastured chickens and eggs, etc. We found a couple of butchers, and while the price is going to be a little higher, it’s worthwhile to have local product. We even managed to find a fish monger where we buy our seafood. We taste the difference and the nutrient value is also a plus.

Surprisingly we've done this all on a budget with a few extravagances like buying ghee and coconut oil from our local health food store. We just stay away from the processed "health" foods and expensive organic produce. If my produce is a little damaged but in season and comes from a local source who raises smaller crops organically, this is going to be cheaper than a large chain like Whole Foods. Learn how to shop locally and according to season for the best prices.

Typically we favor yogurt and in season fruit for our breakfasts or pastured eggs. We normally eat a second large meal but not a third, skipping dinner. We favor beef and game meats, our butcher carries a large selection of meats; fowl, buffalo, elk, sausages made in house. We're especially fond of braising meats because there are so many ways of braising and the "low and slow" method in the BBQ during the summer. Legumes, sweet potatoes, squash, locally-grown corn, chard, greens, whatever is in season, with plenty of butter. A little fruit but not too much. We live where berries are plentiful and we incorporate these into our diet when they're in season. We make our own pizzas and ice cream so we can control what goes in them, but again, this is not to make food necessarily less fatty but to avoid processed foods. The bottom line is, we keep things very simple and basic.

I talked about the lack of quality product coming out of fast food restaurants and chain/corporate restaurants. Our bodies need nutrient dense, fatty foods but we eat bad quality foods that are doctored up with a lot of sodium and HFCS. How do you think a place like Red Lobster is able to afford to sell you lobster for $9.99? Bad quality food and bad nutrition leaves your body lacking and still craving so you eat more bad food and so forth. Obviously I have a vendetta against these types of restaurants but I'm so well fed and satiated, there's no danger that I'll binge on packages of diet cookies because of uncontrollable cravings. There's no imaginary wagon or track for me to fall of off. Not once in two years have I ever thought of my weight loss in those terms.

I just want people to know that this is real and I'm not crazy. I really do EAT.

ME:  You say that you weren't eating dinner. Was this something you did all along or started up recently with all the talk about eating light in the evening? Did you eat anything at dinner at all? And how long did it take for your body to adjust to this eating schedule where you really weren't hungry in the evening? I'm very curious about this because it could be a pivotal maneuver in your weight loss, AND I'm even thinking about re-working RRARF to advise overfeeding until 2pm and then coasting into the evening with a very light meal - to reap the same rewards, but make weight gain a less frequent occurrence. Do tell…

SASHA:  To be honest, the meal schedule wasn't deliberate at all but rather accidental. It started a little over a year ago mostly due to my husband's weird schedule and also because we had become used to eating when we were hungry and noticing that our hunger was greatest after 11 and before 2 in the afternoon. We thought it was because we would cycle, hike or run in the mid-mornings, but regardless of what we do or don't do, this eating pattern simply seems natural. I imagine that people who eat a lot of "lite" processed diet foods and non-fat foods are constantly fighting their appetites (and probably why they just give up on losing weight). The more you get into the habit of eating whole foods and nutrient dense meals, the less time the body begs to be fed constantly. At first you may overeat and gain weight but eventually your body's mechanism gets the signal that it is being fed. My personal experience has told me that obeying my body and appetite should be a priority. If I seem to gain a couple of pounds one week because I was hungrier a couple of days and ate more, the weight comes back off the next week then drops even further. The weight doesn't stay on a logical schedule which I know makes a lot of people crazy, but it will continue a downward trend.

Any eating after 2 is very light and this schedule seems to give my body a chance to catch up and rest during the evening hours and overnight. Some days, if there's a need or desire, I can switch things up and have a heavier dinner if I eat lighter during the day, but I don't do this often, probably once or twice a month at the most. I've learned to be flexible.

ME:  Amen on not being hungry when you have nourished yourself properly earlier in the day. My most recent studies have highlighted just how truly natural this eating pattern is. And I do believe it's a useful tool for weight loss - not starving yourself at night that is, but eating enough early to naturally be satisfied in the afternoon and evening. Once again, the focus is on eating more at the right time, and allowing the "eating less" part to occur spontaneously.

Anyway, this is exactly what I have sought after all along - trying to get people to ignore everything and focus on nourishing themselves, answering the physiological call of their hunger with quality nourishment, and letting things fall where they may. If anything, you seem to have succeeded because you are even MORE dedicated to that self-commitment than others. It's amazing to see the trust that you've developed for your body, nourishing it and letting it sort things out on its own. I think a lot of people, by the time they get near 400 pounds, have an extreme DISTRUST for themselves and a strong love-hate relationship with food. Congrats to you and your husband for overcoming such barriers. Very few people at your former weight and age ever have the kind of success that you have had. But I hope this interview will lead to many more light bulbs going off, and more people will have the courage to do what you've done, and display the kind of patience you've displayed. Thank you so much for taking the time to do this Sasha. Can't wait to see where you are in another 2 years.

The Holy Grail of Weight Loss II

Interview continued from yesterday's post...

ME:  Beautiful... And I'm glad that whatever you managed to squeeze out of my materials worked out for you. As you know, not everyone loses weight when they go all 180D. In fact, many gain weight - at least for the first few months as their metabolism comes up towards normal.

What did you do that you suspect is different from others who haven't had such results? If you could give them advice, or share how you did things specifically, what would you say?

In other words what I'm asking is, what makes you so damn special!!??

SASHA:  180DegreeHealth often hurts my head (in a good way of course!) but I understood enough that I knew I was finding answers to my questions. There are reasons for the massive allure and subsequent failure inherent in the diet culture. I needed to know why and how I was going to do things differently. I think if people really want to succeed at fixing their metabolism using this method, above all they need to be persistent and consistent. Fixing your metabolism and eliminating cravings happens, but it takes time. It took me about three months to eliminate cravings and about two more months before my metabolism kicked in and I started losing the bulk of the weight. Many people don't have the patience for this, which is why fad diets are so popular. A lack of patience and a lack of food and body knowledge is how people end up as lifelong dieters who never reach a goal.

But I'm not special or even particularly intelligent or well-disciplined. I believe anyone can do this. Personally, I think it's most beneficial to restrict yourself to whole, traditional foods. Absolutely no fast food and no processed foods. I even go so far as to not eat breakfast cereals, I don't care how natural they claim to be, they're still processed and in a cardboard box and most taste like the box. One big mistake I see people make is that they fail to see the problem with eating at corporate/chain restaurants. You can't go to an Olive Garden and eat healthy. How do these restaurants maintain consistency from restaurant to restaurant? Much of their food is heat n’ serve. Obviously these types of restaurants are one of my pet peeves. I'm married to a professional chef who's worked in every type of restaurant imaginable and we avoid these restaurants for the plague they are.

Eat fat. When I tell my friends that I just ate a gorgeous piece of fatty grassfed ribeye or pork belly then lost a few pounds the same week, they think it's a joke. It's no joke. I'm proof of that. My body tells me when I need to eat more or eat fat and I listen. People don't listen to their bodies anymore. Train yourself to listen to your body and it will tell you everything you need to know.

Retrain your palate. On a regular basis I complain about how people have trashed their palates with processed foods. Source the grassfed beef, butter, pastured chickens and eggs. Cook with lots of ghee and coconut oil, buy vegetables in season, learn how to cook. After you learn to eat at home you'll find you're going to make better choices when you eat out. I've lost count of the number of people who are trying to lose weight that can't maintain any kind of consistency in how they eat. They're either eating some nasty chicken breast with lettuce and lite dressing at home or gorging out on really bad food at Applebee's or Chili's. The quality of your product at home should be consistent with the quality of product when you eat out.

Be physically active but don't exercise. I know that makes no sense but I hate exercise. I've only been to a gym once several months ago when my husband and I got a free one-month trial. It was dull, boring, my muscles were uncomfortably sore all the time and I stopped losing weight. We never went back. My advice to people is to find a few fun activities you like to do and enjoy. Bicycle, hike, run, kayak, do yoga, whatever you enjoy. Avoid massive amounts of useless cardio, overtraining with weights and silly fads (Zumba, yuck). I do a lot of bicycling, hiking and yoga but not to the point that it becomes loathsome.

(This is right in line with this conversation on exercise from early this year....)


Once your body finds its rhythm and your metabolism mends, the body's weight finds its own level, like water. I'm amazed at how almost effortless the weight loss has become. I say "almost" because sometimes I get thrown off balance, but the correction is always pretty simple. Every individual is different but what works for me has had an equal and amazing affect on my husband who has lost 88 pounds along with my 127 pounds. He ended up coming along for the ride, so to speak, when I started my new way of eating and understanding food and my body and he has reaped the benefits too.

ME:  Great answer - and I knew you were going to say something about retraining your palate and being really committed to eating unprocessed foods. My research has led me increasingly in that direction. I've found that there is a huge difference between a mostly unprocessed food diet and a 100% unprocessed food diet. And it has everything to do with retraining the palate.

You mention not doing exercise but being physically active. How much of a role did exercise play in you and your husband's weight loss? Were you really making a point to move your body more? If you had to estimate, what percentage of the weight loss do you think was attributable to getting more activity, and how much was the diet? Or do you really think it requires both to realistically succeed?

SASHA:  I like this question best because I think the distinction I made is important and deserves some clarification. Just like appetite, a morbidly obese person loses the ability to gage what is a normal activity level so we wind up terribly underactive while still thinking of ourselves as fairly active. How many times have you been told by a morbidly obese person, "Well, I'm pretty active for a big guy/lady, but I don't seem to lose the weight". It isn't because this is true, but because our perception of what normal activity is, is warped. I know my judgment of what it's like to be hugely overweight seems insulting, but it really is like being myopic in a fishbowl. You lose sight of so much.

At my heaviest when I started losing weight, I knew I needed to move more, but because I feel about the same toward the exercise/fitness business as I do about the diet/weight loss business, I wanted to do things opposite of what the mainstream would tell me to do. My plan, pick activities that I imagine myself doing at any weight and for reasons other than weight loss. Make sure it's something I enjoy and something that I can see myself doing for many years to come. This, for me, started with walking and evolved into hiking. I live in the Pacific Northwest so this was a natural evolution. Last winter I started running, then trail running and eventually I bought my bicycle. Every activity I've picked has evolved in some way, either in intensity or mileage, and this is important, because as your body fixes and repairs itself due to the obesity, your body will naturally want to move more.

So, my way of eating and losing weight and my physical activity are not mutually exclusive of one another. When you eat to appetite and eat what your body craves, your physical activity will naturally feel inclined to match that by either doing something more intense, less intense or by wanting more sleep. It's an almost 50/50% relationship between the two and I can't imagine one without the other. It is important to understand what kind of energy your body is "into". I'm more of a slow steady burn with more endurance while my husband has become inclined toward shorter, high energy bursts, which is probably why he enjoys mountain biking and running. Whatever it is, you're going to want to be active.

I know some people would argue that you can lose the weight without any of this, but how long will that last? I've seen enough people go the wrong route in both directions so it's easy to know what to avoid. I see the people who do nothing or very little, lose a few pounds or more, but beyond that not much changes for them physically. I have also seen people engage in frantic and large amounts of cardio, losing large amounts of weight quickly after which they burn out, gain some back and struggle, never to find that momentum again. I guess the bottom line is sustainability. What are you going to eat or do that will become a natural part of your life from here on out? I approach both my food and my physical activity with this in mind.

Continue to PART III...

Topiramate Augmentation in Major Depression

Molecular Model of the Drug Topiramate

Currently available antidepressants provide significant relief from major depression in many patients.  However, a significant number of patients receive little or limited relief following an initial trial of a standard first-line drug from the selective serotonin re-uptake inhibitor class of agents.


A common clinical strategy after initial drug non-response and non-remission is to consider pharmacological augmentation.  Augmentation options for clinicians include lithium carbonate, triiodthyronine (thyroid hormone), a second antidepressant, an atypical antipsychotic or adding psychotherapy if it is not already being provided.


Despite the number and range of augmentation options, additional options need to be explored given the persistence of depressive symptoms in many individuals.  A small study from Iran suggests one alternative to consider may be the drug topiramate.


Topiramate is a drug approved by the FDA for the treatment of epilepsy and migraine headaches  in the United States.  It is not approved for the treatment of any primary psychiatric disorder.  The exact mechanism of action for topiramate is unknown although it is known to have effects on the sodium channel, gamma-amino butyric acid (GABA) receptors, glutamate receptors and act as a carbonic anhydrase inhibitor.


Mowla and Kardeh have published a small study of 42 subjects randomized to topiramate or placebo.  The key elements of the study include:

• Subjects: Adults with DSM-IV major depressive disorder who had failed to respond to eight weeks of treatment with an SSRI drug (fluoxetine, citalopram or sertraline)
• Drug: Topiramate 25 mg per day increased by 25 mg per week throughout the trial (mean dosage 175 mg/day) or placebo
• Clinical trial design: Double-blind, randomized controlled trial with primary outcome measure the Hamilton Depression Rating scale (HAM-D) administered by a psychologist not involved in treatment

Fifty three subjects started the study with 11 dropouts (six in the topiramate group and five in the placebo group).  HAM-D scores statistically decreased more in the topiramate group (21.6 at baseline to 14.7 at 8 weeks) than in the placebo group (21.9 at baseline to 20.8 at 8 weeks).


Since a score of seven or more is considered remission in MDD, the mean score of 14.7 in the topiramate groups suggests significant residual symptomatology.  The authors do not provide the number of subjects meeting remission criteria in the topiramate and placebo groups by 8 weeks.


Nevertheless, topiramate has some potential significant advantages in the treatment-resistant major depression population.  First, it is a generic drug and would have some cost advantages in comparison to some of the other options.  Second, topiramate it typically weight neutral or produces a slight weight reduction.  Most antidepressants increase weight over time so this might be an important advantage.  Third, topiramate might hold an advantage in treatment of MDD populations with migraine or epilepsy--disorders with an indication for the drug.


This study is too small to change clinical practice patterns or guidelines.  Additional larger replication studies need to be considered.  

Molecular model of the drug topiramate from Wikipedia Creative Commons file released to the public domain.  Author of the model is: Fvansconsellos

Mowla A, & Kardeh E (2011). Topiramate augmentation in patients with resistant major depressive disorder: a double-blind placebo-controlled clinical trial. Progress in neuro-psychopharmacology & biological psychiatry, 35 (4), 970-3 PMID: 21291943

Spicy Roasted Red Pepper & Hummus Sandwich with Portabello

This is an amazing sandwich that I know you will love. I used a crusty artisan bread and made my own spicy hummus sandwich spread.  After spreading on my hummus, I added sliced apples, tomatoes, grilled portabello mushrooms, Mezzetta roasted red peppers, Mezzetta jalapeno stuffed olives, basil leaves & romaine lettuce. Talk about flavor plus in a sandwich!!  You could also grill this or put it in your panini maker, just add the lettuce after your sandwich is done cooking. See picture below for this same sandwich panini style. I hope you will give this sandwich a try because I know you and your family with love it.

Spicy Roasted Red Pepper & Hummus Sandwich with Portabello
Serves 2-4
Printable Recipe

4 slices of Artisan Bread
8 tbsp. homemade spicy hummus (see recipe below)
4 apple slices
4 tomato slices
8 sliced pieces of a large portabello mushroom
1 tsp. olive oil
3 tbsp water
½ cup Mezzetta Roasted Red Peppers
8 Mezzetta Jalapeno Stuffed Olives (sliced)
8 medium size pieces of basil
Romaine lettuce leaves

1.) Grill 8 long slices of a large portabello mushroom in 1 tsp. olive oil. Lightly salt and pepper and cook for 2 minutes. Add 3 tbsp of water all at once and continue to cook 2 additional minutes. Remove from heat.

2.) Spread all 4 pieces of artisan bread with 2 tablespoons each of hummus. Slice apples and tomatoes into ¼ inch thick round pieces. To one side of each sandwich add 4 portabello mushroom slices, 2 slices of apple, 2 slices of tomato, ¼ cup roasted red peppers, 4 sliced olives, 4 basil leaves and romaine lettuce. Put the other slice of bread without the vegetables on top to make a finished sandwich.

Spicy Hummus
1 (16 oz.) can low sodium garbanzo beans/chick peas
1/4 cup Mezzetta Roasted Red Peppers
3 tbsp liquid from Mezzetta Roasted Red Peppers jar
3 tbsp water
1 clove fresh garlic
½ tsp maple syrup or agave
¼ tsp ground cumin
¼ tsp ground cayenne pepper
½ tsp paprika
1 tsp dried onion flakes
½ tsp sea salt

Directions:
Put all ingredients in food processor or higher powered blender and blend until smooth. Stop and scrape sides of blender several times.




Spicy Roasted Red Pepper & Hummus Sandwich with Portabello

 

Fitness, Hippocampus and Forgetting

Hippocampus in Green from 3D Brain iPad App

Cardiorespiratory fitness appears to be associated with a variety of benefits in cognitive functioning.  The mechanisms for this benefit are unclear.  Association studies do not provide evidence for the pathways between related variables.  For understanding pathways, clinical trials, longitudinal studies and multivariate approaches are more powerful approaches.

Amanda Szabo and colleagues at the University of Illinois at Urbana-Champaign recently published a multivariate study looking at fitness, hippocampus and forgetting in a group of elderly adults in the journal Neuropsychology.  The hippocampus is a brain region known to crucial to working memory.  Changes in hippocampal volume have been linked to age-related cognitive decline and the development of Alzheimer's disease.

The key elements of design in this study included:
Subjects: 158 older adults with a mean age of 66.5 years
Variables: Fitness level as measured by VO2 estimate from a graded exercise test, brain hippocampal volume from a brain 3T MRI scan, spatial working memory task, subjective rating of forgetfulness (Frequency of Forgetting Questionnaire)
Statistics: Path analysis examining direct and indirect effects of fitness on hippocampal volume, working memory test performance and subject rating of forgetfulness using the comparative fit index (CFI)

The authors started with a presumed pathway model for the mechanism of the relationship between fitness and forgetfulness in the following pathway:

• fitness levels predict hippocampal volume
• hippocampal volumes predicts working memory function performance
• working memory performance predicts subjective forgetfulness

Fitness levels were associated with a variety of sociodemographic and medical variables at baseline including: self-reported physical activity, presence of hypertension, cardiovascular disease, body mass index, education level, gender and age.  These baseline variables were evaluated and controlled in the final pathway analysis.

The authors found their predicted model held up in the analysis: "cardiorespiratory fitness is associated with the frequency of forgetting indirectly through its influence on hippocampal volume and, in turn, spatial working memory".

The study noted fitness level is not the sole determinant of hippocampal atrophy.  Age alone is an independent contributor of hippocampal atrophy.  Fitness may reduce the effects of age-related hippocampal atrophy and forgetfulness but it is unable to reverse the effect.

So fitness is not a panacea but it appears to be an important factor in maintaining cognitive function in later life.  Now, I just wonder if my wife can help me find my running shoes?

3D Brain image of the hippocampus in green screen shot from the author's collection.

Szabo, A., McAuley, E., Erickson, K., Voss, M., Prakash, R., Mailey, E., Wójcicki, T., White, S., Gothe, N., Olson, E., & Kramer, A. (2011). Cardiorespiratory fitness, hippocampal volume, and frequency of forgetting in older adults. Neuropsychology, 25 (5), 545-553 DOI: 10.1037/a0022733

The Holy Grail of Weight Loss

“I must agree that eating like a fiend cuts out all cravings -and- I've lost 100 pounds over the last year eating like a fiend. The weight is coming off naturally and I'm never deprived and I don't waste hours at a gym. People think I'm lying to them when I tell them how I lost the weight. :)”

-Sasha

This week 100% organic Sasha is on the menu. Pure, unadulterated, unprocessed Sasha.

Since the beginning I’ve known that dieting in the traditional sense is a counterproductive measure. Even if you do manage to starve yourself thin, your body and mind do not work properly. Libido gets wrecked. Hair falls out. Neurosis sets in. All the parallels to starvation and eating disorders are laced in there, even if you are still overweight after your weight loss.

So I knew there had to be another way. I knew that it had to possible to lose body fat without going into starvation. And I knew that, theoretically, neither fat nor carbohydrates nor protein needed to be restricted. After all, no macronutrient is inherently fattening. Healthy bodies of all species maintain weight equilibrium on any number of macronutrient blends.

And Sasha Garcia Degn and her husband have, and are, achieving that. The pair has lost more than 215 pounds combined without hunger, without counting or cutting calories, without intentionally cutting carbs or fats or going on some extreme diet, and without doing any unwanted exercise. This is the Holy Grail of weight loss.

Of course, not all that stumble across my information have magically had body fat pour off of them. Many have, but many have gained weight before the fat gain stopped, and then, despite feeling better in numerous ways indicative of a restored metabolism, adopted a small child that never made it to the delivery room (okay, that was kind of a weird metaphor – I’m talking about that swollen belly pregnant look thing – kinda sexy if you actually are pregnant. Otherwise not so much).

Anyway, I thought it was worth taking a close look at what Sasha did specifically, and examine what diet, mindset, attitude, exercise, etc. that she felt was the key to her success. I think we all have quite a bit to learn from her. Here is the first part of the interview – to be continued throughout the week…

Me: Sasha, many people have tried to follow the basic 180DegreeHealth approach to eating - that is, eating to appetite of nutritious foods, not exercising too much, and not restricting calories, carbohydrates, protein, fat - or any food group. Just eating basically, and letting the body "do all the accounting" as author Jon Gabriel says. To date, you have had the most successful weight loss, well over 100 pounds, with that approach since RRARF debuted a year and half ago. We'll get to why that might be, and what you did differently than others in a minute - but first, can you tell us how you got up to 375 pounds, and where you were when you first came across 180DegreeHealth?

SASHA:  I think I can speak for many people when I say that I don't know exactly how my weight got up to its highest. Generally, a person with that much weight will know in retrospect that they were consuming high numbers of calories, probably spending a lot of time on the couch and let's throw some heavy stress in for good measure but ultimately we don't know anything specific. One day we see a number on a scale astonished and think, "how did that happen?" That seems odd, but the part about not exactly knowing really is how it happens. For myself, I do know that my weight started going up just before I got married, eleven years ago. A lot of processed and fast food and little physical activity and later, taking care of my ill, elderly mother all by myself. After a few years of caretaking of my mother, a lot of stress and overeating, my mother passed away and the weight stayed. By that point I was well into the 300s and my metabolism was so completely bonkers that being that overweight felt almost natural.

Two years after my mother passed away, my husband and I moved from Los Angeles to Washington state where I spent four more years, not only suffering from my morbid obesity but from a severe vitamin D deficiency as well. After self-correcting the vitamin D deficiency, I felt much improved and also dropped about 20 pounds without any effort. Taking a clue from my vitamin D experience and tired of not being able to climb a flight of stairs or walk more than a quarter of a mile, I started to think that the body, when given the right things, might be able to correct itself. I knew the diet culture was a sham so this time was going to be different. I was going to fix my body so my body could fix itself.

First, I needed to know what a semi-normal daily calorie intake would be for me. I know that seems anathema to "eating to appetite," but a morbidly obese person, trust me, has no clue as to what anything close to normal is especially where their own appetite is concerned. There had to be some guideline for me. I still use that guideline, but now I use it to make sure I'm eating enough, which most people don't do while they're preoccupied with eating too much. I do not track fat, salt, or protein. My body tells me what it needs. I also started to gather as much knowledge as I could online. Weight Watchers, gastric surgery, Medifast, all of these were already out of the question, even Eating Clean was off limits because I knew the idea of eating only lean meats was not a sustainable way of eating long term. I was looking for something else even though I had no idea what that was. Eventually I stumbled onto the whole foods way of eating, including my personal choice, Weston A. Price Foundation and then, the site that was truly the catalyst of physical change for me - 180DegreeHealth. By this point I'd lost close to 45 pounds and was still well over 300 pounds.

CONTINUE to PART II...

Regulate Blood Sugar

Apologies for the use of the word "blood" in the title, as it is one of my pet peeves that in RBTI the refractometer is thought of as a tool that monitors blood sugar, which it doesn't.  But it does show an incredible connection to available sugar - or what you might call sugar levels in the brain and muscle and available to the cells.  Because of that, the refractometer continues to impress me, as it's about the most simple, inexpensive, and easy-to-use health tool on the planet (up there with the thermometer).  And it demystifies "hypoglycemia," a condition that the mainstream medical establishment more or less doesn't recognize, nor should they, as hypoglycemia means low, sugar, blood.  Having low levels of sugar in the blood is an extreme rarity in today's day and age.  Having radical fluctuations in available carbohydrate is another story altogether, and that is revealed not in the blood, but in the urine.

This is one of my favorite Challen Waychoff videos that I've posted thus far.  In the video he discusses the fluctuation or "the wobble."  This is a central theme in RBTI - trying to eat and drink in a way that makes this fluctuation smaller - allowing your body to heal itself more effectively, gain energy, and "pick up more vitamins and minerals from the food that you eat."  Enjoy, and stay tuned for next week for an exciting interview series with 180DegreeHealth's "biggest loser," who has lost 130 pounds and counting eating the food...  

Is Lithium a Potential Aid in Traumatic Brain Injury?

Lithium carbonate serves as a primary treatment option in the treatment of mania and bipolar affective disorder.  An elemental metal, lithium has atomic number 3 in the periodic table of elements.

The mechanism of action for lithium carbonate in bipolar disorder is unclear.  Some of the proposed mechanisms for lithium in the central nervous system include:

• alteration of the neurotransmitter glutamate (affected by other drugs linked to therapeutic effect in bipolar disorder, i.e. sodium valproate and lamotrigine)
• alteration in gene expression
• inactivation of the GSK-3B (glycogen synthase kinase) enzyme known to be involved in circadian clock regulation
• interaction with the NO (nitrous oxide) signalling pathway

Inhibition of the GSK-3B enzyme has been shown to have potential beneficial effects in stimulating neuroplasticity as it is associated with enhanced expression of brain-derived neurotrophic factor (BDNF).  Fengshan Yu and colleagues at NIH and the University of Health Sciences have recently explored the effect of lithium on traumatic brain injury using a mouse model.

In their experiment, mice received doses of lithium chloride ranging form 1.0 to 5.0 mEq/kg dose of lithium or placebo following a controlled episode of brain trauma under anesthesia.  Doses were repeated daily for three days.

Brain injury response to lithium treatment was monitoring using neuropathological techniques as well as behavior and motor coordination tests.  The key results of the study include:

• Lithium chloride at 1.5 to 3.0 mEq/kg reduced brain lesion volume compared to control
• Lithium chloride reduced post-trauma related anxiety behavior during the outcome monitoring
• Lithium chloride reduced breakdown of the blood-brain barrior
• Short-term and long-term motor coordination was better in the lithium group

The authors note that their study suggests the neuroprotective effect of lithium administration following traumatic brain injury in the mouse model appears related to a GSK-3B mechanism.  The study timed lithium administration to 3 hours after the trauma providing a realistic model for a trial in human clinical scenarios.  They conclude "Our results that demonstrate its (lithium chloride) benefits in the mouse model pave the way for early clinical trials as potential treatment for TBI (traumatic brain injury) patients.

CT of traumatic brain injury showing cerebral contusion, cerebral hemmorhage, subdural hematoma and skull fracture from Wikipedia Creative Commons. Source: Rehman T, Ali R, Tawil I, Yonas H (2008). "Rapid progression of traumatic bifrontal contusions to transtentorial herniation: A case report". Cases journal 1 (1): 203. doi:10.1186/1757-1626-1-203. PMID 18831756. http://www.casesjournal.com/content/1/1/203


Yu F, Wang Z, Tchantchou F, Chiu CT, Zhang Y, & Chuang DM (2011). Lithium ameliorates neurodegeneration, suppresses neuroinflammation, and improves behavioral performance in a mouse model of traumatic brain injury. Journal of neurotrauma PMID: 21895523

Are Athletes Better Performers Outside Sport?

Marlins Mike Stanton Rounds Third Base After Homer

Performing at the highest level in many sports requires the development of a complex group of cognitive, fine motor, gross motor, eye-hand coordination and fitness skills.

These multiple skill domains are often performed in a emotionally-charged environment where multi-tasking.  Think a baseball batter monitoring signals from coaches, remembering a pitcher's preference for pitches in certain situation and performing on the road where a sell out crowd roars with each pitch.

This batter then need to use visual skills, timing and motor skills making a swing that where he hopes to land at least a base hit.

A sports exercise research team recently as a good research question related to this type of sport specific skill: "Do athletes perform better in non-sport \tasks that also require quick action and multitasking?

Laura Chaddock and a research team from the University of Illinois recently published online the results of their study in the journal Medicine & Science in Sports & Exercise.  The authors wanted to know if athletes with specific sport training would be able to perform a non-sport physical activity better than non-athletes.

To do this they developed a real-life virtual reality task of quickly and safely crossing a two-way street.  This paradigm requires a special facility and involves manual treadmills, computer simulation of traffic and wireless liquid crystal goggles that provide a sense of depth perception and movement.

The athlete group in the study include 18 University of Illinois participating in NCAA intercollegiate athletics (two baseball, one cross-country runner, one gymnast, two soccer players, five swimmer's, three tennis players, one track-and-field athlete and three wrestlers.  Athletes spent average of 20 hours per week practicing their college sport. Nonathlete controls were not involved in an athletic activites organized by the University of Illinois.

Athletes and controls completed three separate trials--one with no distraction, one while talking on a cell phone and one trial while listening to music through an iPod.

Both groups also completed a simple reaction time task using a desk top computer.

Here were the key results of the study:

• Athletes successfully crossed the street within a 30 second time limit 75% of the time with no distraction compared to only 56% in the non-athlete controls (statistically significant with p<.05)
• Athletes also were more successful under both distraction trials
• Athletes were less likely to be involved in a pedestrian collision during a simulation (23% vs 39% for non-athlete controls
• Athletes reaction time was significantly less than non-athlete controls and this variable negatively correlated with street crossing success rates (individuals with slow reaction times had lower success rates)

The authors note that their cross-sectional study cannot address causality.  One explanation for the results is that sport training provides improvements in reaction time and other psychomotor performance variables that translate to other non-sport multitasking setting.  An second possible explanation is that those with an innate psychomotor skill advantage perform better in athletics and other performance situations like the one found in this street-crossing simulation.  

It is also possible that both of the proposed explanations contribute something to this effects.  

This study also made me think about the effect of age-related reduction in reaction time and the performance in real-world street crossings and other potentially dangerous situations.  This type of simulation could be used in research related to this topic.

Photo of Mike Stanton homering against Chicago Cubs from the author's collection.


Chaddock, L., Neider, M., Voss, M., Gaspar, J., & Kramer, A. (2011). Do Athletes Excel At Everyday Tasks? Medicine & Science in Sports & Exercise DOI: 10.1249/MSS.0b013e318218ca74

Mango Sherbet

I've been kind of sick of eating commercial ice cream and packaged cookies with my lunch lately.  Eating tons of that crap just doesn't feel right.  Intuitively I think to myself that, sure I might be able to get away with it - especially taking buttloads of minerals and putting blackstrap molasses in all my food, but ideal? 

One of the main objectives of RBTI is to maximize the amount of vitamins and minerals that you absorb.  One way of looking at it is that you can get away with eating fewer nutrients because your body is absorbing them so much more effectively.  That's cool and all.  But knowing that I'm absorbing my food better just inspires me to want to eat better food!  So I've been doing some typical health nerd stuff like juicing, and switching from commercial desserts full of refined sugar (Reams believed that most people couldn't handle more than 2 pounds of refined sugar per year - but he did have hypoglycemics eating pie and ice cream like there was no tomorrow) to mostly fruit-sweetened desserts like light ice creams and sherbets.

Anyway, I've really been enjoying my eating now that I've got my Vitamix and juicer back in my possession after almost an entire year of being separated.  So here's a little show and tell.  I have made two sherbets (by the way a sherbet is basically just a fruit-based frozen dessert with dairy fat added - like a light ice cream) so far - one with mango and the other with frozen bananas (no sweetener added).  I would like to make some with cherries or peaches or papaya in the future. Strawberries are not recommended for consumption on RBTI because the tiny, hard seeds get stuck in the colon.  However, one of Vitamix's sales pitches is that it is so powerful it can grind the tiny seeds in strawberries and unlock the nutrition in them - making smoothies and ice cream made with strawberries more nutritious.  This is debatable, but I may try that one some day as well.     

Melatonin For Tinnitus Clinical Trial

Tinnitus, or persistent ear ringing, has no definitive treatment.  I had recently posted a summary of the status of this disorder based on a research review.

Since that post, a small but important placebo-controlled clinical trial examined the effect of melatonin on a group of subjects with tinnitus.

Here are the key elements of the study design from this clinical trial:
Subjects: Chronic tinnitus of at least 6 months duration as primary complaint (subjects ranged in age from 34 to 86)
Clinical Trial Design: 3 mg melatonin versus placebo for 30 days switchover to other assignment for an additional 30 days
Outcome Measure: Improvement defined as improvement in at least two tinnitus rating scales from 3 administered (Tinnitus Matching, Tinnitus Severity Index, Self-Rated Tinnitus)

In the analysis of the outcome of the trial, 57% of subjects were rated as improved during the melatonin phase while 25% were rated as improved during the placebo phase.   This was a statistically significant difference for the active drug.

Subjects who reported improvement with the melatonin trial were more likely to have the following clinical features:

• male gender
• bilateral tinnitus
• history of loud noise exposure
• no history of previous treatment for tinnitus
• no comorbid anxiety or depression
• higher Tinnitus Matching and Tinnitus Severity Index scores prior to the study

One of the problems with the design in this study is controlling for the potential confounding effect of improved sleep on tinnitus severity reporting.  Individuals who have improvement in sleep with melatonin may generally feel better and report improvement in a variety of domains.  An active non-melatonin comparator hypnotic, i.e. Ambien (zolpidem) would need to be included to determine if melatonin specifically contributes to reducing tinnitus.

The authors note potential mechanisms for melatonin in tinnitus include it's antioxidant effect, autonomic nervous system effects, effects on blood pressure or muscle tone. 

Larger multicenter studies confirming this study result are needed before a significant change in clinical practice can be recommended.  Since melatonin is a generic drug, such a study will likely need public research funding to be completed.

Molecular model of the compound melatonin from the Wikipedia Creative Commons authored by sbrools under the GNU Free Documentation License.

Hurtuk A, Dome C, Holloman CH, Wolfe K, Welling DB, Dodson EE, & Jacob A (2011). Melatonin: can it stop the ringing? The Annals of otology, rhinology, and laryngology, 120 (7), 433-40 PMID: 21859051

Inflammation, Depression and Heart Disease

Sunset in Santa Fe, New Mexico

Major depression appears linked to risk for coronary artery disease and an adverse outcome following myocardial infarction.  The mechanism for this association is unclear.

One proposed mechanism relates to systemic markers of inflammation.  Elevated serum blood levels of inflammatory markers such as interleukin-6 and C-reactive protein are risk factors for heart disease.  Some research point to higher inflammatory markers levels in samples of individuals with depression.

Duivis and colleagues from the Netherlands and the United States recently published an informative study on this issue in the American Journal of Psychiatry.  Their study prospectively examined a series of patients with heart disease with measurements of depression and markers of inflammation.  The key elements of the design of their study included:

Subjects: 667 individuals with documented coronary artery disease interviewed yearly for 5 years
Depression Assessment: 9-item Patient Health Questionnaire corresponding to the 9 items making up the criteria for major depression in DSM-IV.  Subjects were grouped into three categories: never scoring 10 or more on the PHQ, scoring 10 or more at one time, scoring 10 or more at 2 or more interviews
Inflammatory Markers: Fasting blood samples measured for high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6) and fibrinogen.

Subjects with two or more periods with significant depressive symptoms showed statistically higher levels of hsCRP and IL-6 than the other two subject groups (fibrinogen levels showed a trend for higher levels, p=.06)

Subjects with two or more periods with significant depressive symptoms tended to be younger, have a diagnosis of myocardial infarction, use aspirin daily and have lower levels of good (HDL) cholesterol.
They also were more likely to be physically inactive, be a current smoker and have higher levels of obesity (BMI).  This association appeared to occur in only one direction--depression predicted later higher inflammatory markers, high inflammatory markers did not predict subsequent development of depression.

When potential key inflammatory confounding variables were controlled (BMI, smoking and inactivity), the association of depression and higher inflammatory biomarkers washed out.    The authors note that this finding suggests the inflammation linked to depression in heart disease may be amenable to increased efforts to "improve health behaviors".

It is unclear from this study how many subjects received pharmacotherapy or psychotherapy for a diagnosis of depression.  Primary treatment of depression may be necessary to engage and motivate those with depression and heart disease to improve their lifestyle choices and behaviors.

Photo of sunset in Santa Fe, New Mexico from the author's collection.

Duivis, H., de Jonge, P., Penninx, B., Na, B., Cohen, B., & Whooley, M. (2011). Depressive Symptoms, Health Behaviors, and Subsequent Inflammation in Patients With Coronary Heart Disease: Prospective Findings From the Heart and Soul Study American Journal of Psychiatry, 168 (9), 913-920 DOI: 10.1176/appi.ajp.2011.10081163

Ulcerative Colitis Diet

This is a funny video with Challen Waychoff.  One of the attendees mentions something about the RBTI beliefs surrounding how cancer develops, and he stiffens up so as not to reveal anything too libelous on camera.

But he goes on to tell an anecdote of a man basically on his deathbed due to a severe case of ulcerative colitis - an inflammatory and "incurable" bowel disease.  Something was obviously quite off in his "chemistry," but it was something that Challen was able to guide the man to sorting out and fix in short order, like he so often does.  I did not ask him specifically the details of the case, and what was causing the problem, but obviously following one of the simple rules of the RBTI in particular was enough to sort it out (as he hints at in the video).   

Real-Time fMRI Psychotherapy

Old World Psychotherapy: Sofa of Sigmund Freud

There has been a series of interesting research studies examining the effect of psychotherapy on brain structure and function.  These studies have typically shown that effective psychotherapy results in reduction of brain deficits or abnormalities associated with a specific neuropsychiatric disorder.

Now a study published in Plos One summarizes the results of study examining the use of real-time fMRI to provide neurofeedback during an amygdala activation task.

This research was completed by neuroscientists affiliated with the Laureate Institute of Brain Research in Tulsa, Oklahoma and George Mason University in Fairfax, Virginia. (Disclosure: The author of Brain Posts is employed by Laureate Institute of Brain Research but was not involved in the study reviewed in this post.)

The authors of this study noted the key role of the amygdala in the processing of emotions.   They developed a experimental paradigm to train control subjects to increase the activation of the brain left amygdala.  A group of young male subjects were instructed in a happy autobiographical memory task and provided real-time feedback on how successful they were in increasing blood flow to the left amygdala.

Subjects identified three key happy memories from their past.  During the experimental phase, they were instructed to recall these specific memories while being scanned using an fMRI scanner. They were provided real-time feedback on a monitor screen on the changes in left amygdala BOLD signal.  (Subjects were told prior to scanning that fMRI neurofeedback is delayed by a few seconds due to the brain hemodynamic process).

Subjects provided real-time feedback were more successful at increasing the left amygdala activation than those in a control group.  This increase in the experimental group correlated with increases in other brain areas known to have functional connectivity with the amygdala (fronto-temporo-limbic network).

New World Psychotherapy: Real Time fMRI

Additionally, the study identified six specific regions where functional connectivity identified correlations with the left amygdala activation:

• right medial frontal cortex
• bilateral dorsomedial prefrontal cortex
• left anterior cingulate cortex
• bilateral superior frontal gyrus

Subjects were selected based on being free of a history of neuropsychiatric disorders including anxiety and depression.  However, there was some variability in the level of change in left amygdala activation with neurofeedback training.  Subjects who scored high on the Difficulty Identifying Feelings scale had less increase in the left amygdala.  Additionally, subjects with higher scores on a scale of being susceptible to anger showed less increase.

This research is an very important advance in understanding the amygdala and regions connected with the amygdala.  Additionally, it raises the possibility that real-time fMRI may emerge as a tool to understand processes associated with psychotherapy and to be an emerging model for providing therapy under real-time neurofeedback conditions.  

The site of psychotherapy might be moving from the sofa model of Sigmund Freud to the fMRI scanner.  Both methods have subjects that lie down, but only the fMRI method provides real-time feedback of brain effects related to a psychotherapy intervention.

The authors note that this study was a type of "proof-of-concept" study since it focused on healthy control subjects.  They suggest that this type of model might be particularly relevant to cognitive behavioral treatment of conditions such as PTSD and major depression.

Photo of Sigmund Freud sofa from the Freud Museum in London from Wikipedia distributed under the GNU Free Documentation License.


Photo of Functional Magnetic Research Imaging device courtesy of the Laureate Institute for Brain Research. 

Zotev, V., Krueger, F., Phillips, R., Alvarez, R., Simmons, W., Bellgowan, P., Drevets, W., & Bodurka, J. (2011). Self-Regulation of Amygdala Activation Using Real-Time fMRI Neurofeedback PLoS ONE, 6 (9) DOI: 10.1371/journal.pone.0024522