Depression – the 21 century epidemic? Conversations at TFL

A conversation between Dr. Sheela Nambiar MD, Obgyn – (SN) and

Dr. Ennapadam S Krishnamoorthy  – (ESK), Behavioural Neurologist & Neuropsychiatrist.

SN – Welcome to you all. We are happy to be here to discuss this important topic of depression. Dr Ennapadam Krishnamoorthy is a Neuropsychiatrist and Behavioural neurologist. He is the Founder of the Buddhi Clinic chain which offers complementary and alternative medicine, in addition to, standard neurological & psychiatric care and psychotherapy solutions.

SN – Why would you say the disease of depression has become an epidemic of the 21^st century? Is it something that we are calling out more or are people more depressed than say, 20 years ago?

ESK –We understand today that depression is one of the most common medical problems worldwide, a cause of dysfunction and debilitation. At one end it is just a feeling most of us will experience at some point in our lives, due to life circumstances or, a loss. Sometimes it might last for a short spell. At other times it may last for a longer period of time and affect our lives. That is when it becomes a disability.

Let’s say, I break a leg – it is a very apparent disability. But, when I am depressed, no one else may know what I am going through, because it is so personal and internal that it cannot be communicated to others. It is a transient feeling but that which disables an individual and prevents her/ him from having a normal life.

A meta-analysis from BMJ looking at how depression has progressed actually shows that the rates have dropped from 36% to 24% in patient clinics. The paper also says you are more likely to be depressed in your 30s and 40s and then late in your life. So it’s a “U” curve. So I’m not sure if it is indeed more common than before.

SN – So what is the difference between feeling low and having a clinical depression?

ESK – The difference is in the severity.  Is it significant enough to need attention?  How long has this gone on? The duration can be as less as two weeks.   But the most important thing to ask oneself is – ‘is it preventing me from having a normal life?’ If it is, one needs to pay attention to it.

SN – What is really interesting to me is that everybody has problems. I don’t think anyone gets away without problems. How is it that some people are able to withstand them and not become depressed, whereas others having similar issues get depressed?

ESK –  So in your introduction you used the term “bio-psycho-social”. The Bio part of it is how each of us is wired. This is a combination of genetics, early upbringing and the like.  This is when the brain develops.

Your ‘Bio’ is influenced by your genes, by the chemistry in your brain, certain inflammations like the antibody syndrome when your body is attacked by something, the body responds by creating antibodies but which then turns against your own body’s cells.

There are metabolic factors that cause depression. These could be hypothyroidism, low B12, D3, having diabetes, and certain skin conditions like atopic dermatitis.

We, then, come to Psyche which is your temperament.  Certain temperamental patterns, like worriers, obessesive anxious people may be more prone to depression.

There are Social-environmental factors which include parenting, family, outside influences etc

So, the question “why am I getting depressed”? has multiple answers – we all have emotional scars of various kinds, some we may not even remember. We also have nurturing factors that make us stronger. People who are worriers, obsessional, anxious, tend to be more prone to becoming depressed than people who take things in their stride and just move on.

SN –And there is some research on how more creative people tend to be more prone to depression is there not?

ESK – Oh yes. There is a lot of literature on mood swings and creativity. There are a number of examples of poets, artists and people in the creative field who were depressed. That’s also because depression is more of a right-brain than a left-brain phenomenon. Having said that, there are forms of depression that are left-brain too. There is a social aspect to depression, one interesting statistic is that you are seven times more likely to have a mental health problem in the 6 months after your marriage than in any other time in your life!

But interestingly there is another counter-statistic is that one of the things that makes sure that you have a good outcome from a mental health problem is being married.

ESK – Women are twice as likely to experience depression in their lives than men are. Due perhaps to all the life events they go through and the hormonal changes.

SN – Hormonal fluxes can be quite drastic from menarche, to pregnancy and delivery to menopause. These events do influence a woman’s mood. Would you say that social support also plays a role in depression?

ESK – Absolutely. Both in protecting you against depression and in helping you overcome it. Having a good social support system, work and employment, activities you resonate with and a healthy financial status.

SN – I deal mainly with women being a gynaecologist.  I find that women, once they cross the age of 40 or so, find themselves wondering what else to do, now that their children are independent, and probably have ;eft home. Once they are given the right support, they make a change that they perhaps could not attempt in their 20s and 30s. It may be maturity or that after a point they no longer want to please society, norms or the people around them all the time. One of the triggers for this change is that they start to feel depressed about their situation. Have you come across situations like this?

ESK – Absolutely! Menopause/Perimenopause also plays a role. Mood, memory etc. are affected around this time. Apart from life circumstances, there are biological changes that are happening so symptoms of depression etc. can set in.

SN – What do you have to say about this concept of depression being connected to ‘weakness’ and the stigma behind it? Does this hold back people from coming forward to get help? In fact, even family members may brush it off saying, “you need to get over it”.

ESK – That is the most common thing we say, “pull yourself together’. But they cannot! That is why one needs to understand that it is a disability. If one were paralyzed, one would not say “get up and walk”.

There is, also, a burden of expectation we all place on ourselves. The expectation – to be normal and fulfil our obligations. When you are depressed, however, these obligations may seem big.  Getting better, just like with a paralysis, is a slow process.

SN – Can you tell us the different symptoms experienced by a depressed person? Do different personalities express depression differently?

ESK – Children and elders express depression differently. A child might be irritable, agitated or angry. Elders might also show similar signs. Though they are both likely to be depressed. In adults, it can be expressed as low moods, or

“Anhedonia” which is the inability to feel pleasure in things you would normally find in, “Hedonism”- to seek pleasure mindlessly, or “Alexithymia” which is the difficulty in verbalizing an emotion.

Language has an interesting connection with depression. There is no word for depression in Tamil for instance. There is no word to say I am depressed in Tamil. You only express things like ‘the mind is tired”.

There are linguistic barriers to expressing depression. Our culture does not encourage you to express your emotions like Western cultures do. Most of us would not for instance, go on the Oprah Winfrey show and talk about our glorious or miserable lives! This is because our culture does not encourage us to express our emotions. People often use ‘as if” terms to talk about emotions rather than talk about their emotions directly. In a number of Indian and other native languages also lack words for certain emotions. Friends from Africa tell me they don’t have a word for depression.

SN – Coming to the treatment of depression, can you tell us something about anti-depressant drugs?

ESK – Anti-depressants have had some bad press. But they have a unique mechanism of action. We used to think they correct the chemical imbalance in the brain and that is what relieves symptoms depression. We now know that some of these drugs actually help to grow new neurons. They have a neuro-protective effect. This may be why they take a long time to produce relief from symptoms.

Antidepressants take a long time – 6 weeks to 3/6 months. The most common reason for ineffectiveness of treatment is non-compliance to treatment. The second is the failure to try a drug at an adequate dosage for an adequate period of time. So, often, if 3 months later you don’t feel better, you may change your doctor, your drugs etc.

 All drugs have side effects, of course. I think a patient should try anti-depressants under the guidance of a good doctor before they give up. In my experience, most people give up the treatment too easily. It requires a therapeutic alliance between patient and doctor.

SN – Can a patient go off the drugs completely at some stage?

ESK –You cannot stop them suddenly, they need to be withdrawn slowly and gently. Typically, the drug needs to be taken for at least 6-9 months.

SN – Have you come across many patients who complete the course of drugs and do well?

ESK – Depression is one condition where you can actually say you are “cured”. The chances of cure become better when besides taking medication you do other things like psychotherapy.

Psychotherapy helps you understand the roots of your depression. Where is it coming from? It reflects the gap between expectation and reality. So, it is important to engage in good therapy and use this opportunity to understand oneself.  Good psychotherapy will help you prevent further episodes as well.

SN – So Cognitive Behavioural Therapy would be one such form of Psychotherapy?

ESK – Yes, absolutely

SN – Talking about prevention and lifestyle management of depression, I would like to add about why exercise is so important for the management of depression. Exercise does produce endorphins; it makes you feel better and puts you in a better frame of mind.

Diet is also of utmost importance. The gut produces as much if not more serotonins than the brain. The microbiome in the gut is responsible for much of your mood. If you do not feed the gut with the right kind of food, the microbiome in the gut is altered. It has been shown that people with very poor eating habits – highly processed food, sugar and so on have altered microbiome and are more prone to depression. Something as simple as a change in your diet and exercising on a regular basis can be a support system to the medication if you need it.

SN – What can you typically expect from a psychotherapist?

ESK – A good therapist is not someone who will tell you what to do. They will not advice you what to do. Instead a good therapist will show you a mirror to yourself. She/he will be able to help you understand your emotions and verbalize them.

A therapist is a professional, and has no prejudices. All the solutions are within us. We may not see them. So, we may need the help of a good therapist.

SN – Is depression genetic?

ESK – Yes, when the Human genome project was underway a number of single gene disorders were discoved. Certain  disorders of brain and mind also got unlocked. General thumb rule is that 10% of people have a genetic form of neurological or mental health condition.

Talking of psychotherapy – Everyone may not be suitable for psychotherapy. You cannot offer psychotherapy in all stages of depression. You may need to work with some people in other ways.

SN – Lets open the floor for questions

Question – When you are looking after family member with depression, how do you deal with them when they don’t comply with medication? What is the right approach when they refuse to take responsibility?

ESK – The role of the family and in having someone empathetic is important. Sometimes, when the patient refuses to come to the hospital we, at Buddhi Clinic will send someone to their home to try and engage with them. Using holistic care like Yoga and Ayurveda, (which is offered at Buddhi clinic), we can get them started on a self-care journey.

So, engagement, having the family involved, offering people courses that they truly believe in and are willing to explore have a hugely beneficial effect on the management and better cure of depression. I became interested in these other forms of treatment after I found that often people with mental disorders when they try alternative forms of treatment like yoga etc. they are told to stop all other forms of treatment. So I decided why not offer them everything so they can continue their medication when required and also have the option of other treatment under supervision. We don’t understand the power of what other systems can offer.

A friend of ours who does research on Yoga has shown that after a set of Yoga sessions which are aimed at improving mood, the brain changes are the same as taking medication.

SN – With reference to this first question it is important to also rule out other disorders isn’t it? It may not be pure depression. It is possible that it may be a combination of mood disorders, psychosis and so on?

ESK – Thank you for pointing that out. It is important to recognize that what seems to be depression may be something else. It could be a disorder of the brain or body.

SN – It could be a simple deficiency like a B12 or D3 deficiency.

ESK – Yes or it may be an inflammatory condition of the thyroid for instance. Thyroiditis that is completely treatable.

Question – Is it true that depression can teach you something and it is there for a reason? Can the person be depressed because he needs to withdraw and ponder?

ESK – That’s a very interesting question. If you read the life stories of Ramakrishna Paramahansa, Jiddu Krishnamurthy and others you will find that for many, transformation and realization started with depression. “Pathos” is the word used. That does however, not hold good for everyone.

ESK – One of the things we have not mentioned about depression is the Becks Triad – this is the negative view about the world, the self and the future.

CBT is circled around this thought process to identify the thoughts that are making you depressed and work on how you can re-think.

Today we also have Transcranial Magnetic Stimulation TMS. For some this works very well. It modulates your brain and makes the chemicals more available. We have this treatment available at Buddhi Clinic. You need 20 sessions of about 30 minutes each. No anaesthesia is required.

Question – What do you advice people who are the caregivers of depressed people?

ESK – It has a profound effect on the family and caregivers. Caregivers go through a lot of stress. An important part of caring is to also extend it to the caregiver.  Caregivers go through guilt, blame and remorse. Usually the psychotherapist is the best person to discuss this with.

You don’t always have to do something active with a person who is depressed. Just sitting with them, going for a walk with them, listening to music may be sufficient. Just being there sometimes makes all the difference.

Question – What is the relationship between substance abuse and depression and what effect do they have on each other?

ESK- It is a kind of chicken-and-egg story. With some, being depressed may make them turn to substances like alcohol.  In others, the alcohol is the problem and leads to depression. So, the drinking and the mood may be cyclical.

Questioner – What about food? Is that also a form of substance abuse?

ESK – There is a lot of association between eating disorders and mood. Anorexia and bulimia are associated with mood disorders. So, eating disorders and mood disorders can co-exist in a number of people. One can influence the other, the treatment of one can cure the other.

SN – There is evidence that obesity is related to depression and vice versa. So, when you are depressed, you reach for food as comfort, gain weight and then you get more depressed. Frankly I think food is as addictive as any other substance (abused), because it is so easily available, acceptable and accessible unlike alcohol and drugs. Especially sugar, not just white sugar but processed food that has added sugar is highly addictive.

SN – I would like to thank Dr. Ennapadam S Krishnamoorthy who has been so generous to spare his valuable time to come here and spend this hour with us to discuss depression. It is silent, pervasive and so easy to miss. If you have any doubts about anyone (including yourself) heading down that road, there is no stigma. It is like any other disease. Just as you would not hesitate to go to a doctor to treat gastritis, there should be no stigma associated to going to a psychiatrist. I hope Dr. ESK has made it clear and that is all the more reason we should pay close attention to it.

You can connect with him at the following address – poorna@buddhiclinic.com

Phone -+91 9500010065/67

 

Jumpstarting my weight loss journey with TFL

I am Tania Thimraj, and I have lost nearly 12 kgs. after I started the Jump Start program last year with Dr. Sheela Nambiar. I signed up for the 12 weeks summer program in May 2018. I was an anxious, stressed out and overweight PhD student, travelling between the US, Sweden and India for my doctoral thesis projects. As of October 2017, I weighed around 76Kgs. When I moved to Sweden for work, my diet consisted of store bought, ready to eat in 7minutes, pre-packed frozen foods and bread. I had an aversion to cooking and to eating salads and wouldn’t eat anything without meat. I realised it was taking a toll on my health when I couldn’t walk up a flight of 10 stairs without having to stop and catch a breath.

That was me – far left…….

I joined a gym and started doing cardio about 20 minutes each on the treadmill, stationary cycle and the elliptical. This, I was doing aimlessly and wasn’t regular or motivated.

While scrolling through Facebook one day I saw a post from TFL which intrigued me. It said 12 weeks to a Slimmer You. I read it again and I thought to myself, that Dr. Nambiar is not one to propagate the idea of quick-fix diets and false claims to losing weight. So, I emailed her to ask her about the package, which was JumpStart – a beginners program to jumpstart your weight loss and wellness.

We set up a Skype consultation and as expected, it was a very well thought out program with a focus on all aspects of fitness both physical and mental and how the two relate. I had a long chat with Dr Nambiar about how I was feeling and why I wanted to start the program. Following that, on our next online consultations we discussed what my short-term goals were, what my long-term goals were and we discussed how I was feeling and my anxiety and how to cope with it.

She gave me a workout plan for 6 days a week and encouraged me to give it my all for the next 12 weeks. We had weekly consultations over skype/watsapp, as I was living in Sweden and she is based in India. We discussed my food habits and what I needed to include and what I should avoid. She spoke to me at length about the different food groups, the importance of maintaining a food journal and portion and serving sizes. I received a lot of recipes, which changed my attitude towards vegetables. We also discussed pre-menstrual cravings and heathy alternatives to desserts.

Within a few weeks of starting the program I realised that I felt much better mentally and physical I had lost weight too. I became more mindful of what was on my plate and what was missing and how to incorporate different food throughout the day.

Contrary to what I believed, I actually ate more but it was more fruits, more vegetables and all the good stuff.

Another important aspect apart from mindful eating and regularly working out, was working on my anxiety and stress. Dr. Sheela Nambiar helped me understand the reason for my anxiety and that there were things that were beyond my control and how I need to focus on things I can control in my personal life as well as at work. She stressed the importance of maintaining a gratitude journal. Dr. Nambiar also helped me with coping techniques during pre-menstrual mood swings and emotional changes. By the end of the program (12 weeks) I had lost 7 kgs.

I have continued working out with Dr. Nambiar after the 12 weeks by extending the program and have weekly skype/watsapp consultation with her. She helped me adapt my workouts and diet while travelling too. Though I live in a different country and have not trained at the gym with her, anytime I need clarification she is always helping me out. She sends me videos of exercises I don’t know or during our consultations she will show me how to do the exercise with the right form. The routines are always new, with varying intensities and pushes me to better myself and this clearly shows in the way I look and feel. I have become stronger and have more stamina. I can walk up 100 floors in 20 minutes on the stair master now. I couldn’t run when I started and now I run at 10km/h on the treadmill. I lift heavier weights. I have lost a total of 12 kgs. and I have reduced at least a few sizes. My clothing sizes went from XL/L to M/S. I am very proud of myself for having kept at it and not giving up. I do have some bad days and sometimes I don’t feel like working out for a whole week but I know that when I’m on a call on Saturday morning with Dr. Nambiar, I need to report something positive and I push myself to go workout no matter the mood.

This is me now!

I have recommended the program to my family and friends as Training For Life with Dr. Sheela Nambiarhas been one of the best decisions I have taken. The program has been very rewarding not only in terms of weight loss but it has improved my confidence. My approach to dealing with stress and also my outlook on health and wellness has completely changed.I still have a long way to go to reach my ideal goal but I look forward to continuing to work out with Dr. Nambiar, maintaining a healthy lifestyle and incorporating what I’ve learnt from her in my life.

 

Tania Thimraj

Lose weight by optimising your relationship with food

Most of us have an ambiguous, love/hate relationship with food. We love how it brings us instant gratification but we hate what it does for our waistline or health. How do we then lose weight if we are in constant struggle with the aspect of weigh that is critical – food?

– How many of you oscillate between binging on favorite foods and then starve yourself to ‘undo’ what you’ve done?

– How many start on a restrictive ‘diet’, are unable to sustain it and then swing to the other end of the spectrum in frustration and binge-eat or eat everything ‘you are not supposed to’?

– How many feel anxiety and guilt over food?

– How many refuse to actually log in a food journal properly because it’s too difficult, anxiety ridden or painful?

– How many have endless arguments or discussions with your nutritionist, fiercely negotiating what you know you should be avoiding?

– How many have uncontrollable ‘cravings’ for a particular food and withdrawal when you can’t have that particular food (sweets or carbs for instance)?

Food is not supposed to create all this anxiety and guilt. How did we get to this point? Big food companies and clever marketing strategy by ‘diet gurus’ attempt to create a sensation of unrest within you making you believe you’re not doing it right and that they have the solutions. Then food companies proceed to sell you ‘products’ which are supposed to solve your problem and make life easier, except that they don’t. Instead packaged, processed products like meal supplements, processed protein supplements, quick meals, packaged, easy to eat food-on-the-run are the cause of many health problems to start with. 

In truth, if we truly listen to our own bodies we can identify what is good for us and what is not, how much to eat and when to eat. The problem is, we are unable to or won’t listen to our own body’s signals. These signals have perhaps been anaesthetized from years of being ignored. Childhood programming of eating way beyond what we actually need to, of the wrong kind of food is very common. How many of us were told, ‘clean your plate’ when we were children, irrespective of how much is on the plate! It’s also possible that you have turned to food as a source of comfort to soothe stress or anxiety. This may have become your default setting. You are using food for more than just assuaging hunger. It’s also possible that you don’t recognize real physical hunger for what it is. 

To re-establish a healthy relationship with food we need to –

• Pay close attention to the signals the body sends us – Mindful eating, recognising real physical hunger (as opposed to emotional hunger, boredom or stress). This takes training, time and self-awareness. Years of neglect cannot be undone in a matter of days. There will be times when you are still confused about whether you are really hungry or just plain anxious or bored. With patience and attentiveness however, you will start to appreciate your body’s own signals.
• No need for guilt and shame– Even if you have been binging or eating inappropriately, there is no place for guilt and shame if you want to make a change. Guilt and shame are not helpful emotions.  According to studies done on self compassion and the implications of treating oneself kindly (Leary & Tate 2007), it was found that self –compassion was important to buffer oneself against unproductive negative self-talk. Acknowledge responsibility without feeling overwhelmed with guilt. Guilt and shame prevent growth and openness and instead create a closed mindset and cause you to literally want to hide. So what do you do? You hide and eat some more! Instead own up to your behavior that is not helping you and understand what to do. Be non-judgmental about your habit, but take responsibility for it!
• Become conscious of your patterns of eating– All of us have certain ingrained patterns and habits., some of which may not be helpful (late night snacking, or indulging in sweets post every meal for instance). Become conscious (not ashamed or guilty, but conscious) of these and observe their connections in relation to your mood and sense of wellbeing. 
• Don’t be too rigid – Tying yourself to excessively rigid rules and regulations about food can be counterproductive. Having to constantly deprive yourself can be exhausting and will not last. Allow yourself to eat in moderation (and you need to understand what moderation is) and also to occasionally indulge (and you need to understand and define what ‘occasionally’ means). This will give you a feeling of freedom rather than restriction. Over time you will gradually understand that you really do enjoy these occasional, moderately eaten indulgences and feel totally satisfied with them
• Don’t be dependent on will power all the time – ‘Will power’ is not infinite. Make it easier on yourself to follow healthy eating patterns. For instance, don’t stock up on unhealthy snacks at home and expect your will power to hold you in good stead in avoiding these temptations. There will be times you are more vulnerable to indulgences, especially when you are tired, sleep deprived or stressed. These are not times you want to test your will power over food. The best way to avoid the situation altogether is find great substitutes for your unhealthy snacks and stock them in your pantry instead. 
• It’s ok to enjoy food – It’s perfectly ok to enjoy food. It’s perfectly ok to love delicious food. If you want to stay healthy and maintain a good, functioning body and mind then food should be more than just about pleasure. Set about creating better and healthier options you can appreciate and enjoy. Understand that while some foods may taste delicious, they may not be optimum in creating health and wellbeing. 
• Change your perspective – I’ve heard the comment “I’m a foodie, so I cannot diet”. It’s all about perspective. If you view a healthier eating plan (which can be equally if not more delicious), as a torturous ‘diet’ then you will likely not sustain it for long. If you instead start to look as food as nourishment, something that can heal your body and mind, something to value and appreciate for what it does for you, instead of looking at food only as a source of instant gratification, your perspective of food undergoes a sea change. Instead you actually start to enjoy the healthier options. 
• Eating healthy becomes the default position -Eating healthy does not equal deprivation. There are great healthy options to choose from all the time. It may take some readjustment in your brain to prefer a fruit to cake on a regular basis, but when you make these choices often enough, the amazing thing is, you actually start to prefer the healthy options. You really do. A greasy, overly spiced snack starts to make you feel nauseous. That sinful chocolate cream cake is fine for the first two spoonfuls, then you want to push it away. That huge pile of rice you used to eat is just not appealing any more. Your pattern of eating changes gradually such that, healthier options are your default position. 
• Recognize that deep-rooted maladaptive behaviors may stem from early life experiences– Your relationship with food goes way back into childhood. It’s important to understand and accept this. Only then can there be healing from these reflex maladaptive behaviors. Important research has found that adverse childhood experiences like physical or sexual abuse (Gustafson & Sarwer, 2004, Felliti, 1993) increases the risk of obesity and disordered eating several fold. Addressing such trauma will of course require therapy with a counselor experienced in this field.
• Exercise regularly – Regular exercise enhances willpower (Oaten & Cheng 2006). The ability to make better choices with food (or with anything else for that matter) is enhanced with regular exercise. So while cravings may recur from time to time, exercising regularly enhances ones ability to sustain a better diet. 
• Find your ‘why’ – Its important to acknowledge ‘why’ you want to lose weight, eat better or get healthier. The stronger the inner motivation to do so, the better your results at achieving your objective of healing your relationship with food. If this motivation is vague and undetermined, then you will likely go back to eating any way you want as deep down you really don’t see any reason to change. 

Your relationship with food is significant and a healthy one is necessary if you want to avoid food related stress. We have enough stress in our day-to-day lives; lets not add food to the list. 

Here’s want I have found from both personal experience and counseling hundreds of women over the years. 

• When you are busy, fulfilled and occupied in your life, you tend not to obsess about food. You tend to eat to feel good, motivated and energetic not dull, stuffed and lethargic. Food is a means to an end not an end in itself. 
• When you are honest about your choices in a non-judgmental way, it is much easier to make changes. 
• When you are open to learning about how food can create of defy health, then you are more likely to follow through with healthier choices. 

Optimise your relationship with food and watch how much easier it is to eat better consistently! How to stay satisfied with the food you eat, how to appreciate the food you eat and as a result how to lose weight effectively and more importantly, how to sustain that weight loss.

Trust in the Process

So you decide to start exercising. Your reasons may range from wanting to lose weight to getting fitter, looking better, running a marathon or perhaps your last visit to your doctor didn’t go too well and you’ve been told you have to knock off the pounds, cut down on your food and so on.

With all good intentions and some trepidation you take yourself to the gym, hire a trainer, perhaps meet a dietician and get started with your newfound virtuous purpose.

You are enthusiastic initially. You want to lose that weight and get with the program. A few weeks to months down the road the initial enthusiasm starts to wane. You start skipping workouts, that diet plan is making you ‘hangry’. (a newly coined word for ‘angry’ because you are hungry!). It’s frustrating and does little for your self esteem.

The most common reasons for lack of compliance with an exercise or healthy      eating program The expectation of unrealistic results and subsequent disappointment. Expecting too much too soon. Doing too much too soon and getting burnt out quickly. Following a diet that does not complement your exercise routine or lifestyle. Listening to endless advice from all quarters about how best you can lose        weight rapidly or this awesome new workout or weight loss aid. Other lifestyle habits that may be hindering weight loss such as lack of sleep      and stress.

Whatever your reason for starting an exercise program, once you start; you have to – Trust in the process.

– Eat clean

– Exercise smart

– Make good choices through the day

– Address other aspects of your life

– Be patient

– Reward yourself

&

Repeat.

Most people falter in one or all the above and still expect spectacular results. The science behind weight loss is such that it simply cannot happen overnight. The body has to go through the process of changing gradually. It often plateaus; weight loss stalls and you could get discouraged. This is especially true for those inclined towards instant gratification.

Eat clean – If there were two things you should eliminate from your diet it would be sugar and processed food. Eat mainly whole foods, plenty of vegetables and fruit, including enough protein (especially plant proteins like legumes, lentils, beans, nuts and seeds) and some high quality fats.

While many fad diets abound, you have to find a healthy ‘eating plan’, not necessarily a prescribed, rigorous ‘diet’ that will suit your lifestyle. It has to be adapted to your palate, work hours, travel and recreational activities. It goes without saying that encouraging the entire family to eat clean most days of the week, (with occasional treats) goes a long way in supporting weight loss and health for everyone concerned. Women often tell me that they sorrowfully, stay away from the family dinner table to ‘avoid temptation’. That’s a hard way to live and considering this is supposed to be a lifetime commitment, it doesn’t make much sense. Of course there will be times when you eat out, eat on airplanes or at office lunches. Over time, given enough time, you will learn to eat sensibly even on these occasions. You learn to make the right choices. Eating Clean becomes a lifestyle.

Exercise Regularly – Regular exercise has to be a lifetime commitment. It also has to suit your lifestyle. Planning to workout seven days a week with an already hectic work and family schedule is bound to fail.

Your exercise routine has to include cardio, strength training and flexibility in appropriate proportions to suit your needs. It also has to be of adequate intensity that is gradually increased with time, as you get fitter. Doing the same thing, months on end will cause stagnation and boredom. If you miss a workout, or a couple of workouts, get right back on the saddle and keep going. The mistake many people make is to fall right off the saddle and stay on the floor. They give up too soon at the first signs of trouble.

Exercise smart – You have to be strategic in your exercise. Longer or harder is not always better. There is a time and place for low intensity, long duration exercise. There is also a time and place for high intensity interval training. An exercise routine that you can fit into your day may mean a quick workout on some days and longer ones on others. We have to also think about getting the best out of our investment of time.

Don’t forget the weight training to build muscle mass. If there is one thing that will help you sustain fat loss it is building muscle. I’ve elaborated on this in my book ‘Gain To Lose’.

Make good choices through the day – An hour of exercises does not entitle you to be sedentary through the rest of your day, neither does it warrant eating with abandon. Making good, conscious, mindful choices through the day goes a long way in helping you achieve your goals. Even small interventions like walking as much as you can, taking the stairs, not sitting for long periods of time, managing stress with the appropriate tools like time management, meditation, breathing and maintaining healthy, supportive relationships are important. Stay mindful through the day.

Address other aspects of your life – Sleep deprivation, uncontrolled stress, lack of authentic social relationships, loneliness, depression and presence of toxic relationships can contribute to weight gain or the prevention of weight loss. All the aspects of wellbeing need to be considered if you want long-term solutions. Of course life is never perfect but being cognizant of these things and how they may be playing into your weight and therefore your health is the first step to overcoming a weight issue. Learning to deal with our imperfect lives is more important than trying to make it perfect.

Be patient – The body has to adapt to the new lifestyle of clean eating and regular exercise. A new lifestyle takes a while getting used to not just physically but psychologically and emotionally. If you are accustomed to eating a bag of chips in front of your TV everyday, then, stopping this habit will create cravings that have to be managed with appropriate tools until they can be overcome.

Weight loss takes time. This may vary.

Initial weight loss can be quite drastic and no doubt thrilling, only to find, it stalls. This is the time to increase the intensity of your workouts, change them around, revisit your eating and keep moving.

Keys to maintaining patience & staying the course – Find the motivation to keep at it. Finding a support group like a group class,     walking or running buddies is very helpful to stay on track when you start to feel discouraged. Find a distraction. Stop obsessing about your weight. It will happen if you trust  in the process. Start a hobby or volunteer for a social cause to keep your mind busy and distracted from that weighing scale. I know a woman who started       glass painting to keep busy after we chatted about it. Today she has not only     lost her unwanted weight, but has a flourishing business and is truly busy with  an exciting life.

Reward yourself appropriately –The human body appreciates reward. So you have to set up a system whereby when you achieve small goals you reward yourself (not with a sweet treat, because that would be self-sabotage), on a regular basis. It has been found that by doing that you establish motivation to continue. Perhaps a massage, new workout clothes and so on.

You have to stay on course. A couple of detours are inevitable and to be expected. It does take effort and a willingness to commit to a lifetime of lifestyle change. Many people go right back to their old habits after they have lost their weight only to find it creeping back. How can you expect it not to?

All of the above may seem rather mundane. Where is the magic pill you ask? Where is that solution for an instant and permanent fix? Truth is, there isn’t one! You have to trust in the process and wait for your body to respond, which it will, if you do it right.

Dr. Sheela Nambiar MD, Obgyn

Lifestyle Medicine Physician Dip LM BSLM

Fitness Consultant NAFC

Author of – Get Size Wise, Gain To Lose & Fit After 40

 

Mindfulness for Well-Being

This article was first published in The Rotary News in March 2019.

Most religions and spiritual practices have their own repertoire of a variety of meditative practices. Mindful meditation and mindfulness however have no religious trappings and anyone, from any walk of life can (and should) incorporate mindfulness and mindful meditation into their life for just a few minutes in a day to perceive the benefits.

The practice of mindfulness and the corresponding meditative practices have gained scientific attention after several studies; especially from the Center For Mindfulness at University of Massachusetts have explored the benefits. S.N Goenka, a Burmese-Indian, the founder of Vipasana Meditation and more recently, John Kabat-Zinn from University of Massachusetts have been instrumental in popularizing Mindfulness.

Improvement in physical ailments through this mind-body method is now accepted as a very important complement to mainline management of disease. The improvement in psychological health, cognition, decision-making capability, social relationships and general wellbeing are recognised as some of the benefits of mindfulness.

What is Mindfulness?

Mindfulness is nothing but the non-judgmental conscious and purposeful awareness of the present moment. So what’s so wonderful about that you may ask! If you think about it, there is nothing but the present moment. The past is over and the future is not yet here. Being aware of the present moment keeps us more engaged and involved with our lives as it plays out in real time.

Have you been with your kids while distracted and wishing to be elsewhere? Have you driven home reliving an argument with a co-worker, angry and resentful, unable to even recalled your drive? Have you sometimes looked back and wondered where the day had disappeared, having no memory of it? Have you sat in front of your TV and gone through an enormous bag of chips with no real recollection of having eaten it? These are all examples of mindlessness that are typical and not helpful. They rob us of the present moment and spin us into a realm that does not even currently exist.

– Anxious worrying or rumination can cause you to eat mindlessly, leading to obesity and all the subsequent repercussions. – Lack of mindfulness can keep you disconnected from your body and the continuous signals your body sends you. So you may be unaware for instance that what you are really feeling is fatigue or thirst and not hunger and reach for food in a distracted and mindless manner. – Lack of mindfulness can manifest as a lack of awareness of social cues, another person’s body language or even an understanding what they are really saying leading to misunderstanding and grief.

Mindfulness is also the ability to observe without judgment the present moment with its pain, suffering, joy, happiness or feelings of insecurity and recognize it for what it is. Being mindful of the situation as it is helps us firstly concede it and then, when required, make the necessary changes to improve it. So, for instance, if you are angry or disappointed with someone, observing and recognizing that emotion for what it is and then questioning oneself to reveal the source of the anger/disappointment will help us deal with it far better that just acting out on impulse, mindlessly. In fact, embracing the feeling of anxiety or pain instead of trying to escape from it can tell us much about ourselves, increasing self-awareness.

This habit of being present without judgment and being open to acknowledging what is happening in real time transforms our relationship with ourselves, creating a higher level of self-awareness that most of us lack. Our bodies and minds have an innate wisdom and capacity to, for instance, indicate to us what is truly wrong and what is going on within. The only trouble is, we don’t listen because we are too busy living life at high speed and mostly through virtual reality with photographs and social media, comparing, wishing and judging.

Being mindful is a habit. The thoughts in our head can actually cause or aggravate disease or precipitate emotion; our thoughts matter.

Being aware of what they are therefore is critical to our wellbeing. Research from the University of Massachusetts Mindfulness Based Stress Reduction, or MBSR program have shown the benefits of mindfulness and mindfulness-based practices for a variety of medical conditions such as anxiety (Otner 2007), pain (Zeidan 2016) and even skin conditions like psoriasis (Kabat-Zinn 1998). The improvement in such conditions, using mindful meditation appears to be the result of the deepening awareness of our own thought processes related to the disease or pain we suffer. Thinking in a particular manner about our pain or disease can actually increase that pain or alter the course of the disease. Being aware of just how we react to or think about/view our pain or disease will help us modify those thoughts when required thereby altering the pain or disease. Being conscious when we start to ruminate about a negative outcome or recognizing that our pain in the back is aggravated when we are stressed (not necessarily physically) is helpful to alter the course of the physical condition.  Mindfulness also has several benefits for our emotional and thinking brain –

• • Mindfulness calms the brain by quieting the parts of the brain (the Amygdyla) responsible for the fight-or-flight response (Lutz, Davidson et al 2008)

• • It aids in stress reduction (Goldin et al 2010)

• • It helps regulating emotions to improve emotional intelligence (Chiesa et al 2010)

• • Improves attention and focus (Baijal et al 2011)

• Reduction in depression (Napoli et al 2005)

Steps to being more mindful –

• • Pay attention to simple things – it could be something as simple as taking a shower. Be conscious of the water, the temperature, the sound and feel of the experience. It does not matter if you are enjoying it or otherwise. Just be conscious of the sensations and moment. Make it a habit

• • Breathe – Sounds so simple. Rarely are we conscious of our breathing. Make it a habit to become aware of your breath at frequent intervals through the day. It could be every time you move from one project to another, or one client to another or when you walk down a corridor or get yourself a glass of water; stop and breathe.

• Listen to your body – Sometimes we are aware that there is some vague pain or discomfort in our bodies. We may not however really pay attention to how the body moves or how we sit, stand, eat or engage.

How do we position our hips, feet, back, arms? Is there tension in some part of the body? Is it aggravated by the way we move or sit? Do we favor one side more than the other? Is one side weaker? Is our core engaged? These are not always aspects of ourselves we pay attention to. Doing so will bring a deeper awareness of our own bodies. This in turn keeps us tuned into our bodies, working with it instead of against it. Doing things to keep it well.

• • Be aware of your thoughts –recognize your thoughts as they play out in your head. Don’t judge or be upset by them. Just be aware of them.

• • Use all your senses – try to use all your senses from time to time. When you go for a walk outside for instance be conscious of the sights, smells and sounds. When you are cooking, be conscious of the color of the vegetables, the feel of them as the knife goes through them, the changing smells when you cook and so on. Even cutting vegetables can be a mindfully meditative process!

• • Engage fully – This is especially important when you interact with people. Engaging with them fully allows not only for better understanding and relationship but also makes them feel valued when you are present and completely involved. In our fast paced world we tend to skim through interactions without much thought leaving everyone concerned feeling inconsequential and the whole interaction quite superficial.

• • Practice – Mindfulness based meditative practices may last for as short as ten minutes. You can source many of them online on YouTube. You could try the courses offered ones by Kabat-Zinn or Vipasana meditation by Goenka..

• Do yoga – Yoga practices linking movement and the breath are great to help us become more mindful.

How does meditating for ten minutes help you may ask! Practicing this form of meditation for even ten minutes every day will allow the habit of mindfulness to seep into the rest of your day. The practice may be anything from Breath meditation to Body Scans or an actual Mindfulness Based Stress Reduction – MBSR session.  Create a regular practice that you commit to every day, preferably at the same time of the day. Over time, this becomes your way of ‘being’ not just ‘doing’.

Mindfulness has a wide range of benefits from disease management to a general improved sense of wellbeing and increased productivity. Do you wonder sometimes why you are not able to get things done? Why you can’t focus your attention when needed? Why you find it difficult to express yourself properly as your thoughts careen from one thing to another? Why you overeat when you know you shouldn’t or why you can’t sleep with those thoughts spinning around in your head in an endless loop of melodrama? Mindful meditation and a continued practice of mindfulness on a consistent basis may be the answer to calming the mind and creating a more peaceful focused and meaningful life experience.  

Dr. Sheela Nambiar MD ObGyn

Lifestyle Medicine Physician DipLM BSLM

Fitness Consultant NAFC

Author of – Get Size Wise, Gain To Lose & Fit After 40.

www.drsheelanambiar.com

Body Image

Body image is not quite literally what we see in the mirror. It is really the interpretation of what we see, influenced by our own perception of how we view and feel about ourselves.

All of us with decent eyesight are able to see that perhaps we are a bit over weight, we may like the look of our legs, we may appreciate that our arms appear toned, love our hair but concede perhaps, that the waistline could do with some work. Most of us tend to make judgment calls about what we see in that mirror. How these judgment calls affect us emotionally and what we then proceed to do as a result of these emotions is the real relevance of body image.

Take for instance a teenage girl who looks at herself and sees a plump young woman. How she responds to seeing that plump young woman will depend largely on what she really feels about her body. This feeling often comes from subconscious information she has gathered and retained about her body and herself as a whole since childhood.

A teenager who, as a child, was loved and nurtured, who was praised for what she did rather than what she looked like is more likely to see her image, register that she is a little plump and perhaps should do something about it, such as exercise or cut out the sweetened soda. On the other hand, a young woman who has a mother who is critical about her complexion or weight, a father who comments on her looks, peers/siblings who tease her about her size would relate to the image of herself differently. She has already imbibed some distaste for her body. The pain she experienced at the comments or the judgment from family and close friends will remain with her, as a negative body image. My heart goes out to the teenagers brought to me by their (well-meaning) mothers who proceed to tell me their daughter is too fat and needs to lose weight while she sits there with downcast eyes!

How does body image translate in real life?

Having seen that image and interpreted it, what we then proceed to do about it is important.

People with poor body image:

• May do noting about it, but continue to dislike, even hate their bodies.
• They may continue to gain weight, overeat, eat indiscriminately or develop addictions.
• They may turn to extreme measures, fad diets, starvation or extreme exercise to lose weight.
• They may develop eating disorders like anorexia, bulimia or binge eating.
• They may succumb to the surgeon’s knife and other procedures in an attempt make themselves ‘look’ better.

Improving body image is possible. Preventing poor body image to begin with, is also possible. Here are some pointers for parents, caregivers, fitness instructors, doctors and for oneself.

Parental pressure plays a crucial role – A child’s self-esteem rests with how he/she is viewed by his/her loved ones and is important to his/her wellbeing. Being critical about a child’s appearance only lays the foundation for future angst and poor self-esteem. The emphasis should be on health and wellness rather than size or appearance.

The focus should also be on what the child does rather than what she/he looks like. Praising a child for being himself/herself, his/her accomplishments and hobbies rather than praising his/her looks keeps the perspective on what is truly important for emotional wellbeing. Loving him/her (and expressing it) irrespective of his/her height, weight or complexion is crucial for her emotional health.

Lead by example – Parents who practice healthy behavior such as regular exercise and healthy balanced eating are more likely to communicate that to their children. If the parent him or herself has issues with body image, is overly self-critical or self-abusive, the child is likely to imbibe similar behaviou. This then becomes their narrative as they grow older.

Avoid stereotypes – Bodies come in all shapes and sizes. Thin is not always better or more beautiful. Thin is not always healthier. Focus on fitness rather than fatness or thinness. Most cultures have their own stereotypes of beauty and tend to idolize it. Not everyone fits into that mold and neither should they need to. Fairness creams are a typical example of how people are made to believe that ‘being fair’ is somehow aspirational.

Avoid comparisons of any kind – Comparing your own body to that of your best friend or that glamorous film star is simply setting yourself up. Your friend is genetically different, so her body is different. The film star has an entourage of beauticians, dieticians, trainers and hairdressers not to mention, the photo-shopped, airbrushed magazine images.

Parents comparing their children to siblings or friends will only injure their self-esteem setting the stage for poor body image and a host of other psychological problems and maladaptive behaviors.

Emphasize health and fitness rather than physical appearance – Focus on health and fitness rather than just appearance when you (or your child) start to exercise. This improves persistence with an exercise program. Weight loss takes time. An obsession with the mirror or weighing scale will prove counterproductive in the long term as weight does not always come off the way we want or expect it to. Persistence and focus on what we do, (that is, with the exercise and healthy, balanced eating) rather than the scale or how we appear on the other hand empowers us. We have control over what we do; we don’t always have control over how that translates in weight or appearance. Not everyone loses weight at the same rate for instance. Your genetic propensity plays a role in physical appearance. When the focus shifts to being disciplined to our exercise routine instead, the endorphins released with regular exercise make you feel good about yourself, increasing self-esteem and improving body image.

Instructor’s body image – Instructors and trainers should identify and deal with their own body image issues before trying to influence clients. Some instructors are overly critical about their own bodies. This can transfer to or be imposed on the clients. A thin instructor is not always healthier.

Emphasize “form” of exercise – While exercising, rather than focusing on just burning calories, emphasize performing the exercise correctly, improving coordination and balance. This relieves the pressure from appearance to actual performance. It also develops a healthier relationship with exercise and ones own body.  It also helps you find a greater respect for your body and the phenomenal things it can achieve.

Beware of communication in training/teaching/treating areas – Instructors and trainers need to beware of what they communicate with a client. Judging the client’s body is not the trainer’s prerogative. The role of a trainer is simply to guide and encourage, not to ridicule or criticize. Similarly a doctor judging a patients body is not a smart move. Even if well intended, it is never a good idea to be critical of weight and size. Instead keep the focus on what is possible in terms of behavioral change for better health and wellbeing.

Balanced eating – Focus on healthy eating and don’t obsess over micronutrients and calories. This obsession could very well lead to an eating disorder like anorexia or bulimia that is nothing but an endorsement of poor body image.

Take necessary steps to overcome emotional baggage. Understand that sometimes, ‘looking better’, does not always translate into ‘feeling better’ if the ingrained thoughts about one’s self is deeply negative. Changing self-worth takes more than the surgeon’s knife, weight loss or even exercise. It takes the understanding that feeling good has to start from within and will take work. It will also take the effort required to deal with all the negative thoughts, resentment, anger or envy that we harbor. It may require prolonged therapy for some, especially if they develop maladaptive behaviors like eating disorders, self-cutting, addictions and so on. It also requires compassionate support and discipline.

Finally, body image is a perception. Poor body image is preventable. It can be changed into a positive body image with the right tools. Great body image is important for self-esteem/self-worth and good self-esteem is greatly important for emotional wellbeing.