Why Is It So Hard To Control Our Appetites? A Doctor’s Struggles With Giving Up Sugar

We’ve become convinced that if we can eat more healthily, we will be morally better people. But where does this idea come from? Near the end of the hellish first year of the coronavirus pandemic, I was possessed by the desire to eliminate sugar – all refined sugar – from my diet. In retrospect, it probably wasn’t the best time to add a new challenge to my life. My wife and I had been struggling to remote-school three young kids with no childcare. My elderly parents lived out of state and seemed to need a surprising number of reminders that pandemic restrictions were not lifted for Diwali parties or new Bollywood movie releases.

Like many people in those early days, we were looking around for masks and trying to make sense of shifting government guidelines about when to wear them. In addition, as a doctor, I was seeing patients in clinic at a time dominated by medical uncertainty, when personal protective equipment was scarce, and my hospital, facing staff shortages, was providing training videos and “how-to” tip sheets to specialists like me who hadn’t practised in an emergency room for years, in case we were needed as backup.

It would have been enough to focus on avoiding the virus and managing all this without putting more on my plate. But cutting processed sugar seemed like an opportunity to reassert some measure of order to the daily scrum, or at least to the body that entered the fray each day.

My former physique was behind me and the stress of clinical practice during the pandemic was taking its toll. Maybe it was all the pandemic death in the air, but I started feeling like I was what the narrator in Arundhati Roy’s novel The God of Small Things calls “Not old. Not young. But a viable die-able age.” Maybe doing away with sugar could slow things down? More tantalisingly, maybe it could even take me back to a fresher time, the days in college when I had actually gone sugar-free for a while.

My friends offered condolences on what they called my soon-to-be joyless lifestyle. But I was set, compelled by literature about the deleterious, even toxin-like effects of added sugar. I had my doubts about being able to pull something like this off again, though, so I decided – as doctors often do – to tackle the problem by studying it.

That year, in what was arguably an act of masochism, I began the coursework required to sit for a medical-board exam on dietetics, metabolism and appetite. By earning another qualification, I thought, I would credential my way to realising my goal. After shifts at work, during breaks or once the kids were asleep, I would attend virtual lectures and pore over board-review books in a quest to understand the body’s metabolism.

I immersed myself in the physiology of exercise, the thermodynamics of nutrition, and the neuroendocrine regulation of appetite. But this knowledge didn’t break my pandemic eating habits. Cupcakes and ice cream and cookies didn’t call to me any less. And big food corporations were winning the bet that Lay’s potato chips first made back in the 1960s with its “Betcha can’t just eat one” ad campaign. So, I found myself reaching for Double Stuf Oreos while flipping through my medical textbooks and scarfing chocolate bars even as I correctly answered my practice-exam questions.

My body refused to be disciplined by my intellectual mastery of its operations. I passed the board examination, but my appetite for sugar didn’t change. I was left with more questions than I had when I started. Was sugar really a problem? Or had I internalised hangups about desire from the culture at large? Why did my soul feel so inexplicably sick – so unsatisfied – with the outcome of my first effort to quit that I tried it all again? And what does my “success” – I’ve been sugar-free for a year now – even mean?

I turned to Plato – a man occupied by appetite – for some answers. In his body map of the soul, the stomach was the dwelling place of desire. Reason, of course, resided in the head, while courage rested in the chest. In this tripartite architecture, it was up to reason – with the help of courage – to subjugate appetite and elevate the individual. The thinking went that if we could just rule our stomachs, we might be able to hold our heads up high and our chests out wide. For the Greeks, the right moral posture was key to the good life, or eudaimonia.

Early medical science in the west borrowed heavily from Plato, beginning with Aristotle, who practiced and taught medicine throughout his life. Aristotle agreed that eudaimonia could be realized by moderating the visceral and sensual appetites. He saw the heart as the vessel of intelligence, and arguably the most virtuous of organs. In his hypothesis, the heart occupied – physically and figuratively – a central place in the body, controlling other organs. The brain and lungs played supporting roles, merely cooling and cushioning the heart. The heart was, for Aristotle, where reason flowed.

Five hundred years later, the Greek anatomist and surgeon Galen challenged the centrality of the heart but still adhered closely to Plato’s triadic notion of the soul. Galen’s treatises, foundational to the development of modern medicine, are suffused with Platonic assumptions, and he painstakingly tried to stitch the divided parts of the soul – the rational, the spirited and the appetitive – on to specific organs in the human body.

In a striking display of topographical certitude, Galen writes in On the Doctrines of Hippocrates and Plato: “I do claim to have proofs that the forms of the soul are more than one, that they are located in three different places … and further, that one of these parts [rational] is situated in the brain, one [spirited] in the heart, and one [appetitive] in the liver. These facts can be demonstrated scientifically.”

The Harvard classicist Mark Schiefsky writes that, in Galenic physiology, equilibrium is understood “as a balance of strength between the three parts; the best state is when reason is in charge, the spirited part is strong and obedient, and the appetitive part is weak”.

Should we be sceptical of this aspiration to tame appetite? Sigmund Freud doubted whether desire could ever be so readily controlled. In tossing Plato’s map aside, Freud erased the “soul” and instead sketched a three-part atlas of the “self” and its ratio of desires and repressions – endlessly fractured, negotiating between order (superego), consciousness (ego) and appetite (id). For Freud, appetites could not be overcome but only better managed. Perfect harmony and permanent equilibrium were nowhere in sight. Rather, in Freud’s idea of the self, anxiety for order loomed above the ego, with desire buried beneath it. Appetite was the subterranean tether that consciousness could never escape, but only sublimate.

There was something talismanic about my focus on sugar. So often, liberty is conceived of as the ability to say yes to things. To make affirmative choices: to open this door or that window. But there is also a flipside to that freedom: the power to say no. To refuse. Increasingly during the pandemic, I felt like I was powerless in the face of my cravings. If there was a knock at the door of appetite, a tap on the window of impulse, I had to answer it. And this felt shameful. Why couldn’t I say no? And why was realizing this so painful?

I don’t pretend to anything approaching total understanding of my motivations. But there were a few loosely detected currents worth illuminating here. For one thing, not being able to say no to sugar sometimes felt like a form of bondage to the demands of the body, the very body that I was eager to assert power over, particularly during a global health crisis that was damaging bodies everywhere.

If I couldn’t control this plague, could I not at the very least control myself? I wonder now if this insistence on regulating appetite was my sublimated response to the coronavirus’s immense death toll – a way of denying mortality in the midst of its excess. In this respect, perhaps there was not as much separating me from other kinds of pandemic deniers as I would like to believe. Were we all just coping with the inexorability of our decay – laid painfully bare by Covid-19 – in different ways?

Maybe. But there was something beyond the exigencies of the pandemic on my mind as well. The inability to resist sugar cravings – to break the habit – seemed like a victory of the past over the present. It felt like the triumph of the mere memory of pleasure over real satisfaction in the moment. Saying no to that memory – the neurological underpinning of craving – became important, because it felt like the only way to say yes to imagination. “I am free only to the extent that I can disengage myself,” the philosopher Simone Weil wrote.

Detachment from an indulgence, however small, felt like a way to stop being beholden to an old storehouse of desires (and aversions and beliefs). Developing the ability to refuse to reach for the cookie was also a way to break free from the impulse to reach for patterns of the past, from the compulsion of replicating yesterday at the expense of tomorrow. It’s the trick of habit to convince us that we are reaching forward, even as we are stepping back. Or, as the British scholar of asceticism Gavin Flood elegantly summarizes: “The less we are able to refuse, the more automated we become.”

If Freud dismantled the soul, modern medicine mechanized what he left of the self. But where Freud’s psychoanalytic theory allowed for a pinch of poetry, materialist models hold comparatively dry sway today. A look at the biomedical literature on appetite reveals a tortuous mix of neural circuits and endocrine pathways. What’s clear is that if there was a moral aspect of appetite for ancient philosophers and physicians, it’s not readily discernible in the language of contemporary scientific literature.

There are upsides to this development. In the modern era, medicine’s tradition-bound framing of appetite as a moral problem has been demoralizing for patients, who often felt – and still feel – objectified, policed and discriminated against by institutions that sermonize about it. The stigmatisation of appetite remains pervasive in the culture, in and out of medicine. The loss of at least an explicit moral charge in the scientific literature is a welcome shift.

In the century or so since Freud’s conjectures, appetite has been atomised by medicine into a problem of eating, or more specifically, of fighting the body’s tendency toward “disordered” eating. In the pursuit of better and longer lives, maladies of appetite – of eating too much, too little, or not the right kinds of food – have been studied and treated with varying degrees of success. The empirical study of digestion and appetite in the laboratory moved hunger from the moral arena into a biochemical one. Still, in both experimental physiology and clinical medicine, the ancient impulse to locate the appetite persisted: was it in the body or in the mind? Lines were drawn – and defended – between diseases of the stomach and diseases of the psyche.

What was at stake in the difference? Pinning down the appetite – claiming it belonged to the gut or the brain – was arguably the first in a series of steps leading to its regulation. Understood this way, medicine’s mission to uncover the mechanisms of appetite, despite the erasure of the soul from scientific databases, cannot escape Plato’s legacy. Whether we’re trying to improve or curtail appetite, we seem unable to resist the desire to control it.

It would have been different – I wouldn’t have felt the need to go all-or-nothing with sugar – if I could have simply walked away after a few bites. But increasingly during the pandemic, I wouldn’t stop even after I was full. What started off as pleasure would morph into painful excess. Sure, there’s pleasure in abundance, in overdoing a thing. But I found myself barrelling past that threshold.

While studying for the board exam in my first, failed attempt at going sugar-free, I was also using various apps and devices to keep track of my body. I had long used a smart watch to log my steps and workouts. I was also using a calorie-tracking app, studiously punching in numbers for every meal and scheming how much I could eat and still remain under the calorie limit. But all that logging and calculating felt joyless and anxiety-ridden. Sometimes, at a meal, in the middle of tallying up numbers like an accountant, I’d explain to impatient friends and family that “I’m just entering my data”. It was a lot of data.

I grew weary of all the inputting, and so I switched to an app with more of a behavioural focus. This app still had me tracking calories, but also came with recipes, a personal coach and “psychology-based” courses, as part of what the company calls your “journey”. The courses were a welcome shift from the myopic focus of calorie counting, and chatting with a coach added an opportunity to get some clarity about my goals.

The coach would share chipper motivational advice and provide tips to overcome obstacles. I diligently went through the app’s courses, answered its behavioural questions and followed its nudges. There were a few weeks where I was able to go sugar-free, but after a couple of months, the coaching advice seemed more and more generic, and the courses too simplistic when I was already spending so much time studying for my upcoming exam. I lost interest and reverted to simply recording calories.

I eventually passed that exam without much to show for it in terms of changes to my nutritional habits. I needed something different, a way to hold myself accountable and mean it. I stumbled upon another app that described itself as being “on a mission to disrupt diet culture and make our relationship with food, nutrition – and ourselves – healthier for good”. It promised live coaching calls with a certified nutritionist, shared recipes, and even offered to tailor my coaching with a vegetarian dietician. It did not ask you to track calories or enter food items from a database. All it wanted was for you to send pictures … of your food. It felt radically different than tapping numbers into a screen: someone else would see this.

The app’s slogan was “100% accountability and “0% judgment”. But, to be clear, it was the judgment that I came for. The simple fact that my nutritionist wouldn’t just know but also actually see what I was eating was the killer feature. I answered a questionnaire about my dietary habits and goals. I made it clear that I wanted to go sugar-free, and repeated as much to my nutritionist during a preliminary call.

She didn’t exactly endorse this goal, but rather acknowledged it as something that was important to me and gently marked it as a topic we would come back to, adding that she hoped I would get to the point where a more balanced approach would suffice. I told her we’d see. I made a promise to take a photo of every meal, good or bad. She kindly reminded me there are not “good” and “bad” foods, and we were on our way.

It’s been a year since I downloaded the app. Every day since then, I have taken a photo of every morsel of food I’ve eaten, whether it’s a handful of pistachios, a salad or a veggie burger. In every one of those pics, every day, I have been sugar-free. I’ve eaten more vegetables and greens and fruits than I’ve probably ever eaten in my life. My plates look balanced (I make sure of it). I take care to snap pictures that look nice for my nutritionist. Though she never judges me negatively, I look forward to the raising-hands emoji and approving words she sends if she sees a salad with asparagus and garlic balsamic drizzle and avocado up front.

Like an influencer on Instagram, I’ll take another shot if the lighting isn’t quite right, or if the framing is off. It’s been satisfying to upload a cache of sugar-free images, all beautifully arranged on the app’s user interface. Even more satisfying has been avoiding feeling like the guy who said he’d go sugar-free only to end up sending in pictures of donuts and cookies. Compared to calorie logs and food diaries, the prospect of someone else seeing photos of what I’m eating has made the potential pain of falling short feel more proximate than the pleasure of eating sweets. So I just stopped eating sugar. And it’s still working. Was this all it took?

Perhaps the persistent effort to control appetite, replicated across many cultures and times, reveals just how vigorously it resists that very control. The seemingly endless proliferation of constraints on appetite – from the disciplinary to the pharmacological – underscores its untamable quality. And yet the training of appetite – both as physiological fact and, more abstractly, as desire – can function as an ascetic practice. In this paradigm, as religion scholars such as Flood argue, the negation of desire amplifies the subjectivity of the individual.

Depriving the body paradoxically accentuates the conscious subject, because hunger unsatiated allows the pangs of the self to be felt more acutely, and renders being more vivid. In other words, appetite unfulfilled creates the conditions for expanding self-awareness. This is seen in the Bhagavad Gita in the figure of the ascetic, one who has renounced the pull of appetite and “attains extinction in the absolute” – in seeming contradiction, gaining infinity through loss.

If philosophy is after theoretical victories, science aims more concretely to hack, or at least short-circuit, a physiological truth. Take, for example, gastric bypass surgery, an operation that cuts the stomach into two parts (leaving one functional thumb-size pouch alongside a larger remnant) and radically reconstructs separate intestinal systems for each segment to restrict the amount of food that can be eaten. By shrinking the stomach to fool the mind into feeling satisfied with less, this surgery builds on growing recognition that the long-embraced brain-gut divide is far more porous than previously thought.

Recipients of the surgery generally do well in the short term, with reduced appetite, marked weight loss, better control of diabetes and improved health markers. But the percentage of patients who “fail” in the long-term after bariatric surgery (ie achieve less than half of excess weight loss) is reportedly as high as 35%. During that first post-op year, studies suggest, an influx of appetite-reducing intestinal hormones decreases patients’ urge to eat. Crucially, however, there are questions about the duration of those salutary hormonal changes and their effectiveness in controlling appetite as post-surgical days add up.

For a significant proportion of patients, even surgically shrinking the stomach – the historical seat of hunger – doesn’t offer complete freedom from unchecked appetite. This fact is not entirely surprising, given what is now known about the multiple neuroendocrine nodes that govern appetite, but it poses a conundrum for medical science: can appetite, as Freud asked in his own way, ever be fully controlled? And if not, is it a wonder that patients turn back to more personal strategies to pursue the work that prescriptions and sutures leave undone?

I can’t say I fully understand why teaming up with a nutritionist on an app worked so well, so fast. Would sharing pics of my food with friends and family in a group chat or a Facebook page have been as effective? Probably not. The issue seemed to be one of epistemology. My friends and family wouldn’t have been as suitable an audience, since they don’t just know me as I am, but also as I was. That knowledge of what’s bygone necessarily shapes the stories we can tell and believe about one another.

But with my nutritionist reviewing pictures of my meals from god knows what timezone, the app created an epistemological gap into which both of us could step. It was within this gap that my future self – the self I aspired to be, still unrealised and therefore unknown – could intercede in the present with slightly less inertia from the past. The app provided an illusion that daily life could not, offering a space for the dormant commitments of the future to come to fruition in the present. A space for imagination to overcome memory.

As my sugar-free streak extended, I began to wonder about the future of this illusion. Was it a rare example of tech living up to its glitteringly naive promise of liberation? Or was this an instance of the digital panopticon yet again determining our ability to imagine ourselves, revealing just how far-reaching its gaze is? And, more practically, I began thinking about how long I needed to keep eating this way. The cravings that had knocked so loudly at my door at the start of the pandemic now softly shuffled from leg to leg right outside it. I could still hear their shoes creaking at the threshold, but they couldn’t force their way in anymore. Things seemed quiet, maybe a little too quiet.

Whereas the Greeks soughtto regulate appetite in pursuit of the good life, perhaps what is sought after today is a facsimile of it: a corporatised eudaimonia-lite, where the goal isn’t virtue but efficiency; not equanimity, but productivity. In this view, it’s not a better way to live we’re seeking, just a less painful way to work and die – all while “looking good”. A more charitable and poetic possibility is that the constraint of appetite continues to appeal because it provides the same sense of structure to selfhood that metre does to a poem: a limit against which to construct narrative unity of the psyche.

As fascinating as it is to think about this question, even more essential ones – about the links between appetite, scarcity and loss – loom in the writings of Toni Morrison, a writer who provides a necessary counterbalance to the obsession with appetite restriction in societies glutted with luxury. In particular, I’m thinking of Beloved, which tells the story of human beings struggling for survival and wholeness in the face of slavery’s horrors. In portraying this struggle, Morrison uses the language of food and appetite to unfurl narratives saturated with the metaphysics of hunger: the difficulty of sating the self; the confusion between hunger, history and hurt.

I was struck by this unexpected resonance while rereading the book in the middle of my bid to quit sugar. Morrison’s characters think about what it would mean to satisfy what the narrator calls their “original hunger” – and whether doing so is even possible. They imagine getting to a place “beyond appetite”, but are also compelled by history to contemplate the price of doing so.

In my reading of the book, the denial of hunger risks becoming a costly exercise in self-abnegation – a severing of self from history, of self from self – whose consequences Plato doesn’t seem to fully consider, but which Morrison is deeply wary of. I think Morrison is, like Freud, skeptical of the metaphysicians who would have us render hunger subordinate. But where Freud is an anti-idealist, Morrison appears willing to reach for hunger, perilous though it may be. Straddling both the risk of self-destruction posed by contact with the original hunger, and the anguish of self-denial created by leaving it unrecognised, Morrison casts her faith in the human ability to embrace the beautiful, blood-hued predicament of incarnation.

About 10 months into my sugar-free life, a scent from the pantry hit me like it hadn’t for a while. My wife had just baked chocolate-chip cookies for our kids as a treat. By then, I was unfazed by sweets around the house. They might as well have been made of stone. But, at the end of a long day, I found myself unexpectedly at the pantry door. Minutes passed. After a while, I opened the plastic container and inhaled. My mouth began to water. I could almost taste the cookies.

I remembered the delightful way the chocolate melted at the back of the tongue. I remembered the satisfaction of soaking a warm cookie in milk. A part of my brain was humming, eager to replicate the memory of sugar, butter and dough on the cortex. Another part was already dreading the pain of not being able to stop. I picked up the cookie and, having built nearly a year’s worth of muscle memory, simultaneously opened the app on my phone. I centred the cookie in the glowing frame and was about to press send when, looking at the screen, it hit me: what would my nutritionist think?

As of this writing, my streak remains unbroken, despite a few close calls. In many ways the story seems to be going the way I intended: I am eating well balanced, sugar-free meals and haven’t counted a calorie in more than a year. The cravings that were troubling me aren’t gone, but the future version of me – the unsweetened aspirant – grows closer with each picture I snap. I feel the spiritual and physical acuity that comes with ascetic practice.

But I also feel some qualms about neglecting Morrison’s original hunger, with all its attendant risks and possibilities. I think about how I have sacrificed memory at the altar of imagination, recognising the chance that imagination ends up being overrated and memory proves to be the last storehouse of joy. But then I remind myself that visions like Morrison’s may be too large, too untimely for us to inhabit. They come from a place we haven’t arrived at. At least not yet.


Source: Why is it so hard to control our appetites? A doctor’s struggles with giving up sugar | Health & wellbeing | The Guardian

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A New Generation of Weight Loss Drugs Makes Bold Promises, But Who Really Wins

In the months after having her second child, Sarah found herself fed up. The 40-year-old Seattle resident was cutting carbs and sugar, and exercising regularly, but couldn’t seem to shed the pounds she had put on during pregnancy. So when an email newsletter mentioned a new weight-loss drug called Wegovy, Sarah decided to give it a try. Eight months later, she is out more than $10,000—and down more than 60 lbs.

“Wegovy made losing weight almost effortless,” Sarah, whose name has been changed to protect her identity, told Quartz. “I’m not hungry often anymore and it doesn’t take any willpower to eat less. I simply don’t have any desire to overeat.”

Sarah is one of 125,000 US-based patients now taking Wegovy (whose generic name is semaglutide), a member of a new class of weight-loss drugs. These drugs work differently than the appetite suppressants popular among previous generations of dieters. They are also hitting the market at a different moment: one in which people are more eager than ever for realistic, science-based methods for addressing excess weight, even as a growing faction of activists and doctors voice skepticism of weight as an accurate measure of health.

A new class of weight-loss drug

In the mid-1990s, experiments on Gila monster venom found it contained hormones that could help lower blood sugar. That led to the diabetes drug Ozempic, which ultimately went on the market in 2018. People on that drug discovered a funny side effect: They lost weight.

In 2021, that same compound was approved by the US Food and Drug Administration (FDA) under the name Wegovy for the express purpose of weight loss. Drugs like Wegovy work in more complex ways than simply suppressing appetite, and promise fewer (though not zero) side effects.

Like Wegovy, many of these drugs were originally approved for other conditions; liraglutide (brand name Saxenda for weight loss) was also originally approved as a diabetes drug (Victoza). In fact, semaglutide and liraglutide work similarly in the body: They’re known as GLP-1 receptor agonists because they activate receptors for the glucagon-like peptide-1 (GLP-1) hormone, reducing appetite by slowing digestion and the rate at which the body takes up glucose.

Perhaps most important, the new drug promise significant weight loss. “The previous weight loss drugs were just modestly effective,” says John Buse, an endocrinologist at the University of North Carolina School of Medicine. The average patient would lose 5% of their body weight, in some cases up to 8%. But with semaglutide, he says, “we’ve gotten the kind of weight loss that makes people pay attention: 10-15% of body weight. That’s the average weight loss—half of people are losing more than that. It’s a gamechanger in the conversation…now that we have medicines for which a substantial proportion of patients can expect to lose 30 to 50 lbs.”

In one 68-week pre-approval clinical trial, patients on Wegovy did indeed lose 14.9% of their body weight on average, compared with 2.4% for people on a placebo. (Although, as several writers and scholars have pointed out, the study was funded by Novo Nordisk, which makes Wegovy.) Given the average weight of trial participants—100 kg, or 220 lbs.—that meant weight loss of about 15 kg, or 33 lbs. Other drugs in development have had similar results. In a recent trial for one called tirzepatide from Eli Lilly, more than half of patients lost at least 20% of their body weight—50 lbs. in many cases.

What it takes to lose weight

This new class of drugs is entering a market that at first glance seems ripe for breakthrough. According to the US Centers for Disease Control and Prevention (CDC), 42% of Americans—70 million people—meet the criteria for obesity (having a BMI of 30 or more). At one point or another, most of those people will try a diet and exercise regimen to lose weight.

But a growing body of research shows that diets are not an effective way to lose weight and keep it off. “Obesity is a complex disease… ​for most people, lifestyle modifications, diet, and exercise are just not enough,” says Katherine Saunders, a doctor at the Comprehensive Weight Control Center at Weill Cornell Medicine and co-founder of Intellihealth, an app-based platform that brings evidence-based obesity treatment to patients.

In part because of that complexity, bariatric surgery has since 2009 been considered the standard of care for patients looking to lose a substantial amount of weight. But these procedures can be invasive and expensive, and can come with significant and long-lasting complications.

The dearth of other options leaves some patients and doctors excited about this new generation of drugs. “Right now, the field is really looking for more efficacy, number one. People will do almost anything to lose weight,” says Buse. “We have more than just surgery now for promoting substantial weight loss. The most exciting thing is that obesity is on the ropes.”

A complicated picture

While hopes are high, the realities of taking these drugs can be more complicated for patients. There are often side effects—the most common for semaglutide and liraglutide are diarrhea, vomiting, and nausea. On Wegovy, Sarah says she’s experienced diarrhea so severe that a few times she had to delay her next dose.

Physicians can sometimes gloss over or downplay those effects. But a visit to dedicated Reddit pages for these drugs shows whole communities of patients struggling to adhere to the regimen when they’re feeling sick, and seeking support from a community to understand whether what seems like a severe reaction is normal. (Novo Nordisk did not respond to a request for comment.)

How well a patient can tolerate a drug “is something we think about quite a lot,” Saunders says. “We always start with lower doses and increase gradually as tolerated. Everyone is different. We keep in close touch with the patient and monitor them closely.”

And while these new drugs are relatively well-studied, there are still unknowns. They seem to help patients keep weight off more reliably than diet and exercise alone, but those benefits fade after people stop taking the drugs, and patients do often regain weight. There are also questions about long-term effects. In 1997, weight loss drug fenfluramine/phentermine (fen-phen) was pulled off the market after it was found to cause heart problems. More recently, Belviq (lorcaserin), which the FDA approved for weight loss in 2012, was pulled from the US market in 2020 because long-term use was found to increase the incidence of various types of cancers.

Even if a patient does want to go on one of these drugs, she might not be able to. Many patients keen to try Wegovy can’t access it at the moment, due to a supply chain issue that its manufacturer doesn’t expect to resolve until later this year. Even then, most US health insurers, including Medicare, do not cover drugs like Wegovy, and paying out of pocket can cost thousands of dollars per month. After Sarah’s doctor told her she doesn’t prescribe Wegovy, Sarah secured a prescription through an online health provider; she pays for it out of pocket.

The lack of insurance coverage is in spite of the fact that the American Medical Association declared obesity to be a disease in 2013. “The conversation around insurance coverage needs to be had with insurance companies, but also with employers,” says Kimberly Gudzune, the medical director for the American Board of Obesity Medicine. “It needs to be seen as an investment in your workforce.” The Treat and Reduce Obesity Act, which would expand Medicare to include obesity treatments, has been introduced to US Congress every year since 2012, but has never passed.

America’s love/hate relationship with weight

Though excess body fat was once considered a sign of wealth or fertility, over the past century a stigma has developed against larger bodies. Today doctors associate excess weight with medical conditions like heart disease, cancer, type 2 diabetes, sleep apnea, osteoarthritis, and depression. Studies also show that life is harder when you move through the world in a larger body. Fat people are less likely to be hired for a job, are paid less, are less likely to get married, and are less likely to be happy (though not if they’re living around other fat people). One 2006 study found that 46% of respondents would rather give up one year of life than be obese; 5% said they’d rather lose a limb.

The current state of research makes it impossible to unravel the full complexity of weight and health, but the conversation is starting to accommodate more nuance. Ubiquitous metrics such as body mass index are increasingly understood to be unreliable indicators (though doctors often still use them), and even the language around larger bodies is under review. Many physicians use “obese” to describe people who have excess weight or a BMI over 30, but activists are shying away from the word. “The reason…we are reluctant to use the words ‘overweight’ and ‘obesity’ is that they are made up, they can change,” says Tigress Osborn, a fat activist and chair of the National Association to Advance Fat Acceptance.

In fact, some research suggests that fat may have a protective effect on the body. “The body’s weight-regulating mechanism is about survival. It’s a system with more moving parts than we understand,” says Marilyn Wann, a fat activist and author of the book Fat!So? “Trying to remove weight from an individual or from the population is like trying to take a sledgehammer to the weather—we don’t know the unintended negative consequences we’re going to create.”

There are signs that in the future physicians may be more accepting of bodies of different sizes. But as weight loss drugs get more effective and more available, those cultural gains for body positivity (or body neutrality, or fat acceptance) may also be called into question.

A new relationship between doctors and patients

Overweight patients who come to see Shelly Crane might have an experience they’ve never had before. “I don’t initiate a weight-loss conversation with a patient,” says Crane, a family physician at Advocate Aurora Health in Milwaukee, Wisconsin. Most weight-loss programs come with more risk of harm than good, she says, and there’s not enough evidence that people who do lose weight are healthier in the end.

Crane doesn’t regularly prescribe new drugs for weight loss, though she says more patients are coming in and asking for them lately. Instead, she prefers to keep conversations focused on goals of care. “Patients say, ‘I know I need to lose weight,’ and I say, ‘Why do you think you need to lose weight? What would change in your life if your weight was lower?’” That gives her an opening to talk about health more broadly—how is the patient’s sleep? Their diet? Their mobility? “I try to stay in my sphere of what I’m able to do as a family doctor and really address the root of the health issue as much as I can.”

Crane was drawn to this approach by listening to her patients talk about experiencing size discrimination, and by following the work of fat activists such as Ragen Chastain and Aubrey Gordon. Though she’s been trained in a more integrative style of medicine, her approach toward body acceptance was also shaped by her discovery of intuitive eating during medical school. Since then, she’s been working on deprogramming herself and her colleagues from anti-fat bias.

Crane is part of a burgeoning movement among doctors to improve the treatment of larger patients. For some, that means skipping the dreaded weigh-in, a practice that is somewhat controversial within medicine. Medical organizations like the Association of American Medical Colleges also offer guidelines to reduce anti-fat bias among clinicians.

For doctors, the updated approach at least engenders trust, which can in turn get patients to seek medical care more frequently and improve their overall health. At most, it broadens the definition of what “healthy” means, and looks like.

Some fat activists see this shift as an important step. “The thing we hear most often from the public is, ‘I thought I had this thing, but all the doctor wanted to talk to me about is weight loss, and now the thing is worse,’” Osborn says. “It’s progress to have people in the medical establishment recognizing that there are other healthcare concerns besides weight, if weight is a healthcare concern.”

The hope is that this evolution continues. Activists want more people, in the medical profession and outside of it, to respect their autonomy. That becomes even more pressing in a possible future filled with weight-loss drugs—a future where a person can simply take a drug and stop being fat. “The ease with which I could become smaller—why should I? That should be up to me. Just like, if you believe it’s a medical disorder, the treatment I choose should be up to me,” Osborn says. “Like with anything else, if you believe fat is a disorder, we should let people decide whether people will get treated or not.”

“Fatness isn’t a problem to be solved in and of itself. It is not the root cause of all ills, as much as [medicine] would like to think it is,” Crane says. “We can help people live full, rich lives when we focus on goals of care and not on weight.”

By Alexandra Ossola

Source: A new generation of weight loss drugs makes bold promises, but who really wins? — Quartz

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How Should You Deal With Sore Muscles

The spring weather may have prompted you to start running outside or you may be considering returning to the gym, when the coronavirus seems less of a risk. I’m looking forward to hiking in the mountains of New York once mud season has passed.

You might expect to feel out of shape, and you probably gird yourself for the sore muscles you’ll have after that first real workout. What is that soreness all about? Is it an indicator of damage or of growth? And how should you deal with muscle soreness — should you rest or keep moving?

The muscle soreness that emerges the day after a workout is called delayed-onset muscle soreness — or DOMS — by exercise scientists. “DOMS is a normal process of muscle adaptation to some unfamiliar movement,” says Heather Vincent, a sports medicine specialist and the director of the University of Florida’s Health Sports Performance Center.

The movement may be unfamiliar because you haven’t done that workout in months or because you’ve upped your intensity.

Want to get back into exercise following pandemic lull? Then go slow and stay safe.

Pain and tenderness in the overworked muscles generally peak between 24 and 72 hours after the activity. It’s a drawn-out series of physiological events in and around the muscle.

Mechanical stress

DOMS occurs with a particular type of movement — one that loads your muscles while they are long or lengthening. These are called eccentric movements, Vincent says, “such as lowering a weight from a biceps curl or lowering into a squat.” In my case, it’s my quads as I climb down a mountain. In contrast, DOMS generally doesn’t occur with isometric (when the muscle doesn’t change length) or concentric (when the muscle shortens) movement.

When your muscles are not accustomed to the movement — or the weight or endurance of the movement — your muscle fibers undergo mechanical stress and small breaks occur in their membranes.

Keith Baar, professor of physiology and membrane biology at the University of California at Davis, explains that muscles are made up of muscle fibers connected to each other by proteins called dystrophyns, which function like rivets. When the muscle is accustomed to work, the rivets help the individual muscle fibers work as a well-choreographed team to move the body.

Without training however, Baar says, “these connections are weak. So when you do exercise, they slide and shear.” The rivets pull at the membranes, making tiny tears. This causes a number of chemical events in the muscle, including dysregulated fiber contractions, an influx of immune cells, and swelling and pressure buildup.

This may sound bad, but Vincent reminds me, “This is normal.” The repair process not only fixes the tears but also helps the muscle to strengthen, to be better prepared for similar movement in the future.

“The inflammation is necessary to help you regenerate the injured muscle,” Baar says. “When you’re starting a new exercise program, you may have more painful days.”

How older adults can get back into physical exercise following months of pandemic rules

In addition, older people’s muscles tend to undergo more damage than younger people. So as you age, Baar says, “You’re more likely to get sore with exercise and the resulting DOMS is more extended.”

Work up slowly

To prevent soreness, people should work up slowly to the activity they want to do. In the gym, you might start with body weight only, before you start adding external weights. I might do sets of squats or lunges before heading out for my first all-day hike of the summer. These incremental steps help your muscles adapt more slowly and with less resulting pain.

Once you’ve triggered DOMS, however, Baar encourages you to rest while the process plays out. “Take the time to recover,” he says. This is not a time for the ‘no pain, no gain’ mantra.

You may be recovering from your workouts all wrong

What about relief, as with ice or over-the-counter pain relievers? Either treatment may lessen your discomfort, but they’re not advised. That’s because of the dual nature of delayed-onset muscle soreness — it’s both a process of repair and of building strength. “If you block DOMS, the muscle doesn’t grow as much,” Baar says.

An exception can be made for athletes who are scheduled to compete on a day they’re experiencing muscle soreness. That’s because in addition to causing discomfort and pain, DOMS interferes with athletic performance. The athlete may give preference to the day’s performance rather than to her long-term gain in strength.

Studies have examined whether manipulating worked muscles after a training session affects their resulting soreness. A small 2015 study reported some promise for foam rolling — using one’s body weight to massage the muscle with rolling pressure. Eight men spent 20 minutes using a foam roller immediately after a workout, and then again 24 and 48 hours later. The practice reduced the amount of soreness at 24 and 48 hours; the performance deficits that accompanied DOMS were also reduced.

A 2021 study with 20 men and women found that foam rolling immediately following a workout mitigated the performance deficit 24 hours later, but had no effect on pain.

Tools can help with do-it-yourself massage

Of foam rolling, Vincent says, “It sounds gimmicky, but it does work for some people.” She speculates that massaging the muscles may improve blood flow and help move excess fluid out. “And there don’t appear to be downsides, unlike ibuprofen.”

The main thing to know, Vincent says, is that muscle soreness is not in itself a bad thing. “Everyone, even elite athletes can experience DOMS,” she says.

Source: How should you deal with sore muscles? – The Washington Post


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Healthy Lifestyle May Increase Life Expectancy, Research Suggests

A healthy lifestyle may allow older people to live longer, with women adding three years and men six to their life expectancy, suggests research published in the journal BMJ. In addition, more of those years may be dementia-free. More than 6 million Americans 65 and older have the most common type of dementia, Alzheimer’s, for which there is no cure.

The study found that, at age 65, women with the healthiest lifestyle had an average life expectancy of about 24 years, compared with 21 years for women whose lifestyle was deemed less healthy. Life expectancy for men with the healthiest lifestyle was 23 years, vs. 17 years for men who were less healthy.

The findings came from research that involved 2,449 people who were 65 and older and part of the Chicago Health and Aging Project, which first enrolled participants in 1993.

The current researchers developed a healthy lifestyle scoring system for their participants that encompassed five factors: diet, cognitive activity, physical activity, smoking and alcohol consumption. People were given one point for each area if they met healthy standards, yielding a final summed score of 0 to 5, with higher scores indicating a healthier lifestyle.

As for living with dementia, those with a score of 4 or 5 healthy factors at age 65 lived with Alzheimer’s for a smaller proportion of their remaining years than did those with a score of 0 or 1. For women, the difference for those with a healthier lifestyle was having Alzheimer’s for 11 percent of their final years vs. 19 percent for those with a less healthy lifestyle; for men, it was 6 percent of their remaining time vs. 12 percent.

The researchers concluded that “prolonged life expectancy owing to a healthy lifestyle is not accompanied by an increased number of years living with Alzheimer’s dementia” but rather by “a larger proportion of remaining years lived without Alzheimer’s dementia.”

People who engage in a healthy lifestyle, such as eating a balanced diet, taking regular exercise, and avoiding smoking and excess alcohol consumption, incur many health benefits, including a longer lifespan.

It was not previously known if this benefit was also seen in people living with multiple conditions. Multimorbidity is the presence of two or more long-term conditions, ranging from anxiety and eczema to cancer and schizophrenia. It has become a major worldwide epidemic. People with multiple conditions have poorer health and a higher risk of death compared with others in the population.

Researchers compared the impact of a healthy lifestyle on life expectancy in people with and without multiple conditions. It was the first study to be able to look at the impact of different lifestyle factors.

The key finding is that a healthy lifestyle is equally important for everyone, whether they have multiple conditions or not. Age is a strong risk factor; even so, young and middle-aged adults who live in deprived areas are the most likely to have multiple conditions. Engaging in a healthy lifestyle could be more difficult for people in this group.

The study also found that certain lifestyle factors, such as smoking and physical activity, were more damaging than others. Public health policies and healthcare professionals could therefore focus on these lifestyle habits. This study suggests this approach would have more impact than costly strategies to address multiple risk factors.

By Linda Searing

Source: Healthy lifestyle may increase life expectancy, research suggests – The Washington Post


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