thought for food. part 2

Clearly, many people are struggling to navigate the world of healthy eating trends, trying to figure out how to feed their bodies and souls, confused by all the options. Here is my favorite thing I've read about it: "the terrible tragedy of the healthy eater" - it's hilarious! And talk of the microbiome is going mainstream, thanks to the New York Times and Michael Pollan. But eating well is about more than just what we eat, it's also about how we eat, so that's what I want to talk about in part 2.

Fortunately, this is much more straight forward, and it basically boils down to taking the time to appreciate your food. Ideally, we would do this through every step of the process - from purchasing whole ingredients or actually growing them, to preparing a meal from scratch, to eating it mindfully. Usually when I hear people talk about these ideas, it conjures up this image of some do-it-all woman making her own homemade sunscreen, with a chicken coop in her backyard, friend of all the farmers at the weekend morning market, cooking 3 meals a day for her family and baking her own bread each weekend. She probably has an awesome blog with 100s of followers, too. It's beautiful, terribly impractical, and probably nonexistent.

Fortunately, you don't have to treck out to a farm or become a gardener or a gourmet chef. Food appreciation can fit into your everyday life. Even simple weekday meals  can be eaten mindfully. When we know a bit about where our food comes from or have taken the time to pick out the nicest bunch of radishes at the supermarket, it's easier to relish it a bit more. When we take the time to cut and wash those radishes, we begin to think about how nice it will be to eat them. When we eat more slowly, without music or television as a distraction, we enjoy it more and we eat less.

To me, sharing food and recipes is a big part of this as well. I think the most wonderful thing about this bubble of food blogs is that it encourages just that. Similar to church women's leagues creating cookbooks, I often feel like I have a community of like-minded people writing about their love for food. It's a community that has introduced me to all kinds of new ingredients, like spelt flour, chia seeds, and ramps. I also think cooking for others is a very powerful thing. It fulfills a desire to nurture and to give in the most fundamental way. It also exposes people to things they might not try otherwise, like quinoa (really, some people don't know about quinoa yet!) or simply a vegetarian meal. In fact, it's one of my favorite things to do, and I wish I did it far more often.

I recently read a summary of the characteristics of a group of Greeks who tend to live much longer than most people. A few of the "10 ways to live to be 100" are: take naps, stop worrying about being late, grow a garden and eat from it, 'get it on', walk daily, be part of a spiritual community, and surround yourself with people who do the same. Even if you won't live to be 100, don't those sound like ways to have a happier life in general? Taking the time to enjoy your food is the same. It's good for you, and you will enjoy it. Win-win.

Of course, this is all easier said than done. But it's definitely worth striving for.

thought for food. part 1

I've been mulling over the idea of writing a more substantial post about my thoughts on food for a while now. Finally the combination reading tweets from the Nutrition and Health Conference at the University of Arizona College of Medicine, hearing about Michael Pollan's latest book, and a few integrative medicine conferences I've been involved in recently has pushed me to do it. My plan is to break this into two posts: one about what we should eat, and a second about how we should eat.

There's almost no need to even say that we are constantly bombarded with different theories regarding what we should eat. The diet industry has been around for decades, and now the internet gives us access to a near-infinite number of theories about which foods will increase our risk for heart disease, which to avoid to 'lose belly fat', and which to eat if we want to stay young. I think there's actually a lot more to this than people trying to make money. The rates of obesity, diabetes, and cardiovascular disease (CVD) have grown to atrocious levels, affecting people of all ages and socioeconomic statuses. There's a lot at stake here, and I’d like to think we all know that on some level. The problem is that we want a quick fix - turmeric and garlic to fight cancer, veganism to lower cholesterol, raw milk to erase allergies. Even those who are willing to make some sacrifices want a clear-cut answer to health. Ian often asks me which nut is healthiest, or if I could make him some sort of smoothie with all of the healthiest ingredients possible. It doesn't quite work that way, though. Pollan does an excellent job of explaining the downfalls to this route of "nutritionism" in his book An Eater's Manifesto. When we reduce food to it's parts, or try to reduce our needs to a formula, something goes missing. That being said, I completely understand and share in this desire. Navigating the world of food health blogs can be as confusing as the supermarket.

Here is the huge divide in the foodie movement as I see it. [Sorry, I'm going to over-generalize a bit.] On one extreme we have Vegans. The Ornish Spectrum diet is a prime example of this school of thought. It keeps fat down to 10% of your total caloric intake and eliminates animal products (with a few exceptions). Instead, there's an emphasis on vegetables, whole grains, and legumes. In concert with exercise and stress reduction techniques, Dr. Ornish's research indicates that this program may actually reverse CVD. Closely related are Dr. Weil's Anti-Inflammatory Diet and the often touted, though less defined, Mediterranean diet.

On the other hand is the Traditional Foods revival, which is where I’d place the popular Paleo Diet. Here, the emphasis is on grass-fed meats, whole fat (often raw) dairy, sprouted grains or no grains at all, and fermented foods like sauerkraut and kombucha. It seems like gluten-free diets can overlap with either of these branches, whereas the Gut and Psychology Syndrome (GAPS) diet seems to fit better with the latter. To be fair, I don't know nearly as much about this line of thought. But there is research out there indicating that full fat dairy may also help to reduce CVD. The Weston A. Price Foundation is a big name in researching and promoting this type of diet, and they have some really interesting studies to show for it.

But how can this be? Two diets that seem so different at first glance: one focuses on eliminating animal products, the other focuses on eating more, but better, animal products. Let's start by looking at what they have in common. The most obvious thing is the elimination of junk. Nobody is talking about dunking Oreos in their raw or soy milk. Prepared and processed foods account for a lot of the bad stuff in our diets: preservatives, coloring, extra salt, extra sugar, and refined grains. It's amazing how much of this we eat without realizing it - even plain old butter often contains "natural flavor." (Shouldn't it just taste like butter all by itself?) Aside from getting rid of all the non-food in our food, eliminating processed items also cuts down on the simple carbohydrates in our diet. This is a really big first step to eating better. Carbs (bread, pasta, potatoes, crackers) are essentially converted to pure sugar in our diet, so in some ways you can lump them right in there with soda, cake, and ice cream. Without fiber and protein to balance them out, they send our blood sugar level through the roof, forcing our body to secrete loads of insulin and stress hormones to combat all that sugar, and setting us up for developing diabetes. It also augments the immune response, causing some normal protective processes to progress to the point of unnecessary inflammation. Most people have heard of some of inflammation's deleterious health affects by now, like arthritis, irritable bowel disease, and various autoimmune disorders, but it's also being linked to a lot more. In fact, inflammation seems to be turning up as a key player in major chronic illnesses like stroke, heart disease, and even depression. A lot of this research is still in the works, and I don't know of any good studies linking diet with inflammatory markers and a particular chronic disease, but I won't be surprised if we discover that inflammation plays a much larger role than we now know. It's exciting to think about, in a nerdish kind of way.

The second big thing these two ways of approaching food have in common is a lot of fruits and vegetables. I’m still shocked every time a patient tells me he doesn’t like vegetables. There are so many of them! and so many ways to prepare them! How can you possible not like any of them? Hopefully, if you’re reading this, you already know that fruits and vegetables are delicious packages of vitamins and phytonutrients. If you’re not convinced about any one particular produce item, just look it up on this site. They also have lots of fiber, and veggies are low in calories, so there’s no need to limit your intake like you do with other food groups. If you’re not convinced that you should be eating at least 5 servings of fruits & veggies daily, e-mail me and we’ll have a chat.

Finally, what I’m really excited to talk about, is why I think the Vegans and the Traditional Foods folks might both be correct, why both might offer really good advice on what we should eat. Perhaps the link is how we digest and process foods, and it’s all largely dependent on our normal gut flora. There’s been a lot of talk about the importance of probiotics for a variety of reasons, and this is where the fermented foods come into the spotlight in the Traditional Foods diets, so it’s something I’ve thought about casually for a while. I’ve also been fascinated by what I’ve learned about our normal intestinal flora (the bacteria that always live in our gut). But when I read the article by Tang et al. in the New England Journal of Medicine about intestinal microbial metabolism and cardiovascular risk, a few light bulbs lit up. There are two parts of the study, and I’m going to go ahead and explain it in a bit more detail than some might care to read. You see, this is the kind of research that fields like nutrition and integrative medicine need, because it’s so important to say that these lifestyle recommendations are evidence based. The “n” or number of participants is small, but I think the design is fantastic. So, here we go:

For the first part of the study, 40 healthy adults were given a dietary phosphatidylcholine challenge, i.e. they ate two hard-boiled eggs. Phosphatidylcholine is found in egg yolk, and it’s a major constituent of all our cell membranes. The closely-related choline is found in meat. Bacteria that live in our intestines metabolize phosphatidylcholine to trimethylamine-N-oxide (TMAO). After eating these eggs, researchers measured the amount of TMAO in the subjects’ urine and blood. Then, six of the subjects were given a one-week course of antibiotics (500mg each ciprofloxacin & metronidazole), to wipe out the intestinal bacteria. (This is the same process by which taking antibiotics can give you diarrhea.) They repeated the phosphatidylcholine challenge after finishing the antibiotics, and then a third time one month later after the intestinal flora had presumably restored itself. They found that the course of antibiotics significantly lowered, indeed, nearly erased, the amount of TMAO measured. After one month, these levels came back up. This study demonstrates that our intestinal flora is responsible for producing TMAO.

The second part of the study enrolled 4007 adults who were undergoing elective cardiac catheterization without evidence of ongoing heart attack, and measured the TMAO level in their blood. These subjects were followed for three years, to see who had adverse cardiovascular events. Those who did were more likely to have many of the expected risk factors, as well as a higher baseline TMAO level. Even after adjustment for traditional risk factors, a higher TMAO baseline level was still a significant predictor of major adverse cardiovascular events.  Further, it proved to predict risk on a graded scale, rather just a simple high or low cut-off, even for subjects in the lowest quartile of other risk factors.

To summarize without so much jargon, though this may also make it sound more definitive than most scientists like:

·       Phosphatidylcholine is a substance found in eggs. Choline, found in meat, is very similar.

·       It’s not all bad; our body needs it to some degree.

·       Some of the bacteria in our gut convert it to TMAO.

·       It doesn’t get converted to TMAO without those bacteria.

·       More TMAO = higher risk of heart attack or stroke.

Therefore, one would think that more meat and eggs also equals higher risk of heart attack and stroke. The authors give a really nice conclusion in their discussion of what this might mean for dietary recommendations.

“Our data suggest that excessive consumption of dietary phosphatidylcholine and choline should be avoided; a vegetarian or high-fiber diet can reduce total choline intake. It should also be noted that choline is a semiessential nutrient and should not be completely eliminated from the diet, since this can result in a deficiency state. However, standard dietary recommendations, if adopted, will limit the intake of phosphatidylcholine- and choline rich foods, since these foods are also typically high in fat and cholesterol content. An alternative potential therapeutic intervention is targeting the composition of the microbiota or biochemical pathways, with either a functional food such as a probiotic or a pharmacologic intervention.”

The speculation that I would like to make, and this is of course reaching quite a bit, is that the “functional food” component of the Traditional Foods movement – raw milk & yogurt, fermenting – does in fact change the microbiota or biochemical pathways. It would be fascinating to do a similar study as the first part of this article – phosphatidylcholine challenge with 3 arms: a control, a group treated with antibiotics, and a group eating a reasonable amount of these foods on a daily basis for some period of time.

But we’re not there yet, so where does that leave us? I think Aristotle got it right millennia ago with the Golden Mean. Life is about flux and trying to find balance, and this applies to diet too. There are a few things about which we can walk away from all of this with certainty, though. The first is that we should keep prepared, processed foods to a minimum. Anything that comes in a box or a bag with a long list of ingredients, especially if you don’t know what some of those ingredients are, should not make up a large percentage of your diet. The same thing goes for inflammation-provoking carbohydrates and added sugars. The second thing is that we should eat more fruits and vegetables. Everyday. Period. The beauty of this is that once you start eating this way, your body won’t ever want you to go back.

chia seeds

You probably aren't going to be very interested in a recipe without a photo, right? I usually want a photograph before I consider a recipe. It's just so much easier; a quick glimpse and I know if I'll be interested, before I take the time to read the list of ingredients and imagine how they will taste once melded together in my mouth. And eating ought to be a visual experience as well as oral and olfactory. The more senses you use, the more you can enjoy. Unfortunately, I have reached the limit of my free blogger photo space.

I didn't know a limit existed, but it does, and it has me questioning what this is all about. Really though, that questioning is nothing new. I go through phases that range from feeling like I'll keep blogging indefinitely and have this fantastic archive and many followers, to satisfaction that I just enjoy writing it for it's own sake, to the whole thing being utterly pointless...like writing into some void. I recently read a comment elsewhere which read: "when my blog grows up I want it to be like _________." Certainly, many people feel this way. Because there are a lot of beautiful blogs out there (I have a theory about blogs and Victorian letter-writing; perhaps I'll share it another day), and we can be inspired by them, or transported, or educated. And there are a lot of women out there with great recipes, beautiful homes, flourishing prose, and lovely photographs. Do I really have something to add to the near-infinity of what is already on the internet?... I'll think of giving it up, but then another idea will come to mind that I'd like to share, and I find myself writing again. Which is all quite fine. At the very least, I know of a couple friends who read it. And my dad, and maybe even one of his friends (hi Mr. McFarland!).

Anyway, I plan to keep it up for now - even without photographs - because I want to tell you about chia seeds. Chia seeds are about the size of a strawberry seed, get stuck in your teeth just the same, and are packed full of fiber and omega-3 fatty acids. In 1 ounce, they have 11 grams of fiber (reference: recommended daily amount for women is 25g, for men it's 38g), and almost 5 grams of omega-3 fatty acids (that's 8x more than salmon). They also have calcium, antioxidants, and a bit of protein. They have very little flavor, so you can do all sorts of things with them. Throw them in a smoothie, sprinkle them on top of yogurt or a casserole. I bet you could go so far as to sneak them into an omelet and nobody would notice. Apparently you can even use them as a pectin substitute to make jam, and, like ground flaxseeds, you can use them as a substitute binding ingredient in baking. This is because they absorb water and become like a gel. Aside from easing digestion, soaking them in water (1:6 seed:water ratio) is also a great way to soften them up and prevent them from sticking in your teeth, which can be rather annoying. My big chia seed kick has been based on this soaking method. I keep a mason jar in the fridge, and in the morning I stir a spoonful into my oatmeal or yogurt. Here's a recipe for my current favorite breakfast:

Yogurt with Chia Seeds Recipe:
1 bowlful of Greek yogurt - whatever you consider an appropriate serving size. My favorite is Fage 2% fat.
1 spoonful of chia seed gel
1 spoonful of jelly or honey

optional: 1 spoonful of peanut butter. I don't care for this, but Ian loves it!
other extras: nuts, granola, fresh fruit, dried fruit, etc.

Just mix it all together and enjoy!




p.s.: if I did have a photograph, I would want it to look something like this one

stress and breathing

I have realized recently that I often have trouble relaxing. This week I completed my ultimate final as an undergraduate. That, I think, is a good reason to celebrate and to say, "Okay. I have accomplished something. I should now relax for a little while." But that is not how it happened. In fact, before I even took the last final I began feeling anxious about the next thing on my to-do list. I am now noticing that this is a recurring pattern. Maybe it is a pattern of yours also.

Before I finish one project I start thinking about the next one, so that by the time I finish the first I am so mentally involved in the second that the former doesn't even seem like much of an accomplishment. It was just something I had to do to get to where I am now. This is true even with major life events. Why do we have this tendency to let free-floating anxiety stop us from recognizing the value of our accomplishments? When you consider the pace of our lives, maybe this question is not so hard to answer.

When I studied in Spain we took a siesta everyday. Everybody did. Really. There was a pause in the day to go see your family at home, to meet a friend in the park, to take a nap. The whole schedule is different to accommodate for this break from work and from the heat of the afternoon. It just means that the work day is pushed a couple hours later. The evening meal is also pushed a couple hours later. But the beautiful thing about that is that when you do finally sit down to the dinner table you know that it means you are done for the day. Since you don't eat until 10 p.m. there really is no question of getting back to studying or paying the bills or cleaning the house. It will be time for bed. So you can just enjoy your food and a glass of wine, and really have a conversation with your loved ones without feeling rushed to finish eating and get back to work. I know studies show that not eating late in the evening is better for your metabolism, but I think the relaxation encouraged by this schedule must have some serious benefits.

Although eating a very late dinner has not been a lasting habit for me I have tried to hold onto some of those things that I observed and experienced while in Spain. Both during the siesta and during dinner I felt like I was really taking a break from the day. I think we should take a daily break. It doesn't have to be long and it doesn't mean that you are not working hard enough. It just means taking a few minutes to stop what you are doing, take notice of your emotions and physical feelings - if you are tired, if you have been squinting your eyes at the computer all day, or if your body is aching from physical activity. Maybe you can take ten minutes to talk to a friend (without mentioning how busy you are). Maybe you can take thirty and enjoy every, single, simple, tasty bite of your lunch. 

Now, if you don't mind a quick little bit of biology, I would like to tell you why this is so important:

Our central nervous system has two main components, the sympathetic (fight or flight) and the parasympathetic (rest & digest).  These two are constantly in flux and when we get stressed because we are sick, get injured, are running away from danger, or are annoyed by the people around us or worried about getting everything done, the sympathetic system tends to overpower the parasympathetic. When the cause of this is psychological/social it's bad news for our heart because it starts beating faster, which wears on our blood vessels. Again, this is great when we have to fight infection or engage in strenuous physical activity - but when we don't it just causes our bodies to wear out more quickly.

Both the sympathetic and parasympathetic systems are always active and it just so happens that when we exhale the parasympathetic system automatically kicks it up a notch. One way that it does this is by lowering our heart rate. Your heart automatically beats more slowly when you exhale than when you inhale. Every time you do it. This is one reason prayer and meditation are so effective. So...

The next time you feel anxious and think your body might be working over-time, take 2 or 3 minutes just to sit quietly and breathe deeply. Inhale for a count of 4, exhale for a count of 6. Try to think only about your breath, not everything else going on around you. This should help to clear your mind and relax your heart.

health care

While preparing for medical school interviews last summer I made sure I was confident in my response to any questions about health care reform. I had no problem doing this, as it is something that interests me and it really helped me to process my thoughts about the issue. With the historic passing of the health care bill this weekend I think now is the perfect time to share my thoughts. I am fairly ignorant of all the politics and economics involved, but I certainly think the system is in need of repair. I am hopeful that this bill will begin to make that repair possible, but I also think it ignores some of the main problems.

I propose that we need a sort of social health care reform, a new cultural attitude toward health in general. As a society we have become so detached from our own whole well-being. We have dissected it into diets and statistics about exercise and visits to multiple physicians for pills and procedures to make us "better". Did you know that Texas high schools no longer require that students take a health class? And PE is only required until 6th grade? Although I never thought these classes did me a whole lot of good, I  think this is a problem, at least symbolically. It is essential that we educate our children about nutrition and encourage them to form habits of eating well and being physically active. One of my goals as a future physician is to educate my patients about having a healthy lifestyle. I also want to participate in programs that promote these things within my community (and I won't be waiting until I have an MD to do that!).

I think the second thing our country needs is an increased emphasis on preventative health care. We need to encourage all the people who will finally be able to have health insurance to see family doctors and OB/Gyn's on a yearly basis, rather than waiting until they get sick and going to the emergency room on a Friday night. If a 30-year-old man finds out that he has high blood pressure and can work with his physician to control that, he might not need a heart catheterization when he is 50. The benefits of this to the individual, the physician, the nation's health care system, and the health of America as a whole will go a long way.

After voicing these thoughts one interviewer said that I sounded like a passionate primary care physician-to-be. I'm not sure about the primary care part, but the passion is definitely there.