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.

soda and cigarettes

In the Seven Year Itch the main character, Mr. Sherman, sends his wife and son away to Maine for the summer. He is initially determined to obey the doctor's orders to quit drinking and smoking and to eat healthily. He locks away his cigarettes and eats dinner at an outrageous vegetarian restaurant. He goes home and removes a bottle of soda from the fridge. He reads the back of the label: "Carbonated water, citric acid, corn syrup, artificial raspberry flavoring, vegetable colors and preservative." Then he asks himself, "Why is this stuff better for you than a little scotch and a twist of lemon? I'd really like to know." Of course, it's obvious to us that it is in fact much worse to drink the soda. What I find interesting is that this must have been obvious to the 1955 audience as well.

There is a lie that I have been telling myself for some time now as a means of explaining how our tolerance of preservatives and artificial flavorings developed. It is the same story that we often hear regarding cigarettes. They didn't know any better. I reasoned that we must excuse ignorance, and that the food industry was out of control before we realized that these things could be so bad for us. But clearly that is not the case. In 1955, although he still got milk delivered to his apartment door every morning,  simple Mr. Sherman knew that drinking corn syrup and preservatives was unhealthy and his doctor told him to quit smoking.

Then how did we get to where we are today? Well, clearly health is not the biggest concern in these matters. I think it is reasonable to argue that media plays a huge role*. Although Mr. Sherman was the protagonist, he was just a nice guy, a bit of a schlump. The real star in this film is clearly Marilyn Monroe. She is oblivious to any reason that one should quit smoking. And she eats potato chips with champagne. Today we don't see the glamorous cigarette adds that were common in the 1950s, fewer Americans smoke, and fewer Americans die from diseases associated with smoking, like stroke and heart attack. But it certainly took a while to get to this point, and it is still a problem. How long will it take for better eating habits to become the norm?

I'm actually very optimistic about this. I think change will come sooner rather than later because it is necessary. I certainly see it in my peers (okay, so maybe they are all medical students, but still). I also see how many people are drawn to farmer's markets and  and preparing their own meals. There is even a movement for specialty ingredient foods - chocolates, wines, gelato. Even if these are not the healthiest items, the call for natural whole ingredients is promising, and it proves that Americans are willing to pay for quality, not just quantity.

I recently began reading In Defense of Food: An Eater's Manifesto by Michael Pollan. He argues that America's nutritional problems have been complicated by the rise of what has been called Nutritionism. Nutritionism is the idea that we can calculate what we should eat and follow those numbers in our diet and be perfectly healthy. But that has lead to catastrophes like Liebig's Extractum Carnis, the idea that multi-vitamins would solve all our problems, or that simply cutting back on fats or carbs would solve all our problems. This idea forced me to think a bit more, because I am very interested in understanding more about nutrition - what different foods can offer us, how different nutrients work together as our body attempts to metabolize them, etc. But the more I thought about it the more I came to understand that when we try to apply a formula to each meal we can no longer enjoy our food. It becomes like a pill we have to take or a temptation we must resist.

When I was in high school I paid no attention to the nutrition information on packages and I definitely could not tell you what percentage of my calories came from fats or if there was too much sodium in my diet. First, I want to clarify that understanding these things are essential for people that are already overweight or have Diabetes or Hypertension or are at risk for heart disease. Second, I do think that for most of the population we can totally forget about these numbers and follow our instincts when it comes to eating well. Michael Pollan's manifesto is this: "Eat Food. Not too much. Mostly plants." So, basically, avoid artificial anything, be mindful and don't eat past the point that you are full, and listen to your mother - eat all your vegetables.

It is likely that I will have more to say about nutrition in the coming months, as I read more of this book, but I'm curious to hear what you think. Should we rely on our gut to tell us what to eat? Or do we need science to guide us?

*So does the government - according to Pollan, as recently as 2004 the Bush State Department was enlisted in a campaign to recommend that Congress threaten to cut WHO funding unless they agreed to raise their daily recommendation of calories from added sugars from 10% to 25%, the official U.S. recommendation at the time. I believe that has been changed, adding to my optimism.