Cabbage Done Spicy

This final recipe comes from the book Moosewood Restaurant Celebrates, and details a dish invented on the fly by a Tibetan chef who was working at Moosewood many years ago. Though the book itself is below the par of most of Moosewood's books, this dish has been a guaranteed crowd pleaser with just about everyone I've served it to. The original recipe calls for this to be served as a burrito, though I find it's just as good on its own with rice. Additionally, this being a Moosewood recipe, the original was vegetarian, though my adaptation contains meat.

2 cups chopped onions
2 tbsp oil (I find that untoasted sesame oil is a great option, but avoid olive oil at all costs)
2 tbsp minced/pressed garlic
3 tbsp fresh ginger root
1 tsp salt
4 cups shredded napa cabbage
1 or 2 tsp asian chili paste (such as sriracha)
2 cups peeled and grated carrots
8-16 oz seitan/tempeh/chicken/pork
1 tsp dark sesame oil

To start with, let me say that I recommend preparing the ingredients beforehand, rather than on the fly. The shredding and grating involved in this recipe is fairly labor-intensive and the ingredients are subsequently added to each other fairly quickly.

Before, however, you tackle the vegetables, deal with the meat, if you're using meat. Though this is a stir fry, I don't recommend cooking the meat in the stir fry, as the flavor is less impressive cooked that way, and if you're going to use meat, do it justice and get maximal flavor out of it. I recommend salting and oven roasting it, similar to the roast chicken recipe. Allow it to cook until slightly browned, then allow to cool. When cooled, slice it into thin strips, perhaps a quarter inch wide. I typically use chicken thighs, but pork chops can be just as good.

Ok, now that you've finished prepping the vegetables, it's time to get to work. I typically use a wok for this dish.

Start by frying the onions over medium heat until golden brown. Add the garlic, ginger root and salt, and cook for about 2 minutes, until the aroma rises nicely. Next, stir in the cabbage and cook until the cabbage is limp (about 10-15 minutes). I recommend napa cabbage for this recipe, as it wilts well, and makes a great stir fry.

Once the cabbage is soft, add the chili paste, carrots and seitan/tempeh/meat. Cook 10-15 minutes more, until all veggies are soft and golden brown. When finished, remove from heat and drizzle the dark sesame oil over the dish and mix well. Serve immediately.

If the last dish didn't make you a fan of cabbage, this one is guaranteed to do so.

Cabbage Done Heartily

This recipe is a take on colcannon, a traditional Irish dish involving cabbage and potatoes. It works as a great standalone meal, and reheats very well in the oven. It involves a few pots, but the result is excellent, and worth the work.

Colcannon is a hearty, stick-to-your-ribs type of meal that is fantastic in the dark and dreary days of late autumn and winter, and what's more, it features bacon! But wait, isn't this a natural health blog? What's bacon doing in the recipe? Quite simply, I've found that the appeal of bacon is stronger than the repulsion of Brussels sprouts or cabbage, and that not only does bacon work with the flavor of crucifers quite well, but is also an effective way of introducing people to these fantastic, health-promoting foods.

2 pounds potatoes
2 1/2 cups chopped/shredded green cabbage or kale
2 cups chopped Brussels sprouts or broccoli
8 oz bacon
1 onion, chopped
1/2 tsp salt
1/4 tsp black pepper
1 cup grated cheddar cheese

Peel and chop the potatoes, then boil them in salted water until soft. Waxy potatoes (such as Yukon Gold or red potatoes) work as well as mealy potatoes (such as Russets) both work well, though clearly produce slightly different dishes. I personally prefer waxy potatoes, which give the dish a chunky consistency, whereas mealy potatoes make for something more like a mash.

Meanwhile, steam the cabbage/kale and Brussels sprouts/broccoli. The trick here is to steam them just enough that they can be easily pierced with a fork, and then remove them from the water (if you're using kale, add that after the rest of the veggies have cooked, and allow it to cook until wilted). Many of us grew up eating overcooked veggies in general, and overcooked crucifers in particular. Not only does overcooking bring out the sulfurous flavor of these veggies, but it also gives the veggies a soggy, limp consistency. And seriously, if you're trying to get people to eat challenging veggies, at least cook them so they're appealing.

Ok, so finally, the bacon part. Cook the bacon as usual, and then allow to drain on a plate. Please allow for house/apartment to smell like goodness and draw all parties to the kitchen. Using the bacon grease, cook the onion until browned, adding the salt and pepper as it nears completion.

Now for combining. Drain the potatoes and veggies and place in a large bowl, add the onion mixture, crumble in the bacon, and mix thoroughly. Place in a casserole and top with shredded cheese. Place under broiler and allow the cheese to melt and bubble.

Serve immediately. For a true British Isles experience, serve this with stout or porter.

Cabbage Done Savory

Cabbage is one of my favorite winter vegetables, in part because it's surprisingly versatile. The next three recipes will feature cabbage prepared three different ways. It's not everyone's favorite vegetable, but it deserves to be in everyone's diet, so hopefully you'll find you enjoy one of these three recipes.

Throughout these next few recipes, we'll be using different types of cabbage as well, and today's type is red cabbage. Though all types of cabbage are rich in cancer-fighting compounds, such as sulphoraphanes, indole-3-carbinol, and a variety of vitamins and minerals, red cabbage is unique in containing anthocyanidins, compounds which give the cabbage its unique color, and which also are potent antioxidants.

The first recipe is designed to accompany the roast chicken recipe from earlier this week, and features a savory, but mild take on cabbage that won't steal the show from that fantastic chicken.

1 red cabbage
4 tbsp olive oil
1/2 cup water
2 garlic cloves, crushed
2 sweet apples peeled, cored and chopped
1/4 cup raisins
5 tbsp wine vinegar
1 tsp salt
1/4 tsp black pepper
1/4 cup pine nuts

As always, peel off the outer leaves of the cabbage, and remove the core. Shred the tender leaves of the cabbage.
Add all ingredients except pine nuts to a large pot, and simmer over low heat for about an hour, until the cabbage is quite soft. You'll want to initially bring the mixture to a simmer and then reduce the heat, so that the cabbage steams.
Toast the pine nuts in a small skillet or pan until lightly browned on all sides, and stir into cabbage before serving. Even over low heat, this requires close attention to avoid burning the pine nuts (which can be quite expensive).

(Recipe adapted from Claudia Roden's The Food of Spain)

A Podcast About Medicine Done Badly

A few weeks ago, I posted a link to an article by Ben Goldacre, a columnist at the Guardian who's just published a book called Bad Pharma. Soon thereafter, Ben was interviewed for the Guardian's Science Weekly Podcast, and an abbreviated version of the interview was featured in their weekly podcast a few weeks ago. Just yesterday, the full version was released, and let me tell you, it's excellent. While Ben has been a harsh critic of complementary medicine (and so he and I don't agree on everything), his critique of the pharmaceutical industry and the effect they have had on both debasing science, as well as putting patients at risk, is excellent. The interview is about an hour long, but is well worth your time. I hope you enjoy it.

A Roast Chicken Recipe

Roast chicken is probably one of my favorite dishes. Over the years, I've come to think of it as something of a benchmark for quality cooking - while it's not too hard to slather the chicken in sauce, stick it in the oven, and then emerge with something that's fully cooked and doesn't taste too bad, it's a lot more difficult to gently highlight the rich flavor of the chicken itself.

Here's the main takeaway message - the key to a properly roasted chicken is salt. Lots of salt. Many folks worry that salt will raise their blood pressure, and avoid salt religiously. While it is true that salt does raise blood pressure, for most people, the main culprit here is processed food, which is far saltier than home-cooked food, even heavily salted home-cooked food. Salt may raise your blood pressure by a point or two, but the enjoyment of a delicious roast chicken dinner will lower it back down again.

Have I mentioned skin? When chicken is properly roasted, the skin becomes the primary repository of flavor - a crispy flavor conveyor, not a layer of slimy goo to be peeled off. Again, a lot of folks remove chicken skin in the belief that it makes their diet healthier. It's true that chicken skin contains more saturated fat than the rest of the bird, but removing it isn't the solution - adding vegetables to your diet makes it healthier, removing chicken skin just makes it less enjoyable.

So here are the ingredients:

1 whole chicken
Approx 1 tbsp sea salt
1/4 cup olive oil
1 tsp assorted herbs and spices

Pretty minimal and vague, isn't it? Approximately 1 tbsp sea salt? And what are assorted spices? Read on to find out.

A good roast chicken starts in the store. Avoid chicken that has been injected with water to make it appear fuller. The water weight will inflate the price of the chicken, and won't add to flavor. Look for natural or organic birds, but be clear about what organic means - sometimes, the only difference between an organic and natural bird is that the organic one was fed organic feed, while the natural one (which costs less) was also free range and spared excessive antibiotics.

Once you bring it home and have removed it from the packing, it is very important to pat the bird dry, both inside and out. When it comes to meat, water is the enemy of flavor. This step is overlooked by most home cooks, and it makes a real difference. No matter what recipe you're using, dry the bird first.

While you're doing that first thing, have some herbs and spices soaking in the olive oil. Which herbs and spices? Assorted herbs and spices. Pick a few and add them to the oil in small quantities - I usually recommend 1/4 tsp each. Favorites include black pepper, paprika, thyme, oregano, rosemary, coriander, and others. Pick ones you like and have them soak/infuse slightly in the oil.

Think also about the kind of oil you're using. Most recipes call for extra virgin olive oil, but that's not always the best for roasting. Extra virgin olive oil has a very delicate flavor, as well as a fragile fat and antioxidant profile that is easily destroyed by heat. Extra virgin oils are largely suitable for dressing salads and very low heat cooking, not roasting. Consider instead using a semi-refined oil that can take the high heats we use in roasting. Refined oils often get a bad rap, but a high quality, heat-stable refined oil is less likely to form dangerous oxidized fats during roasting. I don't like to plug products here, but I will say that, after reading the olive oil exposé Extra Virginity, I favor Bertolli olive oils - they offer an extra virgin olive oil, semi-refined olive oil, and fully-refined olive oil.

Once you've fully dried the bird and have your oil ready, you're ready to oil it up. Rub that chicken down with the oil, making sure that you get it everywhere.

When the bird is fully oiled, salt it, making sure to hit every exposed surface. You don't need to cake it in salt, but you'll want to use about a tablespoon or more of salt to cover the whole thing. The salt should be clearly visible on the bird by the time you're done.

Next step. Many recipes will say to start the bird on it's breast and to flip it onto it's back halfway through the process. You can do this if you like, but I find that it's an unnecessary step that results in the pain in the butt of having to flip an oven hot bird while trying not to tear the skin. Instead, just put the bird on it's back and leave it there the whole time. Most of the skin you'll want to be crispy and browned is on the legs and breast, so leave that part exposed while cooking.

And finally, temperature. Chicken can be roasted at a variety of temperatures for varying lengths of time. To get a tender, juicy chicken with a crispy, flavor-packed skin, I recommend roasting at 450 for 50-60 minutes. And of course, always remember to fully pre-heat the oven.

Bon Appétit!

A Carrot Recipe

It's rare that you eat carrots and think, 'Wow! Those are amazing carrots!' but that's exactly what I'm hoping you say after you try this dish.

This recipe comes again from one of my favorite cookbooks, Claudia Roden's The New Book of Middle Eastern Food, and it's a guaranteed crowd-pleaser. I'm including it today because we're now in the grips of fall, and good, hearty dishes like this one are finally returning to our tables.

Though this is Tunisian dish, it will always remind me of the bags of dirty carrots I'd get from Lindentree Farm in Lincoln, MA when I had a farm share there. I'd come home after picking up my weekly veggies, and one of the first things I'd do would be to wash the carrots and make this tasty salad.

1 1/2 pounds carrots (peeled or scrubbed clean)
Salt to taste
4 tbsp of oil (olive, sesame or walnut)
3 tbsp red wine vinegar
2 garlic cloves, crushed (or an equivalent portion of garlic powder)
1 tsp paprika
1/4 tsp chipotle powder
1 1/2 tsp ground cumin
1/4 tsp galangal or ginger

Slice the carrots into large pieces and either boil or steam until easily pierced by a fork.
When cooked, drain the carrots and place in a large mixing bowl. Add the other ingredients and mix thoroughly. Allow to sit 10-15 minutes so that the flavors can marry.
Mash thoroughly or puree.
When mashed coarsely, this can be eaten as a salad, but when pureed can be eaten on bread much like hummus.

A few notes: The original recipe calls for the carrots to be peeled, but leaving the skins on retains more beta-carotene. Similarly, steaming the carrots, rather than boiling them, also retains more nutrients.
I prefer sesame oil for this dish, as it gives the dish a slightly nutty flavor that I prefer over olive oil in this case.
Ground galangal can be hard to find, but is uniquely good in this dish. It is similar to ginger, but imparts a slightly camphor-y, mustard-y taste. Use it sparingly, and it really makes the flavor pop.

A Link to A Colleague's Blog

John Weeks is not a naturopathic physician. Even so, he was honored by the American Association of Naturopathic Physicians this year for his lifelong commitment to promoting the profession, largely through his work as the publisher and editor of The Integrator Blog, though this is only the latest of his contributions to the profession. John also periodically contributes to The Huffington Post, and last week, he commented on a great article recently published by Patricia Herman, ND, and Michael Eisenberg, MD, which assessed the cost benefits of complementary and integrative medical therapies in a variety of conditions, populations, and settings. I had the pleasure of seeing this paper presented at the AANP's annual conference this August, and while I will admit that much of it went over my head (it being economic research, rather than medical), I was encouraged by the core finding of the study, which is that complementary and integrative therapies can offer both clinical effectiveness and cost savings in a variety of medical conditions. I've read a number of individual studies that have shown that naturopathic medicine offers considerable cost savings, including a great study done in Vermont, where one naturopathic physician saved the Vermont Automobile Dealers Association approximately $1.5 million dollars in direct and indirect healthcare costs over 12 months, but this new cost benefits study is especially exciting because it has compiled data from a number of other studies, and in doing so has established a larger pattern. Next Monday, I'll be posting some recipes, which have been missing from the blog for several months, but this week, I'd urge you to read John Weeks' article.

Omega-3s and Traumatic Brain Injury

This past weekend, I went to Hershey Park and spent the entire day going on roller coasters, or, as they were called by the medical advisory signs posted throughout the park, Aggressive Thrill Rides. Over the course of the day, I was tossed, shaken, rattled, and accelerated within an inch of my life, confirming my suspicion that I’m not a huge fan of roller coasters. By the end of they day, I felt pretty sick and had a headache.

While it wasn’t exactly like having a concussion, I spent a lot of the next day wondering whether modern roller coasters are designed to prevent brain injuries in the same way they’re now designed to prevent whiplash injuries. I don’t have any clear answers, but allow me to explain my concerns. As most of us know, whiplash injuries happen due to rapid deceleration, frequently because of some kind of impact, which causes the head to move rapidly forward and then backward. Fortunately, roller coasters decelerate a bit more gradually, so that whiplash injuries don’t happen. Additionally, the simple use of headrests means that whiplash injuries are less common.

However, the brain is also injured by rapid deceleration. Of course, many brain injuries happen because the head itself comes into collision with a solid object, such as a windshield, the ground, a tree limb, etc. but many other injuries happen because of the motion of the brain inside the bony skull. This type of brain injury happens when, for example, a car stops suddenly – the skeletal body stops quickly, but the brain, resting in a liquid environment inside the skull, doesn’t stop at the same time as the skeleton. Instead, the brain keeps moving forward after the skull has stopped moving, and collides with the skull. This is referred to as a coup injury. What happens next is that the brain ‘bounces’ off of the interior surface of the skull, and then hits the opposite side of the skull. This second impact is called a contrecoup injury. In both cases, the brain is bruised where it came into contact with the skull. So, as you can imagine, with all of this rapid deceleration and changing of direction on the roller coasters, at speeds in excess of 50-70 mph, I was concerned about how my poor old brain was doing.

One of the most concerning things about brain injury is that there are no established therapies for recovery after an injury, be they from car accidents, collisions on the football field, or IEDs in Afghanistan. To be sure, a lot can be done to medically manage acute trauma, and there are physical and occupational therapy treatments to help patients recover function, but there is little that can be done to help conserve or repair brain tissue. If you break a leg really badly, you treat the acute injury, you put a cast on it, and then you go to physical therapy to regain function – when it comes to the brain, there is no cast to use, so this crucial repair phase is lost.

However, there may be some hope for preserving brain tissue when it comes to traumatic brain injury. A number of interesting animal studies have suggested that the omega-3 fatty acid DHA, which comes from fish oil, reduces inflammation in the brain following brain injury (1, 2, 3), and at least one of them also indicates that DHA also helps preserve brain function. In addition, there is a published case study in the American Journal of Emergency Medicine of a case in which a teenager was able to progress from an injury-induced vegetative state to near-normal functioning after use of extremely high doses of DHA and EPA. This is all extremely exciting information, and prompted two authors to suggest in the journal Military Medicine that the Department ofDefense seriously investigate the prevention and treatment of traumatic braininjury using omega-3 fatty acids. This isn’t quite time to start jumping up and down giving one another high fives, but, should human trials pan out, this could be a great treatment for a very serious problem.

So what does all of this mean to a consumer? First of all, do what you can to prevent injuries in the first place. This means wearing proper protective equipment when playing contact sports like football and hockey, wearing a seatbelt when driving or riding in a car, and, possibly, limiting your use of roller coasters. An ounce or prevention is worth a pound of cure, and when the cure is experimental, that ounce is worth much more than a pound of it. Second, this is yet another reason to take fish oil for preventive health. While the effects of omega-3 fats as treatment for brain injuries are questionable, these studies have demonstrated that fish oil seems to exert a protective effect when taken in advance, and hopefully you’re already taking fish oil for cardiovascular health.

Before I sign off for the day, here are a few notes about omega-3s, separate from their use in brain or heart health. The first is that quality does matter when it comes to fish oil, and it’s worth investing in ‘the good stuff’. While mercury, dioxins and other contaminants are of some concern with fish oil (and high quality oils will have removed these substances), the greater concern is freshness – fish oil spoils easily in processing, and taking spoiled fish oil is as good as not taking any. You may pay less in buying a low price fish oil, but if the fish oil has spoiled, you’re losing money.

Secondly, it’s now becoming clearer that relatively high doses of fish oil are necessary to achieve true benefit both in the cardiovascular and neurological realms, so consume your fish oil or cod liver oil with some liberty. A number of companies are now selling concentrated EPA/DHA products that allow you to get relatively high doses of these active compounds without taking massive amounts of capsules.

Finally, we are now, at long last, seeing the emergence of vegetarian EPA/DHA formulas. Previously, these were completely nonexistent, and vegetarian consumers were left with the choice of either taking non-vegetarian fish oil, or taking flax oil, whose benefits on cardiovascular health were largely hypothetical. Now, finally, we are seeing oils containing EPA and DHA that are derived from algae. These oils offer patients the ability to gain important nutrients, while maintaining their dietary preferences.

A Non-Inflammatory Article About Vaccinations

Last week, the New York Times published an article about Washington state’s efforts to increase vaccination rates, which include a new law that would require parents to get a physician’s signature should they choose to opt out. Interestingly, the article quoted a naturopathic physician who supported vaccination and talked about some of the reasons parents avoid them, rather than opposing vaccinations, as NDs are often accused of doing. It always makes me happy to see NDs portrayed positively in the media, but on this topic in particular I was glad that an ND got a voice.

Let me put it in simple terms right here at the beginning: in a conversation dominated by loud voices at either end of the spectrum, the naturopathic profession should promote a moderate point of view, one the resonates with what the majority of parents and healthcare providers understand, and that respects the needs of both the population as a whole and individual children. Both the movement against vaccines, as well as physicians who ‘fire’ patients for refusing vaccination have major failings. Rejecting vaccines ignores the tremendous victories over infectious diseases that we’ve seen in the past century, and allows for the re-emergence of diseases that are currently well-controlled. On the other hand, firing patients who decline vaccination alienates people from the healthcare system and is self-defeating in the effort to increase vaccination rates.

As healthcare providers and as good scientists, NDs understand the important role that vaccinations have played in the history of disease. Smallpox, a disease which in the 20^th century alone killed over 300 million people worldwide, has been eradicated in the wild since 1979. Polio, a disease that affected even the future President of the United States, has been nearly eradicated, save for isolated regions in Nigeria, Afghanistan, and Pakistan. Many potentially fatal diseases, such as pertussis and diphtheria have been curbed, primarily due to vaccination. Clinical success of this magnitude is undeniably important.

Vaccines are sometimes called victims of their own success – their importance is easily forgotten because, when successful, nothing happens. To draw modern analogies, imagine that we were able to completely eliminate smoking, or Type II Diabetes, or Breast Cancer – the effect on public health would be massive. To prevent these illnesses through a public health campaign would save millions of lives and prevent suffering on an enormous scale. This is the same type of effect that vaccinations have had. To be able to continue to eradicate these infectious diseases, and prevent future epidemics, is a great opportunity for our profession.

At the same time, because of our attention to individual needs and individual cases, NDs understand that some patients have needs or desires that must be respected. A growing number of physicians are ‘firing’ patients who decline vaccinations, and while this is not without reason, I think there are serious problems behind this practice. Firing patients (or more specifically parents) who refuse vaccinations alienates these families from the healthcare system, and may result in these families seeking out providers who agree with them regarding vaccination, but who may not be fully qualified to deal with the ramifications of non-vaccination. Additionally, firing patients loses the battle for vaccination – while parents may not be willing to have their child fully vaccinated at 2 years old, they may be persuaded to do so a few years later, with the birth of a second child, for example. Vaccination is not an on-or-off switch, and catch-up schedules do exist for children who are not vaccinated on the first pass. It’s important to keep these families in the conversation, and at least under medical supervision.

I should note here that the American Academy of Pediatrics’ official position is that physicians should respect parents wishes, but continue the conversation on vaccination. The American Association of Naturopathic Physicians has a similar position. Of course, these moderate points of view don’t make headlines, as it’s the loudest, most extreme voices that make it into newspapers.

My last note today is simple: we need to understand more. One of the primary concerns raised by vaccine objectors is the proposed link to autism. I’m not going to make a comment on that proposed connection, but what I will say is that we need to understand autism better than we currently do – we can describe it quite well, and have diagnostic criteria for it, but still have little understanding of why it occurs in the first place, and are still scraping the surface of how to treat it. There are treatments and theories out there, but nothing has really come to the fore as a unifying explanation of autism. Autism can be a very scary disease for parents, and it’s not surprising that parents are frustrated with physicians’ lack of answers; a better understanding of the cause and treatment of this disease would almost certainly take some pressure off vaccination.

Additionally, we need to understand more about vaccines and adverse events. We know that they happen, we know the basics of preventing them, but we haven’t fully eliminated them. Some are minor, like pain and redness around the injection site. Some are more serious, including neurological damage, high fevers, and other issues. Vaccines have improved over time, even in the past few years, so that they are far more targeted, with less likelihood of side effects – even so, though, their near universal use necessitates that we understand why adverse events happen in isolated cases. Unfortunately, this will take some time to determine, as these events are rare enough that it takes significant amounts of time for enough cases to accumulate to make conclusions.

The system isn’t yet perfect, but efforts are being made. In the interim, consumers should work with qualified healthcare providers who are willing to have a conversation about vaccines and supply information. Likewise, providers shouldn’t alienate skeptics, but rather keep them in the conversation. A moderate course of action, based on advancing public health and respecting individuals is currently the best solution to this slightly thorny issue, and it’s no surprise that both the AAP and AANP have advocated for this approach.

Another Article on Money and Medication

A few months ago, I wrote a brief blog entry that directed you readers to this article, written by a former editor of the New England Journal of Medicine. The article, one of the most strongly worded condemnations of the pharmaceutical industry I've ever seen, goes on at length and in detail about how money has corrupted the science behind the practice of medicine. If you've not read it, I recommend it highly. However, this article was written some years ago at this point, and precious little has been done to improve the situation.

I recently came across another article on the topic, again written by a medical doctor who decried the influence that pharmaceutical companies have on research, and thus the practice of medicine. A main example he cites is the use of antidepressants in children - not only have these drugs not been proven to be effective in children, but there is strong, clear evidence that they cause harm by increasing the risk of depression-related suicide in children.

This Monday, I highly recommend you read this piece, which was published in The Guardian last Friday. While Dr. Angell's article from several years ago was excellent, it cited few examples, and this newer article cites many specific cases and a good amount of research - research that shows the biases of research conducted by pharmaceutical companies. If you don't finish the article feeling indignant, you may not have been paying attention.

Of course, the issue is not that drugs don't work, nor that as a naturopathic physician I'm 'opposed' to drugs, but rather that when the lives and health of patients is on the line, we should have access to accurate, unbiased information, be it about pharmaceutical drugs, herbs, supplements or other treatments. Articles like this one and other recent events may be moving us towards an era of unbiased information, but it's still some time off. In the mean time, working with a healthcare provider you trust and know, who stays abreast of current information and is open to learning more is your best bet. Even if research is fallible, individual docs can still sort the wheat from the chaff and guide patients to health.

Garlic and Hypertension

A busy schedule in recent weeks has kept me from diving deeply into research the way have been able to in the past, but this week I‘ve got a bit of extra time and some research to share, so am excited to dig in and talk about evidence.

Earlier this week, I posted a great graphic that presented evidence about supplements in a clean and easy to read format. Though I think the graphic was great, I thought that I might put it to the test, just to see if the assessments bore out. The subject I chose was garlic as a treatment for hypertension. Though I’d previously reviewed garlic for its use in lowering cholesterol, I didn’t run into any significant references for garlic’s use in hypertension – to be sure, it’s often mentioned as an herb for high blood pressure, but as I hadn’t seen any data, I was surprised to see it listed so highly.

The article the author of the graphic referenced was this one, a recently updated meta-analysis originally published in 1994. The researchers, working at the University of Adelaide in Australia found that, according to data from the eleven studies included in the meta-analysis, garlic preparations produced approximately an 8 point drop in both systolic and diastolic blood pressures in patients with hypertension. While that number is on the one hand statistically significant, it’s also clinically significant as well – in combination with lifestyle changes which can generate some pretty important reductions in blood pressure themselves, an extra eight points can help bring the blood pressure under control.

While this study was the one cited in the graphic, it’s not the only one that showed positive results. Another meta-analysis, which looked at many of the same studies as the first study mentioned, found that the effect of garlic on blood pressure was quite strong in patients who had elevated blood pressure in the first place, but not on those who did not. Those of you who read my blog post on hawthorn a hypertension may recall that hawthorn appeared to have a similar effect, i.e. normalizing elevated blood pressure, but not causing hypotension in those with normal blood pressure. A variety of individual studies have shown positive effects, but these two meta-analyses, which compiled data from these smaller studies, throw some pretty strong weight behind garlic’s use in hypertension.

However, not all studies have raved about the benefits of garlic. One systematic review, done by the well-respected Cochrane Database, found that, while research indicated very positive trends, and that garlic held promise for future research, current research was lacking, and that it was impossible to make firm statements regarding the efficacy of garlic. Likewise, another study, published in the Netherlands, also found that there was too little evidence to make firm statements about the effect of garlic on blood pressure, and that garlic could not yet be recommended as a treatment for hypertension. Neither of these studies were negative, pe se, but both said, ‘We have to wait and see.’

Before I go on to discuss the conclusions that I’m drawing from this evidence, I’d like to mention an issue in research that these studies bring up.

Conflicting evidence exists on just about every topic in medicine, and that it takes the human brain of a physician to interpret and apply evidence correctly. In some cases, the conflict between pieces of evidence is due to problems in one of the study’s design – mistakes in design can result in incorrect results. In others, it’s because the studies asked slightly different questions, and found differing answers about a common topic. These conflicting results are an issue not only with research into ‘alternative’ treatments, but even commonly prescribed medications. Without being flippant, I think it’s safe to say that, given all the research that exists in the world, there’s some piece of evidence against nearly everything we do, but we do these things anyway, because the job of a physician isn’t to be a slave to data, but to pay attention to the patient, and use data (positive and negative) to aid the patient in their return to health. When the evidence is overwhelming, this job becomes a little easier, but frequently it's a careful balanced approach taking into account conflicting pieces of data.

So here’s my take on the data. Sometimes, when data is conflicting, it’s because the positive studies were just outliers, and the bulk of the research is negative. Other times it’s the opposite. However, sometimes, when research conflicts, it’s because there’s something going on that we didn’t previously know. Based on these articles, it would appear to me that garlic modulates/normalizes blood pressure, but doesn’t act exactly like a hypotensive drug – this might explain why many of these studies found little or no effect, but that the most specific study (that which looked at the effect of garlic on blood pressure in hypertensives) was so strongly positive. It’s not yet known how garlic lowers blood pressure, but it may be that it does not do so directly, but rather secondarily, as a ‘side effect’ of a primary action.

A Graphic About Evidence

I think I have a new favorite graphic. Shown below is a great graphic that combines information on the popularity of supplements with the amount of evidence that exists regarding their efficacy. The blue and darker green ones at the top have more evidence, whereas those lighter green or yellow ones at the bottom have less evidence behind them. The orange-ish ones have less evidence, but look very promising, so are singled out because they may rise in the ranks in the future.

What's great about this graphic is that it addresses the perennial question of evidence, and presents the information in a clear format. If you're having a hard time reading the fine print in this image, click here to see the original version.

What makes this graphic truly excellent, however, is not that the data is presented well, or that it looks nice, but rather that it's a live graphic that is continually being updated with more information. Click here to see a really cool live version, which you'll notice that it's slightly different than the one below. What's especially cool is that the bubbles link through to the studies being cited - talk about a great interactive data presentation! You'll also be able to select for data related to various topics, like cardiovascular disease, cancer, etc.

I can't say that this is a perfect graphic, as there are some inclusions that strike me as ridiculous - the glaring one here being the assertion that omega-6 fatty acids (omega-3 fatty acids' more inflammatory counterparts) are heart healthy. Nonetheless, on the whole, this is a great piece of work.

As always, this is unfiltered data, and working with a healthcare professional is important, because even though this graphic might show that a given supplement is efficacious, it can't tell you how much to take, monitor for side effects, or track your progress over time, not to mention the fact that it can't advise you on improving your exercise regimen or diet. Have fun playing with this device, but don't forget that it takes the human brain of a trained practitioner to assess and implement this information.

Hair Loss and Vitamin D

I were able to solve the problem of male pattern baldness, I'd be wildly successful and famous. At this point, I think everyone in America has seen an ad for hair replacement surgery. They are nearly ubiquitous in American society at this point, cropping up on TV, in magazines, and on billboards by the side of the highway. This is a multibillion dollar industry worldwide, and it's one that's not likely to go away soon. My patients ask me about hair loss very regularly, and so I keep my eye out for any info that might be helpful - I recently read an article in the Wall Street Journal about hair loss that presented some info that was new to me, so I'm going to comment on it here.

The article presented info on the use of vitamin D in hair loss, a recent area of research that has started coming up in the past few years. Hair replacement surgery and the use of Rogaine or Propecia has been  the standard of care for some time now, but these treatments are not fully effective, and come with side effects or hefty price tags. Vitamin D may prove to be an important ally in reversing baldness, but the research is still very preliminary.

What has been shown is this - the vitamin D receptor has a role to play in determining whether a hair follicle is active or dormant, and that interfering with the activity of the receptor, either positively or negatively, can either stimulate or decrease hair growth. Additionally, vitamin D can promote follicle growth in the lab in conjunction with traditional treatment, suggesting that it may have an important role to play as an adjunct to treatment.

However, though this is all very intriguing, there isn't a lot of clinical information to go on yet. We don't know if people with healthy vitamin D levels have less baldness and we don't know if taking vitamin D supplements helps prevent or reverse baldness. Having read the article, I did a literature search, and found that, actually, very little research has been done into vitamin D and hair loss, and that most focuses on less common forms of baldness.

The most common form of chronic baldness is androgenic baldness, also called male pattern baldness, which is believed to be caused by an excess of DHT, a metabolite of testosterone. Propecia and some natural treatments are aimed at reducing the conversion of testosterone to DHT, thus preventing male pattern baldness. However, other causes of baldness include dietary deficiencies, hypothyroidism, chemotherapy, and severe stress - these causes are reversible, and can be resolved using treatments meant to target these specific causes. The point is that hair loss can be attributed to a wide variety of vastly disparate causes, and so a unified treatment is going to be difficult to devise. While vitamin D has shown some interesting results in the lab, its only clinical evidence relates to less common types of baldness, and I've not found any information about that all important holy grail of baldness, male pattern baldness. Future research may show that vitamin D may be effective in this condition, but at the moment we're best to rely on better understood, more common treatments.

Of course, vitamin D can be effective in a variety of conditions, and optimal vitamin D levels help to prevent a variety of conditions, and so health-conscious Americans should continue to work to achieve and maintain optimal vitamin D levels, but for now, consuming large amounts of vitamin D supplements with the hope of regrowing hair is ill-advised.

A Graphic on What Americans Eat

I'm not a big reader of Men's Health Journal, but I was recently looking for a graphic to share with you all, and came across this little beauty. According to their research, the average American ate 2000 pounds, literally a ton, in 2011.

I don't know how this compares to previous years, or to historical trends. Of course we'd all guess that Americans haven't eaten such Herculean amounts in the past, but I don't have any figures to back that up. What is interesting, though, is that our eating patterns have changed considerably - more meat, soda, cheese and grains, and interestingly, less coffee. Obviously, this chart leaves out the important question of how many fruits and vegetables Americans ate in the 1980s and 1950s, but it sheds light on how our diet has changed in the past 50 years. Some of you might recall this graphic from a few months ago, which further underlines that Americans are shifting their eating habits, and eating more. Is it any surprise, then, that Americans are eating more meat, cheese and soda?

Primary Care vs. Complementary Care

Naturopathic medicine is a work in progress. I’m not saying that it’s in need of significant improvement, or that it’s lagging in some way, but rather that it’s a profession undergoing evolution. I’ve written in the past about how the terminology of naturopathic medicine has reflected the shifting focus of the profession. The latest, and most recent shift, has been a move from strictly complementary or alternative care to primary care – NDs, who used to be doctors of last resort when all else had failed, are now emerging as the entry point into the medical system, the doctor who keeps you well and prevents illness.

That the nation is facing a shortage of primary care providers is not news. More and more medical students are electing to go into specialties rather than primary care, leading to a significant lack of primary care providers. This shortfall, which was in place before the passage of the Affordable Care Act (ACA), will probably become worse as 30 million previously uninsured Americans will enter the insurance market.

Many groups are scrambling to fill this shortfall. Physician’s Assistants (PAs) have been working to fill the void, and the expanding role of Nurse Practitioners (NPs) has been partly motivated by the need to get primary care providers in the field. There have even been efforts to design 3-year MD programs (a year shorter than traditional medical school) with a strict focus on primary care. In addition, of course, there have been efforts to woo medical students back to the practice of primary care, which can be a hard sell to newly minted students with $250,000 in student loans to pay off.

Naturopathic physicians have also been entering the fray, and practice as primary care providers in a number of states. In Washington state, NDs are licensed as PCPs, and can be designated as such on a variety of insurance plans. Vermont and Oregon have both passed recent legislation that provides for NDs to head medical homes, organizations that serve as one-stop-shops for primary care. Other states include language in licensing laws that specifically designates NDs as primary care providers.

This all makes me excited because of the potential that NDs offer the healthcare system.

While different people will have differing opinions on the ACA, we can all agree that we need to save money in order to maintain our healthcare system and serve the American people. A lot of wrangling has gone on about cutting reimbursement to doctors, trying to save money on pharmaceuticals, and a variety of other cost-cutting measures, but I don’t think nearly enough time is spend discussing the importance of preventing people from getting sick in the first place. While not all disease is preventable, a significant portion is; just a few months ago, I blogged about a study which suggested that 40% of cancer cases were due to lifestyle factors and therefore preventable.

In the  20^th century, we’ve managed to stem the tide of infectious diseases, which used to be the main emphasis of healthcare, but have seen grow up in their place a large number of chronic, lifestyle-related diseases. This is exactly the type of disease that naturopathic physicians are trained to prevent and manage. While MDs get a precious few hours of training in nutrition and lifestyle medicine (exercise, stress management, etc.), NDs get this from day one, and it’s drilled home in every class an ND takes. At the same time, unlike a nutritionist, an ND knows how to diagnose and treat disease, integrating the diagnosis with changes to the patient’s diet and lifestyle.

A very interesting study came out this summer on the topic of primary care and naturopathic medicine. The Puget Sound Health Alliance is an organization that tracks healthcare results in western Washington state in order to provide information to consumers. Every year, the PSHA publishes a Community Checkup, which tracks the performance of healthcare institutions (both clinics and hospitals) in meeting healthcare goals in areas such as prevention, management of certain conditions, and patient experience. The survey covers everything from small clinics to high volume institutions, and includes high profile institutions such as Virginia Mason, the University of Washington, and Swedish Medical Group. While the Bastyr Center for Natural Health (the teaching clinic of Bastyr University) is a smaller clinic and, like many smaller clinics, didn’t service enough patients to be ranked for outcomes measures, it hit the top of the rankings for patient satisfaction, coming in first place for timeliness of care and quality of doctor-patient communication, and in the top three for customer service and overall provider rating. This is an important verification of quality from a well-known third party that naturopathic primary care offers great promise in modern healthcare.

This study highlights two essential features of primary care that NDs excel at. The first is that, in primary care, the role of the physician is partly to ‘do’ science, but primarily to communicate science, connecting lab values and physical exam findings with the personal experience of the patient. That providers at the Bastyr Center ranked so highly in the study indicates that the school is providing excellent training in this regard. The second is that, in primary care, it is crucially important that the patient feel cared for. It’s right there in the name primary care, and yet this is often lost in the modern medical experience. The Bastyr Center’s excellent performance in this study again indicates that NDs are excellent healthcare providers.

Other research will be necessary to bring naturopathic medicine fully to the forefront of primary care, but it’s clear to me that as the nation moves from a disease-care model to a wellness-promoting model, naturopathic physicians will have a vital role to play in keeping our nation healthy and happy, while saving us money.

A Graphic About Driving and Obesity

Why are so many Americans overweight? If I had the answer, I'd be rich and famous, and would be writing this blog - actually, scratch that, dictating this blog - from the comfort of an armchair overlooking the Mediterranean. People have suggested a lot of answers to this question, from too much saturated fat, to too many carbs, to hidden food allergies, to undiagnosed thyroid conditions. These are all potential causes in unique cases, but when we are looking at the US population as a whole, none of these really hold up as the primary cause.

This fantastic graphic looks at driving as a cause of obesity. The graphic (which can be enlarged) charts state-by-state use of public transportation, bicycles, and cars, as well as walking rates, and then correlates them to obesity rates. The chart doesn't show direct one-to-one causation, but a general trend can be seen - the more we drive, the less we walk, bike and ride public transit, and the more we weigh.

Now obviously, this isn't an formal study, and the graphic doesn't give important information like caloric intake by state, but does give us a worthwhile message - one reason that Americans are overweight isn't because they eat McDonald's, it isn't because they drink soda instead of water, it isn't even because they haven't joined a gym to take spinning classes - it's because they don't incorporate low-intensity regular exercise into their activities of daily living. Walking to work, biking to work, even walking to and from the bus we take to work apparently help maintain normal weight, and in no small part.

Shedding weight can be a more difficult process, and one which may necessitate the assistance of a health professional, but this graphic underlines the importance of the basics - just because you haven't signed up for a rigorous weight loss program with a personal trainer doesn't mean you're doing nothing.

Adolescent Cannabis Use and IQ

One thing I’m asked about quite regularly is my view and the naturopathic view on medicinal cannabis usage. Everyone seems to want to ask me about this, whether it be friends, colleagues, or patients – it seems that everyone wants to know whether I think it’s a good idea, what my experience with it has been, and whether or not I prescribe it.

I’m not sure whether it’s because I use a variety of other (legal) herbs in my practice, or because I’m an ‘alternative’ provider, but this is a question that some people can’t wait to pose to me.

The irony of all of this is that, in four years of naturopathic medical school, I don’t think that the use of medical cannabis was discussed once. If I recall, we discussed cannabis usage in our Addictions and Disorders class, we discussed it briefly in our Jurisprudence class, and I believe that we discussed it in Normal Maternity class one time as having a potentially damaging effect on the developing fetus. And that was pretty much it – we didn’t discuss it in Botanical Medicine class, we didn’t discuss it’s use for cancer patients in Oncology, we didn’t discuss it in the hours we spent discussing chronic pain in Orthopedics, Naturopathic Manipulation, and Sports Medicine classes. To be completely honest, if I were to go out and prescribe medical cannabis, I would be practicing pretty much in the dark, drawing on basically no instruction, very little research, and no clinical experience.

Few would argue that cannabis doesn’t have an effect on the human body, but important questions regarding clinical use have yet to be answered. These questions include: What is the proper dose of cannabis? What is the proper dosing schedule? How does one evaluate response to therapy? I feel confident in recommending 1000 mg of curcuminoids twice daily and re-evaluating at 4-6 weeks, but when I’m not aware of similar regimens for cannabis prescription. Prescribing cannabis in a manner that amounts to supervised self-medication is haphazard and prone to inconsistent results.

Not, of course, that I would prescribe medical cannabis. Though Washington, D.C., where I practice, does allow for the usage of medical cannabis, cannabis remains a scheduled drug that is without a doubt outside the prescriptive scope of naturopathic physicians. All of this continues to add to the irony.

What this all boils down to is the fact that I’m really not the guy to ask about medical cannabis. I haven’t been trained to use it, and even if I were, I wouldn’t be able to prescribe it. That said, I do take some interest in the topic, and so wanted to share an article that came across my desk recently.

A study published in the Proceedings of the National Academy of Sciences has found that chronic use of cannabis does in fact result in loss of IQ points. The study tracked approximately 1000 people from the area in and around Dunedin, New Zealand. The study has achieved a remarkable 96% retention rate since its inception in 1972, thus adding credibility to its results – not only were a large number of people included in this study, but they have been taking part in the study for approximately four decades. This is some of the first solid evidence that cannabis use does in fact impact cognition – we’ve suspected as much for several decades, but this study helps confirm it.

What was also extremely interesting is that the study found that those who started using cannabis before their 18^th birthday were more susceptible to the damaging effects – those who started using cannabis in their teens suffered an average loss of 8 IQ points compared to their non-partaking counterparts. 8 IQ points may not seem like a lot for a test where people regularly score above 100, but can actually make a significant difference in percentile rankings – 8 points in either direction of 100 (the average score) can place you in either the 70^th or 29^th percentile.

So what’s the message of this study? It’s pretty plain: cannabis is not for kids. We live in a time when cannabis laws are becoming more relaxed, and are likely to continue to become more relaxed. Without making comments on that trend, I will say that this study indicates that, no matter the direction of legislation, future laws should maintain the same type of age restrictions that current laws for tobacco and alcohol do. The law restrictions for alcohol and tobacco were done a bit arbitrarily, but given that we now have some data to go on for in this case, I think we owe it to ourselves and our children to act on it.

Two (Similar) Graphics About Quitting Smoking

Last week, while on vacation, I posted about a recent court ruling by the Australian government, which would require tobacco to be sold in generic packages with graphic pictures on the box, a ruling which would effectively cripple the tobacco industry's ability to market their products. To say that I am impressed with this move is an understatement.

I was happy to find out, then, that the Australian government continues to impress in its efforts to fight smoking. I recently found these two images, which are nearly identical, that summarize the benefits of smoking cessation, even going to far as to give a timeline of benefits. Quitting smoking is among the hardest things that a person can do, in part because the goal often seems so far away, and it comes with little reinforcement along the way. Fighting each craving is often its own individual battle, and with no rewards along the way, it can become a seemingly endless effort. Of course we all know that quitting smoking reduces one's likelihood of developing lung cancer, or having a stroke or heart attack, but these goals are way off in the future. I love this chart, because it gives goal posts along the way, starting at 8 hours, and proceeding through the days, weeks, and months that follow, each with an additional health benefit. 

An Article About Smoking

It's Thursday, and even though I'm no longer at the AANP conference in Seattle, I'm still on vacation. I hope you're all getting some time to enjoy the summer weather with your friends and family.

That said, I'm sending a quick missive to you readers that I feel is of great importance. Last week, Australia took a great step forward in the battle against lung cancer, emphysema, stroke, hypertension and heart disease, when the nation's highest court upheld the constitutionality of a law that would cripple the tobacco industry. The law will force tobacco companies to completely de-brand cigarette packaging, requiring that cigarettes be sold in generic, olive-green packages listing only the brand and product name, accompanied by graphic pictures of the disease associated with smoking. I haven't seen this receive much press here in the US, so I thought I'd share it with you all.

Given that our country that considers itself a world leader, I think it's shameful that many other countries have taken the lead in targeting big tobacco companies. Australia, and even our (sometimes mocked) neighbors Canada have taken much stronger stances against these disease-mongers, and it's time we followed suit. Having shown our ability to lead the world in the political and financial arenas, it's time we similarly got moving in the health arena - we've made some steps forward recently, but in most, we're still playing catch up.

A Graphic On Cooking Oil

Today’s blog entry focuses on fat, and I’ve found this interesting graphic to share with you folks to serve as a talking point. I don’t totally agree with the following recommendations, but I think it’s helpful to learn from them. The broad brush strokes of these images are correct, including using saturated fats for high heat uses, and reserving unsaturated oils for dressings, salads, and other circumstances in which they would not be exposed to heat. The reason for this is that unsaturated fatty acids are damaged by heat, becoming oxidized in the process – oxidized compounds breed more oxidized compounds, and unless you’re eating an antioxidant-rich diet, this fire can be hard to put out.

Similarly, the graphic recommends avoiding highly-processed, refined oils, including margarine, hydrogenated oils, canola oil, and others. Many of these oils are heavily oxidized in the refining process, with the concommitent problems that that causes. Others contain trans fats, which, thankfully, many of us know to avoid.

However, this graphic is not altogether perfect, so let me offer my own opinions on a few topics. One thing I’d like to note is that the author doesn’t emphasize enough that saturated fats should be avoided. Coconut, butter and ghee may be preferable to margarine or hydrogenated oils, and are less-easily damaged under high heat conditions, but modern American diets still overwhelmingly favor saturated fat, and nearly all of us could do with some reduction in the amount of saturated fat we take in.

Secondly, there’s a small note saying that PUFAs (polyunsaturated fatty acids) should be avoided in the diet, which I don’t agree with. The author is right in that ALA, the main omega-3 fat in flaxseed oil, may have some negative effects (and I do want to emphasize the word may), but this fact is far overshadowed by the massive benefit offered by the polyunsaturated fatty acids EPA and DHA, which are found in fish oil, and are remarkably beneficial to health. You wouldn’t want to put fish oil on your salad, but at the same time, I think it’s important to underline the health-promoting qualities of PUFAs.

I hope you enjoy this chart, and I’ve come back from the AANP conference buzzing with ideas for the blog! Stay tuned!

An Infographic About Beer

I don't drink much beer anymore, but that doesn't mean I don't still have a lot of affection for it. Beer, in its pre-industrial, natural form, is high in B vitamins, high in minerals, and was an important source of calories for those who spent their days toiling in fields. Of course, things have changed significantly since then, and modern, mass-produced beers have little nutritional value, not to mention the fact that beer can pack the weight on for us sedentary Americans. Craft beer has returned flavor to beer, but these high-alcohol beers are a far cry from the 'liquid bread' beers of old.

I came across this lovely infographic on beer recently and felt I should share it. Some of the health statements made about beer are embellished to say the least, but hey, it's August, and most of us are on vacation anyway. I myself am off to the AANP's annual convention in Seattle, Washington, and while I won't be posting this coming Thursday, I'll be bringing some great info to you folks next week!

Source: FrugalDad.com

How Common Is Celiac Disease?

Following a gluten-free diet is suddenly mainstream – there’s even a Prius ad that mentions ‘gluten-free alternatives’. Unfortunately, determining how common celiac disease – a severe immune intolerance to wheat gluten – is has proven a difficult task.

Part of the problem is that celiac disease has proven notoriously hard to diagnose in a simple, affordable manner. A disease like hypertension is easy enough to diagnose, and anyone with a blood pressure cuff can do it, but celiac is a complex interplay of symptoms, blood tests and tissue damage. We’ve all learned that an intestinal tissue biopsy is the gold standard for diagnosing celiac disease, but obtaining a biopsy is invasive and expensive, to say the least. There are a variety of blood tests that can be run, but combining them to achieve perfect sensitivity and specificity hasn’t been fully agreed upon, and genetic testing, while theoretically perfect, can also be prohibitively expensive. The combination of imperfect testing and high costs means that very frequently, celiac and gluten-sensitive enteropathy (a fancy word that includes a spectrum of gluten-sensitive intestinal syndromes) are diagnosed clinically, based on symptoms and clinical picture.

While lab testing still leaves a little bit to be desired, one thing that is clear is that celiac disease itself is far more common than we thought it was even a few years ago.

A recently published article in the American Journal of Gastroenterology found that celiac disease (as measured by a combination of the more established blood tests) had a prevalence of 0.71% among Americans a whole, but was higher among non-Hispanic white Americans, at 1.01%. This is in stark contrast to previous data on celiac disease, which in the distant past put its prevalence at around 0.02% of the population, but also more recent data, which put prevalence at around 0.33-0.70% of the population.

Sometimes, when diseases become ‘more common’, it’s because testing methods improve and awareness increases – the disease itself doesn’t become more common, but our ability to detect it and patients' likelihood of asking their doctor about it means that the amount of cases increases. This, however, does not appear to be the case with celiac disease – yes, our methods of detection are improving, and awareness of the disease is also increasing, but the disease itself seems to be increasing in prevalence. A population study that analyzed blood samples drawn from adults between 1948 and 1954, and compared them to blood samples of matched subjects drawn in the mid-2000s found that contemporary adults were 4.5 times more likely to have celiac disease than their counterparts 50 years ago. Why the disease is apparently more common is unclear, but what is clear is that the disease is rapidly on the rise.

What is also clear, especially based on this last study, is that we need to continue to improve diagnostic methods around celiac disease, so that we can screen for the disease, and institute treatment for patients. Among the findings of this study was an indication that all-cause mortality for persons with undiagnosed (and therefore untreated) celiac disease was 4 times higher than people without celiac disease – even though the percent of the population with celiac disease is much smaller than the percent of the population with, for example, high blood pressure or high cholesterol, this greatly increased risk of mortality is enough to make us pay attention to this population. There was no further discussion of the increased mortality, but because celiac disease results in chronic immune activation, inflammation, and poor nutrient assimilation, there are any number of potential causes for increased mortality.

Of course, this doesn’t really address the growing population of people who follow gluten-free diets, but who haven’t been formally diagnosed with celiac disease – the study mentioned previously, in addition to finding that celiac disease was more common than expected, also found that more people follow gluten-free diets than have been formally diagnosed with celiac disease. While we are improving our ability to diagnose celiac disease itself, there will probably remain a set of people who have some degree of gluten sensitivity – this is a grey area, and one which lab testing is unlikely to clarify any time soon. These folks are the ones whose IBS or eczema improve with a gluten-free diet, but who don’t test positive for celiac disease. It’s still advisable to be under the care of a health care provider if you fall into this category, as with any long-term treatment – a naturopathic physician can help assess whether or not it would help to follow such a diet, help determine your progress, and above all help you implement it. While resources do exist for celiac patients, it’s an overwhelming world of information, and almost everyone needs some help in sorting it out – a naturopathic physician can help guide you through the process, pointing out pitfalls, and helping you overcome obstacles.

While celiac disease is indeed on the rise, it is in some ways surprising that gluten-free diets have become popular, because of how restrictive they can be. Unlike vegetarianism, it’s not a diet that I would advise anyone to undertake unless they were working with a healthcare professional, for the reasons listed above. Even so, a gluten-free diet can be extremely helpful for a variety of immune-related conditions – sometimes celiac disease itself is at fault, but in other cases, it’s a gluten-sensitive spectrum syndrome. As always, I urge you to work with a healthcare professional, as they can best determine the cause and solution to your health issues, and provide needed guidance and support in finding resolution.

Your New Favorite Fish Sauce

I'm a late convert to eating fish. I grew up in a household that embraced seafood of all types, even anchovy pizza, but I was never able to get a taste for fish myself. However, as a naturopathic physician intent on eating a healthy diet, I've made a strong effort to start eating fish. Part of this effort has meant learning about the omega-3 content of fish, as well as mercury content of fish. However, it's also lead to a lot of experimentation with fish recipes, a process that I'd like to continue to bring to you blog readers.

Here's the latest, greatest fish recipe, featuring your favorite sauce you've never heard of: Chermoula.

Chermoula is a spicy, garlicky sauce from Morocco that is traditionally served on fish of all sorts - grilled, baked, fried, etc. It is a strong flavor to be sure, and it can overpower just about all other flavors, so use it wisely. I've become a great fan of it, but it's not well known here in the US, which is a shame.

Now without further ado, here it is:

2/3 cup of chopped cilantro
4 cloves garlic
1 tsp cumin
1 tsp paprika
1/4 - 1/2 tsp ground chili pepper
6 tbsp olive oil
Juice of 1 lemon or 3 tbsp wine vinegar

Combine them all in a food processor.

The sauce can be used as a marinade for grilled fish, or added afterwards. The easiest way to use the sauce for us grill-less apartment-dwellers is to pan-cook whole fish fillets in sauce - marinate the fish for 30 minutes, and then cook the filets on medium heat for 3-4 minutes a side.

Note: This recipe has been slightly adapted from Claudia Roden's excellent cook book, The New Book of Middle Eastern Food.

What’s The Deal With Fasting?

I get regular questions about fasting, from people trying to lose weight, cleanse their bodies, or just learn more about ‘alternative’ practices. It’s sometimes a tough question, as fasting is a practice associated with both life-changing healing experiences as well as horror stories, and so there are some strong opinions out there. Additionally, fasting has a long association with religious practices – monks, shamans and lay people the world over have fasted for spiritual reasons since recorded history began. Finally, it’s Ramadan, the Muslim month of fasting, so this week, I’ve opted to give my thoughts on fasting.

Let me start by saying that there is not a lot of research on fasting in humans – the little I have been able to turn up focuses on the performance of athletes observing Ramadan, and a few lab studies on how fasting affects gene expression. There is evidence that caloric restriction does increase lifespan among a wide variety of animals, but there are questions as to whether this would apply to humans as well. The most interesting research I came across was a group of studies that indicate that fasting induces production of a group of proteins called sirtuins, which have been characterized as ‘anti-aging’ proteins, and have the effect of increasing alertness and energy efficiency. From an evolutionary perspective, it appears that these proteins were induced during periods of famine, increasing our ancestors’ likelihood of finding food and surviving to pass their genes on. They have recently become major targets for commercial ‘anti-aging’ products.

So in the absence of a large body of research, here are some basic ideas on fasting, based on clinical experience and sound judgment.

First of all, let me say that I am not in favor of drastic fasting, like multi-day water fasts, multi-day juice fasts, or the perennially popular Master Cleanse. I don’t see benefit in depriving oneself of all calories for substantial periods of time, and I especially don’t see benefit in consuming sugary drinks at the expense of nutrients. It’s my belief that juices and the Master Cleanse, because they lack the mollifying effect of fiber and protein, subject your body to the stress of a blood sugar roller coaster, without much benefit. One of the benefits of fasting is giving the body a bit of a ‘metabolic break’, and drinking juice causes unhealthy spikes and valleys in blood sugar levels.

That said, I do believe that fasting can be healthy. Here are some essential components of healthy fasting: avoidance of unhealthy foods, mild caloric restriction to induce sirtuin proteins, reduced activity levels so as not to stress the body, short duration to prevent negative outcomes, and easily digestible foods consumed to break the fast.

Before I cite specific fasting practices, let me say that I think our bodies are more complex than we understand, and that practices that have a long cultural history are worthy of our attention. Our scientific minds have limited understanding, and can sometimes lead us astray – low-carb dieting is a good example – and I believe that long-standing cultural practices have survived because they work. This is why I recommend the Mediterranean diet over low fat diets.

I find two main healthy examples of intermittent fasting, or periods of lean eating, in our cultural history. The traditions of both Lent and Ramadan are associated with forms of fasting, which I believe may have more beneficial health effects than our modern aggressive forms.

Fasting during Lent has taken many forms in the past, including daytime fasting with evening breakfasts and abstinence from animal products. Certainly, the abstinence from animal products for substantial periods of time has beneficial health effects, as it provides a respite from significant sources of saturated fat and cholesterol in the diet. In our modern time, Lent has been associated with abstinence from meat on Fridays, a theme that I believe can be converted into a plan for weekly fasting – caloric restriction once a week for a set period of time satisfies the criteria I mentioned previously for a healthy fast, and I think that we may do well to embrace this form of fasting.

Daytime fasting, followed by breaking of fasts with balanced, easily digestible meals is also worthy of our attention. I’d posit that this method of fasting is effective at inducing sirtuin proteins while also providing adequate nutrition. While this method of fasting is practiced daily for long periods of time in Ramadan, and was practiced for long periods of time in older Lenten traditions, I don’t think that it needs to be practiced for long periods to be effective. Fasting once a week on occasion may be similarly effective. Most important, I think is that the meal that breaks the fast be easily digestible and provide a balance of protein, fat, and carbohydrates, along with a range of vitamins and minerals.

Several years ago, I learned of the Moroccan practice of eating harira to break the Ramadan fast, and was really inspired. Harira is a soup consisting of lentils, chickpeas, tomatoes, onions, rice, olive oil, a small amount of meat or broth, and a rich array of herbs and spices. This meal provides a good balance of protein, carbohydrates and unsaturated fat, and is rendered extremely easily digestible by a combination of long-cooking and the use of spices that aid digestion and assimilation, such as ginger, pepper and coriander. When it comes to easily digestible foods after a period of fasting, I think harira may have it nailed.

And finally, one important oversight that I see people make consistently is that they don’t give themselves a break while fasting, and just keep at their normal activities. Sometimes this is difficult to avoid, but I think it’s important to give our bodies a break while we are depriving them of calories – maintaining a high level of activities on a low amount of calories stresses the body physiologically, which I think is less than healthy.

My final message today is a restatement of the important components of a fast: avoid unhealthy food, mildly restrict calories, take it easy, keep it short, and eat gently to break the fast. Above all, keep it sane – crashing your system is the opposite of what a fast should achieve.

A Graphic on the Cost of Fast Food

I've blogged extensively in the past about the health-destroying effects of fast food, but this week, I'm posting a graphic on the wallet-destroying effects of fast food. One of the main arguments made about fast food is that it's simply less expensive, and that's why it's causing such health problems amongst people of lower socioeconomic status. As this graphic, created by the New York Times, illustrates, that's simply not the case.

The accompanying article goes into a detailed analysis of why people continue to purchase more expensive food, even when they are strapped for cash. Access is a big issue, as is time - many folks simply do not have the time to cook for themselves, nor do they have the know-how to make meals they want to eat. There's a lot of inertia holding these behaviors in place, but as I've said before, we're a people who have solved some pretty astronomical problems - it's time we dealt with this one.

A Physician’s Take on the Shooting in Aurora, Colorado

Let me begin by saying that the news of this event was truly shocking to me. In those hazy early hours of the news reports, I wasn’t clear as to where the shooting had taken place, and my thoughts automatically went to my friends in Colorado, as well as my many friends who have family in Colorado. Fortunately, no one I know was injured or killed in the shooting, but even so, the event weighs heavily on me. I am probably only one of many who are most dismayed by the fact that this shooting, though undoubtedly horrific, is not unfamiliar to us Americans – the recent shootings at Café Racer in Seattle, Arizona representative Gabby Giffords’ shooting, and many, many similar events seem increasingly common. These events may not actually be becoming more frequent, but they bring into sharp focus a general problem with gun violence in America. As horrible as it is to hear of even one death, let alone fourteen, it should be pointed out that, if July 19^th was a day like any other in America, the fourteen killed in Aurora were matched by another 70 Americans who were shot to death elsewhere.

I make an effort to avoid political topics in this blog, so I don’t want to address this as a political topic. I’m not going to be discussing the constitutionality of gun ownership, I’m not going to be discussing the NRA, and I’m not going to be discussing responsible ownership. I have a number of friends and colleagues whom I respect enormously who are gun owners, and I don’t have any interest in causing offense. I want to discuss this as a public health issue.

Let’s first do some basic math. Several sources (1, 2) I’ve read have stated that 84 Americans are shot to death each day, and that about twice that number are injured by gunfire. A quick expansion would suggest that 30,660 Americans are killed by guns per year, and 61,320 are injured. Because I’m using rough figures, I’ll round them down to 30,000 and 60,000.

To put these numbers in perspective, here are 2009's death rates for some other leading causes of death (2009 is the most recent year published by the CDC). Heart disease continues to top the list, claiming nearly 600,000 Americans in 2009, the most recent year I was able to find. Malignant neoplasms (cancer) come in next at approximately 568,000. The numbers fall sharply after this, with chronic lower respiratory diseases coming in third place at 137,000. The numbers keep going down, through cerebrovascular disease, Alzheimers, diabetes, kidney disease and others.

Included on the list are accidents/unintentional injuries, intentional self-harm/suicide, and homicide – gunfire is not listed separately by the CDC, but we might assume that guns cause a portion of the deaths in these categories. If gun-related deaths were counted separately, and the figures listed above are accurate, gunfire would have been the 13^th most common cause of death in 2009, placing right between chronic liver disease/cirrhosis and essential hypertension/hypertensive renal disease.

So how do we interpret these facts? Let’s look at how physicians have responded to the other major causes of death.

Clearly heart disease and cancer are the two biggest killers in America, by a significant margin. In an effort to stem the tide, the American Heart Association and the American Cancer Society have launched massive awareness campaigns, and physicians are actively engaged in efforts to prevent these diseases. We encourage healthy eating and exercise, we encourage patients to quit smoking, we order imaging studies, we order labs, and we use medications to reduce the likelihood that our patients will die from these causes. In the political arena, we’ve banned smoking in many public places, a step that is aimed at these two causes of death, as well as the third cause of death, chronic lung disease. In short, we're hard at work combatting these diseases.

Even with some of the less common causes of death, we have taken measures to prevent them. At an annual physical, a doctor screens not only for heart disease, hypertension, cancer, and lung disease, but also kidney disease, liver disease, depression, and a whole host of other causes of death. When I was still in training, our clinic’s intake sheet even had questions about seatbelt and helmet use. Many of these are so routine that they involve little more than checking a box. As patients, many of us have our liver and kidney function checked without even knowing it or with much discussion. Why then, as doctors, are we not asking our patients about gun use or safety? As a cause of death, it’s at least as important as these two other diseases, and yet we as doctors are doing very little, either in our offices or politically to reduce deaths due to gunfire.

Some of the other causes of death are more complicated. Heart disease and cancer are a complex mix of environmental and genetic factors, and while they are largely preventable, it’s unlikely that we will ever get a full grip on these diseases. Deaths due to gunfire, however, are far more preventable – there will be occasional accidents, but I think we can all agree that deaths due to gunfire are nearly entirely preventable. We as physicians work hard to prevent these other causes, and it’s high time that we made an effort to prevent gun deaths as well. As I stated at the beginning of the article, I’m not going to make this political, but as physicians who have taken oaths to do no harm and to alleviate suffering, I believe we have an obligation to do what we can to combat death and injury due to gunfire.

(For those interested, here's a petition to Pres. Obama and Mr. Romney on behalf of the Brady Campaign.)