Even Kids Will Love This Cauliflower Recipe

Last Monday's blog entry featured a recipe for salmon, a fantastically healthy food, but one that can be hard to get kids to eat. This week's recipe is for cauliflower - the very same cauliflower recipe pictured in last week's blog, in fact!

Mark Twain once said 'Cauliflower is nothing but cabbage with a college education' - people often assume he's mocking the vegetable, but in reality, he's extolling its improvements over the simple cabbage. Even so, it's no secret that kids have a tough time with cauliflower. When overcooked, it can take on a sulphurous smell and soggy texture that makes children the world over run. However, when cooked properly, it can be slightly sweet, with a pleasant firmness. Additionally, cauliflower, like all foods of the Brassica species, imparts large amounts of fiber and cancer-fighting antioxidants. Building kids' love for cauliflower early establishes great habits for the rest of their lives.

This recipe is adapted from a favorite of mine, Claudia Roden's The New Book of Middle Eastern Food.

1 head of cauliflower
1/2 cup water
1/4 cup white wine vinegar (red wine vinegar is also OK)
2/3 cup of tahini, approx.
1 clove garlic, crushed
1/2 tsp salt

Cut the cauliflower florets off from the head. Steam until stems can be easily pierced with a fork, but are not overly soft. Remove from heat, allow to cool slightly, and then chop into smaller pieces.

Meanwhile, combine all ingredients except tahini in a blender or food processor. Add the tahini in parts, until you reach a consistency you like. If you add the full amount of tahini, it will come out with a fairly thick consistency, similar to hummus, so smaller amounts will produce a more dressing-like consistency.

Toss the dressing and cauliflower while the cauliflower is still warm, and serve. The result is a tangy, creamy mix of cauliflower and sauce that is not entirely unlike macaroni and cheese (really). This should please even the most finicky of little eaters.

In Defense of Homeopathy

Of all forms of complementary and alternative medicine, homeopathy is one of the most, if not the most controversial. Indeed, to bring up homeopathy with many medical doctors is to invite an argument. However, an English translation of an interesting Swiss government report on homeopathy was just released, and I’m feeling punchy. This report, which has been about 10 years in the making, found that homeopathy is indeed both a clinically effective and cost-effective treatment for many conditions, which subsequently paved the way for the Swiss government to include homeopathic treatment in its publicly-funded national healthcare system. Homeopathy, dismissed here in the United States, and currently under attack in the United Kingdom, may have just scored a considerable victory.

While I could probably talk about homeopathy at length, today I’m going to address a specific misconception about homeopathic practice. Many of the most vocal opponents of homeopathy suggest that its use discourages people from seeking ‘real’ medical care, and that the public is at risk of serious disease and debility as a result. I’ve heard it suggested that homeopaths allow massive infections to ravage their patients completely unchecked, and that they also discourage patients from seeking care in cases of advanced cancers.

Let me be the first to say that, as a naturopathic physician who practices homeopathy regularly, I believe that these practices would be completely irresponsible, and are anathema to my beliefs as a healthcare practitioner. Far from an ‘either/or’ dichotomy in the practice of medicine, naturopathic physicians embrace a ‘both/and’ philosophy. The naturopathic approach is pragmatic, outcomes-oriented, and above all, patient-centered. The mode of practice falsely ascribed to homeopathy is not the practice of medicine, it’s the practice of dogmatism, and as I love to point out, ‘There’s no room for dogma in medicine’.

In addition to my clinical practice, I’m actively involved in the effort to pass a law that would license and regulate naturopathic physicians in Maryland. One of the main arguments that we’ve been making in our efforts is that licensing naturopathic physicians helps to increase access to complementary healthcare practitioners that are trained in appropriate usage of natural treatments. Properly trained naturopathic physicians understand both the potential and limits of homeopathic medicine, and use homeopathic medicines judiciously. If anything, the argument that some people practicing homeopathy are irresponsible in their treatment is an argument in favor of establishing licensing boards for naturopathic physicians, so that consumers are better able to access care from well-trained practitioners.

Without going into an extensive discussion of homeopathy, here are some of my thoughts on when homeopathy can be effective and when it can’t.

Here are some situations in which homeopathy can be very effective:

- Symptomatic chronic disease – When a patient has a clear diagnosis and they are suffering greatly as a result of their symptoms, homeopathy can be very effective in alleviating symptoms. It’s effect on labs and imaging studies depends significantly from patient to patient, but the symptoms can usually be alleviated.

- Functional problems – By this I primarily mean situations in which the patient is symptomatic, but pathological changes that would lead to a clear diagnosis haven’t occurred yet. Laboratory findings may be absent or vague, but symptoms are clear and troubling to the patient. Homeopathy can help alleviate these symptoms.

- Acute illness – When the body is acutely ill, it’s actively trying to fight a virus or bacteria, but in the process, creates symptoms, like fever, sore throat, cough, etc. Homeopathy allows the body to fight more effectively, and above all, alleviates the suffering of the patient. As always, this is subject to appropriate usage, and a well-trained naturopathic physician knows when a patient just needs relief of symptoms to get over an illness, and when the illness is more threatening.

There are two main categories of disease that homeopathy is generally not effective against, but I’ll include three just to make the point:

- Asymptomatic chronic disease – Examples include high cholesterol and atherosclerosis, diseases that are clearly present, but are often completely silent until it’s too late. I’m going to say here that I don’t think homeopathy is effective against these types of conditions – it may provide relief from the angina that results from atherosclerosis, but it won’t stop the narrowing of the arteries themselves. Fortunately, however, naturopathic physicians are well-trained in a whole host of effective natural treatments that can help manage things like high blood pressure, high cholesterol, diabetes, etc.

- Cancer – I could make the argument that cancer fits into the above category, but I’m listing it separately for emphasis. As with atherosclerosis, homeopathy can’t cure the cancer itself. Homeopathy may alleviate some of the symptoms associated with cancer, but cannot cure the cancer itself. Cancer is a prime example of a condition that, no matter what complementary treatments are being pursued, should be primarily managed by conventional medicine.

- Anatomic or chromosomal anomalies – These are very rare, but they encapsulate the point I’ve been making. Homeopathy can improve function around the defect, but can’t fix the anatomic or chromosomal problem itself – if you look at the previous examples, you’ll see that the thread running through it all is that homeopathy can help the body function with the pathologic anatomy, but can’t fix the anatomy itself.

If you’re a consumer and you made it this far, I congratulate you, as this was somewhat more directed towards practitioners, and want to give you consumers a take-home message. Let’s sum it up like this: homeopathy is remarkably effective for a lot of conditions, but not everything, and I gave some examples of some diseases where homeopathy can help and some diseases it can’t. As with all acute and chronic diseases, it’s important to seek out a licensed naturopathic physician, who can determine if homeopathy is an appropriate treatment in your case.

I’m looking forward to reading the Swiss government report, and when I’m able to get my hands on a copy, I’ll write a more complete reaction. Stay tuned.

A Salmon Recipe

Of course we all know that salmon is healthy. It's low in saturated fat, high in omega-3 fats, and high in protein. Despite knowing the health benefits, getting it into our diets can sometimes be a challenge, especially with kids - even those of us who would roast a chicken with little fear can be intimidated when it comes to cooking fish. That's why, when I first made this salmon recipe a few weeks ago, I knew I had to share it. It's relatively simple and is a guaranteed crowd-pleaser.

Honeyed Onion-Encrusted Salmon

1 large onion, chopped in half and sliced thinly
4 tbsp olive oil
2 tbsp honey
1 tbsp lemon juice
1/2 tsp salt
1/4 tsp pepper

1 full-sized salmon fillet

Heat the olive oil in a medium-sized sauce pan over low-medium heat. Add the onion and cook, covered, until the onions are very soft. Remove lid and allow to brown slightly. Add honey, lemon juice, salt, and pepper and cook another 5 minutes. Allow to cool.

Meanwhile, preheat the oven to 425°.

Place salmon fillet in a low baking dish and cover with the onion sauce. Place on middle rack in oven and cook for 25-30 minutes. Finish the baking by putting the salmon under the broiler for 5 minutes to achieve a golden-brown crust on the onion topping.

(Pictured here with steamed cauliflower tossed in a garlic-tahini dressing)

Black History Month and Naturopathic Medicine

There’s a prevalent myth that complementary and alternative medicine is strictly the domain of upper middle class white people. In reality, nothing could be further from the truth. In my experience, different groups of people use complementary and alternative medicine for different reasons. Many immigrants from Asia and Latin America, for example, seek out alternative medicine that has a historical basis in their culture, a phenomenon I sometimes call the ‘Grandmother Effect’, because I often hear patients say that they sought out such-and-such treatment because their grandmother told them to.

But what about African Americans? Do Black folks seek out alternative medicine? As a white guy, I clearly can’t claim expertise or claim to speak for Black people, but I can speak from my experience (as I did in an article last year), and I think it’s an important topic to discuss, largely because it’s not a major topic of conversation in school or on the internet – I tried to do some research before writing today’s entry, but a lot of the info out there points back towards the same small number of sources.

I was spurred on to explore this topic after a conversation with a high school friend whose mother is a doula. An African American born in the States but who spent much of his childhood in Senegal, he spoke quite easily and confidently about herbal medicine, vegetarianism, and homebirthing. I find that I usually have to explain this sort of stuff to the middle class white people who are supposed to love it, and even then I have to butt up against resistance and skepticism about whether or not complementary healing methods actually work.

All of this brings me to my first point, which is that interest in natural healing is alive and well in the African American community. A few weeks ago, I happened to take a cab on my way to a job interview. I mentioned to the cab driver, a grandmotherly Black woman, that I was a doctor and she related to me the following tale of her battle with lupus. A few months prior, she’d been released from the hospital, where she’d spent 6 months in active treatment for lupus – for those familiar with the disease, you’ll know that hospitalization for it is rare, especially for such a long period of time. She told me that in that time, she’d made a bargain with her doctor that she could go home on weekends, during which time she’d tend her garden, eat home-grown vegetables, and pray. Now in remission, she was struggling to deal with the high blood pressure and weight gain that had resulted from months of bed rest and corticosteroid use. This too, she was trying to deal with naturally, through diet and exercise. As I said, I think it’s a myth that only white people want to deal with disease using natural methods.

The preceding story also highlights another point that I think is important: Black people also want to take control over their health. One of the reasons that people of all colors seek complementary and alternative health care is a desire to take powerful, proactive steps against disease, and African Americans are no exception. Eating well, exercising, managing stress, and taking other positive steps towards a healthy lifestyle are empowering, because they affirm that through our own actions, we can prevent and manage disease. In my practice, I’ve seen dozens of Black women especially who want to do more than just take a medication. The medication is often part of the solution to be sure, but medication alone cannot provide the sense of empowerment that comes from taking proactive steps towards health.

If you are still in doubt, let me make one final point – the most health-oriented presidential administration in my lifetime is currently in office. President Obama is finally tobacco-free (hooray!) and presided over a vitally important healthcare reform bill. Even more impressive, however, is Michelle Obama’s work. Not only has she set up a vegetable garden at the White House, not only has she started the Let’s Move! campaign against childhood obesity, but the White House kitchen staff are losing weight and feeling healthier than ever, largely due to Michelle’s efforts to get healthy food on the table in the White House. The core of naturopathic medicine, beyond the herbs, beyond the supplements, is a belief that the body is can become healthy if you feed and exercise it well. After decades of Reagan classifying ketchup as a vegetable, Bush Sr favoring pork rinds instead of broccoli, and Clinton’s McDonald’s runs, it’s a refreshing change to have someone in the White House who eats well.

The message is clear – no matter the color of your skin, if you’re a practicing ND and you’re not reaching out to the African American community, you should be. In preparing to write this article, I found an NPR interview with Eric Bailey, author of African American Alternative Medicine: Using Alternative Medicine to Prevent and Control Chronic Diseases, in which he describes the widespread use of alternative treatments for chronic conditions, and how patients integrate it with their use of traditional medicines. In the interview, he emphasizes the importance of working with qualified practitioners, a sentiment NDs are all to familiar with. African Americans are using complementary medicine, just the same as people in other communities, and there’s need for well-trained, qualified individuals. We NDs can and should work to improve access to high quality healthcare by addressing this need.

Why Are Pharmaceuticals So Expensive?

Another Monday, another great chart. This one's from the folks who made last week's chart, and is even more informative.



Created by: MBACC

What’s The Benefit of Knee Surgery?

Ok, it’s true. I just titled it this way to get your attention. Now on to this week’s blog entry…

Over my years in medicine, I’ve often heard people mention a clinical trial in which patients who received ‘sham’ knee surgery experienced the same relief as those who had actually undergone real knee surgery. In some ways, this has grown to ‘urban legend’ status among naturopathic medical students. Despite having heard it mentioned several times, I’d never read the study myself, wasn’t sure of the type of knee surgery involved, and wanted to read more – consider this blog entry as a Snopes report on this study. If you’ve never heard of this study, I recommend you take a look, as it’s the only trial I know of that has utilized a ‘placebo surgery’. I think there’s a lot that can be learned from the study, which was published in the New England Journal of Medicine in 2002.

Here's a basic run-down of what happened. Three groups of people with chronic knee pain and osteoarthritis, approximately 30 in each group, were randomized to either receive an arthroscopic lavage, arthroscopic lavage and debridement, or a placebo surgery. In the placebo group, the patients were put under anesthesia, had the same incisions made as those who were receiving actual surgery, and then had their knees manipulated, as though they were undergoing surgery. In both the short term and long run, those receiving the placebo surgery did just as well as those who received the real surgery, and this applied to not only subjective measures of pain, but also mobility as measured by researchers.

As I said, this has achieved near-urban-legend status in some circles, and I don't think it's quite deserved. Here are my conclusions about the study.

The type of surgery studied matters. When I hear people talk about this study, they rarely say what kind of surgery was performed – it’s usually just ‘knee surgery’. The truth is that the type of surgery studied is vitally important. Though the patients were evaluated radiologically to determine the severity of disease, the type of surgery performed (arthroscopic lavage and debridement) is largely done to reduce patient symptoms, rather than correct a grossly limiting deformity. Were the knee surgery performed to repair a fracture or an ACL tear, I doubt that we would have seen such a drastic response rate from a placebo surgery. Symptoms are at the same time extremely important and slightly tricky – because they are subjective, they can be influenced by factors aside from the physical pathology itself.

What you’re looking for matters. This was not a study to demonstrate the power of placebo, as is sometimes suggested. In fact, this study was done to investigate the mechanism of action and efficacy of arthoscopic knee surgery, and in fact the investigators went to great lengths to see if they had missed any side benefits from the procedure that they had not been looking for. In the world of scientific study, only what is being studied matters, not incidental findings – this study shows that the surgery is not very effective, not that placebo is remarkably effective. If the study had been intended to investigate the placebo effect, it would have been designed differently. Similarly, any additional data points we might pull out of the study can’t be considered valid, because they were not actively studied and so researchers were not controlling for them.

Who you study matters. As the researchers point out, the group of patients who took part in the study was a self-selecting group that may have been more easily influenced by a placebo effect. This may or may not have been the case, but it highlights an important issue in research. When you’re working with a small number of research subjects, you sometimes end up with results that are not reflected in the population as a whole because the research subjects all share an unanticipated trait which is relatively uncommon in the general population.

Don’t distort the results. As I said earlier, this study shows that this surgery is only as effective as a placebo procedure, and that the surgery does not provide any additional clinical benefits that were not initially studied. I’ll go on to talk about placebo in a moment, but as I said earlier, this study was not designed to study the effect of placebo, and so placebo-specific factors were not taken into consideration when designing the study. The researchers note that placebo was more effective than they had anticipated, but even so, we shouldn’t distort the results of this study.

So here’s the conclusion. Patient symptoms are simultaneously extremely important but also extremely plastic. Most docs can relate stories of patients who trucked along seemingly unphased by advanced heart disease or rheumatoid arthritis, and others who suffered greatly from relatively minor complaints. Addressing the person who has a disease, rather than only the disease itself, is an important part of medicine, and one at which naturopathic doctors excel. Even so, this study does not vindicate our profession, nor damn MDs and surgons. The past 15 years has seen a surge in the number of studies into herbs, vitamins and other complementary medicines, and they’ve shown remarkable results. We NDs have literally thousands of studies to draw on when explaining our methods – this should not be one of them.

Why Are Medical Insurance Costs Still Rising?

Many of you probably remember the bitter debate over health reform a few years ago. But why is healthcare still so expensive? Check out this great chart and get some answers.

Created by: MBACC

Legislation Week!

Unlike most weeks, I’m not posting a long research article today. Why?

I’ve spent the last two days in Annapolis working with the MDANP to secure a naturopathic licensure law in the state of Maryland. If you’re a Maryland resident, or know someone who lives in Maryland, go check out the MDANP website to find out how to get involved.

Here’s some basic reasons to support licensure of NDs in Maryland (briefly and succinctly):

1. NDs focus on preventive medicine. Diseases like cancer, heart disease, and diabetes are major public health problems, and can be prevented in a significant number of cases through preventive care. NDs have long recognized the value of an ounce of prevention compared to a pound of cure, and because of our education’s focus on diet and lifestyle, we are in a strong position to help the community tackle these conditions before they arise.

2. NDs save the healthcare system (and businesses) money. Because naturopathic doctors focus on diet and lifestyle, and do not rely on costly pharmaceuticals, NDs have the potential to save the healthcare system significant amounts of money. Studies in Vermont, Oregon, Ontario and Washington have documented significant direct and indirect healthcare savings from naturopathic primary care. Licensing NDs makes a lot of economic sense.

3. Patient safety. The people have spoken and they want naturopathic medicine. The profession, though still relatively small, is growing at a rate of about 400-500 providers per year, and they are going to all 50 states. Because it’s a national phenomenon, people living in unlicensed states are seeking naturopathic care, but aren’t guaranteed that the person they see has been trained at an accredited school. As in the days before the medical profession was fully regulated, there are providers out there who are not qualified to provide care. Licensure laws guarantee that anyone using the term ‘naturopathic doctor’ or ‘naturopathic physician’ has been trained at a four-year accredited school and is qualified to practice.

4. There’s a shortage of primary care providers. This is a point where I frequently have to educate about naturopathic medical education. Having received my training in Seattle, Washington, I was trained to practice to the full scope of a primary care provider, from putting in stitches, to annual gyn exams, to making sure a patient was up to date with colonoscopies. States that license naturopathic physicians don't always license them to to fill this primary care role, but it is within our training to act as such. The shortage of primary care providers is well documented, and as more people enter the healthcare system, it’s only going to get worse. Plain and simple, we need more people on the ground practicing healthcare.

If you haven’t done your part to support the bill, please do so now. Let your senators and representatives know that you support licensure of NDs in Maryland (or wherever else you may live!).