Thursday, December 26, 2013

Brewing Black Tea (Improperly)

It's the day after Christmas, and whether you celebrate the holiday or not, I hope you're finding some downtime today to spend with friends or family. In fact, I hope you're not spending your day reading my blog! But even so, I'll give you a short piece to read. We've been alternating between posts on health issues and recipes, and it's been a few weeks since we had a recipe. I'll keep today's entry short, and so I'm just going to explain how to brew black tea the 'right' way.

There's some discussion on how to brew black tea, with the British having a very specific procedure involving warming the pot and specifications on the temperature. The truth, however, is that this is only correct for certain kinds of black tea. Black tea is more variable than many know, and some types will require differing preparation methods. Here, then, is a general procedure, with variations noted.

1. Add black tea to the pot. Generally, this is accepted to be 1 teaspoon per 8 ounces, but those who like it strong will add a bit extra - I usually use 1 1/2 teaspoons per 8 ounces. Some of the fuller, leafier black teas, such as high-end Darjeelings, will necessitate slightly more tea, because they are not as tightly packed as traditional black teas.

2. Boil the water. Tea must always (always) start as cold water and be brought to a full boil.

3. Pour the water over the tea. Most black teas must be given water at a full boil in order to bring the best flavor out. Green teas take slightly cooler water, but black teas generally need absolutely boiling water. Again, one exception is Darjeeling; some high end Darjeelings should be given cooler water, which prevents bitter flavors, and allow floral elements to fully express themselves, though for most black teas, the cooler water will result in weak, unstructured tea.

4. Steep the tea, and then either fully decant or remove the leaves from the pot. Of course, the question is on timing, and again, this is variable. Some British-style black teas grown in India and Sri Lanka will take 7-8 minutes to gain full flavor, but other will need only 5 minutes. Chinese black teas generally need only 4-5 minutes to steep. Darjeelings will not only take cooler water, but also shorter brew times. Some experimentation with brew times will be necessary to get optimum flavor.

5. Add milk if desired. Milk, while anathema to green and white teas, is regarded by many as part of the black tea experience. I generally add a small amount, enough to give the tea a rich texture and dark caramel color only. But again, this depends on the specific tea. Many black teas have been bred and processed to take lovingly to milk, though others will not. Generally speaking, Indian and Sri Lankan teas will do well with milk, whereas Chinese and Darjeeling will not, though this is not a hard and fast rule.

6. You may add sugar, but do this at your peril. Remember, you're drinking tea, not eating candy.

And finally, on the topic of re-steeping. If you've brewed using a high quality tea, it should be able to take a re-steeping. Though black tea should be re-steeped at the temperature you brewed at initially, you will have to increase brew time. Again, experimentation is key, and while an extra minute will suffice in some cases, in others you may have to add far more time. Milk may or may not treat your tea favorably on a second steeping. My experience has been that second steepings lack the tannins present in the first steeping, and so do not tolerate milk well. But again, this is only my opinion - I don't even warm the pot, so what do I know?

I hope you are enjoying your winter holiday and find time for a bit of black tea in the process. While I'm a daily drinker of green tea for both flavor and health benefits, a little black tea now and again really hits the spot, especially in the cold winter months, where the heat and heft of black tea is exactly what the doctor ordered.

Thursday, December 19, 2013

Thoughts On Multivitamins

The Annals of Internal Medicine, a well-respected medical journal, recently published an editorial titled "Enough Is Enough: Stop Wasting Money on Vitamin and Mineral Supplements." The piece was then widely disseminated to the news media both home and abroad. The editorial claims that the research indicating the uselessness of multivitamins is now so overwhelming as to condemn their use on a vast scale.

It is with sadness that I have to critique this piece. Naturopathic physicians such as myself, both individually and as a profession, have long strived to further research into nutritional approaches to disease and complementary therapies, not to mention furthering the cause of research generally. It is rare that I have to describe an article as unconstructive, but this editorial is such a piece. As I'll argue, this editorial is poorly conceived, poorly intended, and does not engender constructive scientific dialogue.

But before I go further into discussing the particulars, I'd like to discuss a point of irony. The point of irony is that I am not a big advocate for the use of multivitamins. In working with patients, I am far more interested in fostering good eating habits than recommending a multivitamin to "cover the bases." It is perhaps ironic therefore that I might criticize a piece whose point I do agree with. So given that, why argue with it?

Well, there are two big reasons I'm forced to differ with this editorial. The first is that despite claims of overwhelming evidence, the editorial is based on imperfect evidence. It took into account only about 32 studies, some of which are older (a colleague of mine called them "academic leftovers"). While that's no small number, compare it to the article I discussed last week, which examined nearly 300 studies in an effort to understand the role of vitamin D supplementation in disease.

The editorial was written in specific response to two studies published in the Annals of Internal Medicine this month, which bear attention.

The first article found that multivitamins did not appear to provide protection against cognitive decline. This piece suffered from significant limitations, including the fact that it was performed on physicians, who in general eat above average diets and may not need additional nutritional supplementation. Additionally, the use of a multivitamin to prevent cognitive decline is unorthodox, even in complementary medicine, and slowing of cognitive decline is not an outcome that could be reasonably expected from the use of a multivitamin. The most authoritative reference I know of, Nutritional Medicine by Dr. Alan Gaby, includes no references to the use of multivitamins in cognitive decline; this is an exhaustive reference book that draws on published medical literature as far back as the 1940s. This study then, is a prospective study examining a completely novel use for multivitamins, but has been misrepresented as a refutation of the use of multivitamins for a given condition.

The second article discusses the use of multivitamins in prevention of cardiovascular events (such as heart attack, stroke, chest pain, or death) in patients who had previously had a heart attack. Patients who were taking part in the study were also undergoing conventional medical therapy. Here also, the use of a multivitamin in preventing a second cardiovascular event is not common practice. This study is not a refutation of an accepted practice, as it is presented in the editorial, but a prospective study that failed to find a positive effect. Though individual nutrients have been studied in regards to various cardiovascular risk factors, including some with positive results, it would not have been reasonable to anticipate that a multivitamin would have the effect of preventing a second event. Additionally, this particular study was confounded by low levels of compliance with treatment, and the study authors themselves admitted that firm conclusions could not be drawn.

A weak rationale for the editorial is one reason that I have to object to the argument.

The second reason I have to object is that the tone of the editorial, especially when taken in light of the evidential basis, leads me to strongly suspect that the authors were writing with substantial bias against the use of nutritional supplements. While attitudes are changing to an extent within the medical profession, there nonetheless remains a strong undercurrent of bias against nutritional medicine and other complementary therapies. As a provider committed to integrative medicine, which incorporates the use of conventional and complementary therapies, recommended on an individual basis, I find it disappointing that the authors did not check their biases at the door. Scientific method has been developed to decrease the influence of bias in research, and it does no good to bring bias back into the equation when interpreting results.

Of course, the editorial itself is not the entire problem. Of greater frustration is the fact that this editorial was then widely disseminated via the news media, during which it received an additional level of distortion. Given that the articles that incited this process found that multivitamins did not engender an additional benefit on top of a balanced diet or conventional treatment, and for conditions that would not be expected to benefit from use of a multivitamin, it is incomprehensible that the subsequent news articles bore titles such as "Should We Toss Our Vitamin Pills?" and "Vitamin supplements are a waste of money, say scientists." It is difficult to know whether the blame lies at the feet of the journalists or the publicists, but it is clear that limited evidence was spun dramatically out of proportion as this made its way from the lab to the public. While the information gained in the clinical trials is valid and deserves to be incorporated into clinical practice, it does not warrant a massive news campaign intended to convince the public to stop taking vitamins.

Finally, experience and an understanding of scientific progress has taught me that it never pays to close doors, as these authors are suggesting. Statements of absolute certainty rarely hold up under scientific scrutiny, and the broader-reaching they are, the faster they tend to succumb to criticism and new evidence. In the final analysis, this editorial was unconstructive for this reason. It offered little new knowledge, and proposed a radical departure from well-established norms. Had the editorial been limited and stuck to concrete information, I would probably have been chiming in my agreement, because after all, we've learned that multivitamins are unlikely to prevent cognitive decline, though they may have other benefits, and that they are also not a helpful addition to conventional medical therapy immediately after a heart attack. But to take that evidence and then goad the news media into publishing articles that deride vitamins as useless is not helpful, not constructive, and frankly, bad science.

Thursday, December 12, 2013

New Information About Vitamin D

Vitamin D has gotten unending amounts of press lately. It's been touted for a whole number of health conditions, including cancer, immune conditions, heart disease, and diabetes. That said, research into the therapeutic effects of vitamin D supplementation have been inconsistent, and there's been some discussion of the importance of blood levels of vitamin D as a test. The version of vitamin D tested by health care professionals is not the active form of vitamin D, but is a 'pre-hormone' that acts as a reservoir and is converted into vitamin D for use by the body. Researchers are asking themselves what exactly this test measures, and whether raising those levels has a therapeutic effect.

Enter into this a paper that was recently published which suggests that serum vitamin D levels are the result of chronic disease, rather than the cause of it. The authors postulate that during chronic disease, vitamin D levels fall, rather than inadequate vitamin D levels being the cause of the chronic disease. The paper is a review of hundreds of individual studies of vitamin D, some of which looked at serum levels of vitamin D, while others looked at the effect of vitamin D supplementation on disease. While I think it's of limited clinical use to assess the effect of vitamin D on health generally, rather than on specific diseases (consider the results we'd get if we were to assess the benefits of a statin cholesterol drug on human health over a variety of conditions), the study nonetheless deserves enormous plaudits for the sheer scope of the study. With 290 studies to draw from, the information they generated should have some weight.

In summary, the findings were this: Low blood levels of vitamin D appear to be the result of chronic diseases, rather than their cause. The researchers noted many, many associations of low vitamin D with conditions such as cardiovascular disease, multiple sclerosis, mood disorders, and weight gain, but did not find strong evidence that vitamin D supplementation resolved these issues.  As stated previously, there are some issues with applying this information - reconciling the broad conclusions of this study (that vitamin D supplementation does not affect disease generally) with the specific conclusions of others will be a challenge for clinicians.

The primary concession the authors make is that among the elderly, vitamin D supplementation has a clear beneficial effect on reducing overall mortality. They were hesitant to discuss why this was, but agreed that vitamin D supplementation was an important intervention for the elderly, who are susceptible to a number of ailments.

Nonetheless, the idea that the body responds to chronic disease by lowering serum levels of vitamin D is not without precedent - it does similar things with iron. However, the reason that the body appears to do this is still unclear. Stay tuned as we continue to learn more about vitamin D.

Vitamins have risen and fallen in the past, be they vitamin C or vitamin E. This study will likely not prove to be a nail in the coffin of vitamin D, but it will certain shape our understanding of vitamin D in the future. Consumers should still note the fact that this study will not change recommended supplementation guidelines. The Institute of Medicine increased the recommended amount a few years ago from 400IU to 800IU for healthy adults, and that number still stands. Supplementing with vitamin D, despite the findings of this study, is still strongly recommended.

Thursday, December 5, 2013

A Dirty Dozen Of Fish?

Smart consumers know about the Dirty Dozen, a list of vegetables and fruits includes the one most often contaminated by pesticides and other environmental toxins. The recommendation is to buy organically-grown versions of these foods in order to avoid unnecessary chemical exposure. These are contrasted with the Clean Fifteen, which aren't heavily sprayed or otherwise contaminated when grown conventionally and are fine to eat when conventionally-grown. These lists are clear, organized, and easy to use and many shoppers have the lists memorized, or at least key members of the lists.

However, when it comes to fish, things get a lot murkier. There are mercury issues to consider, there are issues related to overfishing, and questionable farming practices also enter the picture. Unfortunately, while lists for each of these criteria exist independently, none are compiled into something as clear as the Dirty Dozen.

Well, at least until now. The Food & Water Watch has put together a handout that compiles the criteria into a "Dirty Dozen" for Fish. The list includes fish that are contaminated with metals and other toxins, fish that are not sustainably caught, fish that are subject to unhealthy farming methods, and others. The list includes: Atlantic cod, Atlantic flatfish, caviar, Chilean sea bass, eel, farmed salmon, imported catfish, imported farmed shrimp, imported king crab, orange roughy, shark, and Atlantic bluefin tuna.

The list also includes recommendations of fish and seafood that can be substituted for the "dirty" fish. In all, it makes a great guide for buyers looking to increase fish in their diets while promoting their own health and the health of the planet.

The one and only downside of this otherwise great document is the fact that it doesn't incorporate information on omega-3 content, but we can hardly fault it for that. For those interested in omega-3 content of fish, reference this handy blog that I posted last year. Eat well and be healthy!