Rhubarb-Strawberry Dessert Soup

I'm not much of dessert maker, but in the springtime, when rhubarb is almost too plentiful, and the strawberries begin spreading delight, even I get inspired. Rhubarb and strawberries are a match made in heaven, and this delicious dessert is probably the simplest recipe you'll see me offer on this blog. This
recipe allows the natural flavors to shine through, and the color... wow. Just check out the picture below. Your guests will swoon at this unique offering.

2 cups rhubarb (cut into chunks)
1 1/2 cups water
2 cups strawberries
1/3 cup orange marmalade (or 2 tbsp sugar)

Add rhubarb and water to a covered pot and bring to a boil. Boil for 5 min, until  the rhubarb is significantly broken down. Transfer to a medium-sized bowl (including the water) and cool in the refrigerator for 20-30 minutes.
While the rhubarb is chilling, prep the strawberries - just chop the green tops off and you're set.
When the rhubarb is cool, add the strawberries and the sweetener. The traditional recipe calls for sugar, but orange marmalade brings sugar and accentuates the bitter/sour flavor of the rhubarb nicely.

Top with a scoop of ice cream - vanilla is best. The cream quells the acid a bit and brings the full flavor out, without interfering with strong flavors.

Vitamin C and Smoking

Regular readers of this blog will know that I talk a lot about smoking, and believe anything that can be done to help smokers quit should be done. However, I'm also a realist, and recognize that sometimes harm mitigation is the best approach. If you can't stop the problem, sometimes you can at least lessen the negative effects of the problem. Now enter a big topic - smoking in pregnancy. In modern America, this is as near to sinful behavior as we get. Smoking is a bad habit, but smoking while pregnant conjures anti-smoking sentiment as well as sympathy for children; you're welcome to ruin your own health, we say, but at least think of the baby.

Even so, some people, despite their best intentions, can't quit smoking. So what's to be done? Are we to throw our hands up and admit defeat? Are we to simply shower scorn on the smokers we know? Well, a recent research study, conducted at the Oregon Health and Science University, suggests that there may be a middle path.

In this study, pregnant women unable to quit smoking were randomized to either receive a placebo pill or 500 mg of Vitamin C, and their newborns were then tested for lung function. Babies born to women who smoke are at a higher risk for asthma and lifelong problems in lung function, and the study was performed to determine whether this would help counteract the effect of in utero exposure to smoking. Giving vitamin C doesn't fix anything, per se, as it doesn't address the fact that smoking is the real problem, but it does aim to mitigate the damage caused by smoking, and the results were promising.

The researchers found that while smokers receiving a placebo had very low blood levels of vitamin C, smokers who received the vitamin C had blood levels of vitamin C that were nearly the same as non-smokers. This correction of a 'smoking-induced vitamin C deficiency', if you want to call it that, had important effects. The newborns of the smokers who received vitamin C had improvements in lung function as compared to their non-vitamin C counterparts, which from the outset puts these children in better standing for their long-term health. The authors note that this finding should have important repercussions in public health, and I would agree with them.

But of course, I have a few comments to make on the study. Critics of the study may say that this opens the door to loose attitudes towards smoking by providing a 'way out' to those who want to keep the habit but lessen its negative effects. This argument is often trotted out on any number of topics, including availability of condoms, needle-exchange programs, and the e-cigarette phenomenon. Whether or not it's a generally valid argument is a topic for another article, but in this case I think it's not. Social stigma is strong enough against smoking that we're unlikely to see a return to the days of Mad Men-level smoking, only this time paired with vitamin C consumption.

At the same time, I think this serves as an example of compassionate care for people who suffer from limitations and fallibility. I've said before that, though parents' failure to vaccinate their children has potentially devastating effects on personal health and public health, 'firing' patients over refusal to vaccinate only worsens the problem. Instead, I believe it's important to keep such patients in the system so that they can be monitored and hopefully convinced otherwise in the future. In the case of vaccination refusal and smoking, patients, fallible humans that they are, don't always make perfect choices, but that doesn't mean that they shouldn't continue to receive the best care that we can provide. This study offers insight on how to continue to serve patients when they need us most, and I hope it makes it into general practice guidelines.

The Brits Need Vitamin D

Vitamin D deficiency is extraordinarily high in the United Kingdom. Some time back, I was shocked to find that some 75% of the general population was vitamin D deficient, and that this number progressed to nearly 100% in some subgroups, such as the elderly, or those who had suffered hip fractures. Of course, regular readers of this column will know that the diet is a poor source of vitamin D, and in a place as overcast as the British Isles, we should expect that vitamin D deficiency would be common. Nonetheless, 75% prevalence is appalling, and something should be done about it. Low vitamin D predisposes people to bone fractures, increases their likelihood of falls (especially in the elderly), and has been associated with a number of chronic health conditions.

Fortunately, something is being done about this, at least in the UK. The National Institute on Health and Care Excellence (NICE) has issued a statement calling for millions of Brits to be given access to free vitamin D supplements. While the perfectionist in me notes that this doesn't really solve the problem per se (that would only be solved by the British moving closer to the equator and adopting outdoor lifestyles), the pragmatist sees good policy in here.

Of course, we've seen attempts to introduce nutrients into the food supply before but in these cases, the nutrient introduced is being reintroduced after having been stripped out by processing. 'Fortified' bread is a classic example; B vitamins are naturally present in reasonable amounts in whole wheat, and bread made from unprocessed whole wheat is rich in B vitamins. However, when wheat is processed in order to make white bread, the B vitamins are lost, and so when the bread is 'fortified' by adding B vitamins, it's not so much an attempt to 'supercharge' the bread, as much as restore the bread it its original nutrition level.

In the case of vitamin D supplements, however, I believe this to be a genuinely good idea. As I've noted a few times in the past, vitamin D is extremely hard to get from the diet, and it's very difficult to get enough from sun exposure, especially in a place as far from the equator as the United Kingdom. Nonetheless, it's essential to normal human health, and so supplementation is often the best and only solution. That the NICE has recommended that supplements be made available to millions of British is encouraging; I do hope, however, that they make the bioactive D3 form available, rather than the less active D2. Given that vitamin D deficiency is also prevalent in the US, I hope the NICE's efforts are successful, and that a similar policy can be implemented here.

Bonus Graphic Friday

This past week, I suffered from a pretty rough case of writer's block, and though I posted yesterday, it's not my finest work. However, since then, I came across a great graphic, and I love nothing more than a great graphic. So in today's bonus round, I'm posting this fantastic image. I hope you like it.

Naturopathic Medicine, Insurance and Medicare

Insurance coverage for naturopathic doctors is one the great frontiers in medicine at the moment, though you may not know it. While much of the country continues to argue about the Affordable Care Act, quietly entering the scene are naturopathic doctors, who are working to set the scene for when our healthcare system transforms from a way to make sure you can pay for care go terribly wrong, into a way to keep you healthy so things don't head south in the first place. Long-term health savings will start with guaranteeing access to medical care, but won't end there; the true health savings won't come until healthcare starts in our homes, our lives, our grocery stores, and in our public places. This greater phase of healthcare means education, and education means naturopathic doctors.

Leading the way were Connecticut, Washington, Oregon and Vermont, four trailblazers in healthcare. Following soon behind were Montana and New Hampshire, and we are now starting to see the tide turning in Maine and Hawaii as well. While this is a small number of states, it has an outsized impact in the US. Naturopathic doctors have always punched above their weight class, and that trend is continuing in the realm of cost-effectiveness. The evidence that naturopathic medicine saves money is mounting, and the message is getting out.

While insurance coverage is still expanding, it's already become clear that there's a gap forming. Though patients may have insurance coverage for naturopathic doctors throughout most of their adult life, as soon as they hit 65 and enroll in Medicare, that coverage disappears. In some cases, these patients will have had a naturopathic doctor as their primary care provider for 15 or 20 years, only to have that primary care provider taken from them because Medicare doesn't cover naturopathic doctors. Therefore, last week, naturopathic doctors and students from around the country came to Washington, DC to lobby for Medicare coverage for NDs. In addition to the fact that naturopathic medicine helps reduce healthcare costs, including naturopathic doctors in Medicare helps promote continuity of care, which has a major effect on determining healthcare outcomes.

Naturopathic doctors not only emphasize the education and self-care that is so important to the long-term goals of our healthcare system, but also the importance of the doctor-patient relationship that is being lost in our modern medical system. While our healthcare system allows for patients to bounce around between specialists, with little oversight to how things connect, naturopathic doctors emphasize continuity and a patient's whole experience.

Mole Verde For Everyone!

Next week will feature a return to the hard and fast work of naturopathic medicine, but this week will feature another tasty sauce to follow up on last week's sofrito recipe.

Of course, there are many types of mole verde, but this one in particular is especially delicious and not too difficult to make. It makes a great sauce for chicken and goes well with beans. I guarantee that you'll be astounded at how flavorful and complex this sauce is, given its apparently straightforward ingredient list. Even so, the ingredient list may surprise you, and it may surprise you even further to find yourself putting lettuce leaves into a sauce, but I assure you that you'll love it.

15 poblano chiles (yes, 15)
5 jalapeño chiles
1 white onion
1/4 cup olive oil (not extra virgin!)
1 head garlic
1 quart chicken stock
2 tsp salt
1/2 tsp coriander
1/2 tsp oregano
1/2 head romaine lettuce
1/4 cup fresh tarragon (epazote is more traditional)
1 bunch fresh cilantro
1/2 cup fresh parsley (I usually use Italian/flat-leaf parsley)

Start by coring and seeding the peppers, then cutting them into strips - these strips of pepper are called rajas. Next, peel and dice the onion. Fry the rajas and onion over medium heat in a large skillet, stirring frequently, until they are nice and soft, and beginning to brown. This may take 10-15 minutes.

Peel the garlic and either slice, dice or press the cloves. When the peppers and onion are nicely browned, add the garlic, stock, salt and coriander. Cook for 20 minutes.

Start preparing the other ingredients. Wash the leafy greens (lettuce, tarragon, cilantro, parsley) and chop them. When the 20 minutes of cooking are up, add the leafy greens and cook another 5 minutes.

Finally, puree the ingredients. This can be done with a food processor, but I always recommend an immersion blender - it's easier to use and you won't have piping hot mole verde sloshing around your kitchen. When you've got it at a nice smooth consistency, you are good to go!

To use the sauce with chicken, first roast and shred the chicken. Then combine the chicken with a liberal amount of mole in a sauce pan and heat through - this can be served in tacos, over rice, with beans, or with fried plantains.

The mole flavors become richer if you leave them overnight, so don't worry that you have leftovers! They'll be great the next day.

(Note: Tomatillos are a traditional ingredient in mole verde. I haven't included them here, not because I don't like them, but because they can be hard to come by in the US. If you have a bunch that are begging to be eaten, feel free to use between 1 and 2 pounds of them. First remove the husk and boil them, then add them when you add the stock.)

Sofrito, An Unknown But Delicious Sauce

It's been a few weeks since I've posted a recipe, so I'm including a favorite this week. Sofrito is a sauce coming from the Spanish Caribbean that is most commonly associated with Puerto Rico, but that also has variant styles in the Dominican Republic and Cuba. Its roots are not only in Spanish cooking, but Native cooking, African cooking, and even Italian cooking, so it's a mix of flavors that is totally unique.

Sofrito can be used in beans and rice, on chicken, fish and in all types of other dishes. Some even call it the pesto of the Caribbean, noting its central role in Puerto Rican cuisine in particular.

This recipe is adapted from a Puerto Rican style of sofrito. I've tried to stay true to the roots of the sauce, but have noted that many of the authentic ingredients are impossible to find in the US, even in well-stocked ethnic markets. Aji dulce and recao/culantro are very hard to find in the US, to the point of being nonexistent, even to those of you who know where to look, so I've made substitutions.

1 large red bell pepper
1 large yellow/Spanish onion
16 aji dulce peppers -- can substitute with 8 cubanelle or Anaheim peppers
1 head of garlic
1/4 cup pitted pimenton olives (alcaparrado is more traditional, but make sure to remove pits)
1/2 cup olive oil
4 sprigs recao/culantro (may omit if you can't find it)
1 bunch cilantro
1 tbsp ground black pepper
1 tbsp oregano
1 tsp ground coriander
1 1/2 tbsp salt

Start by coring and seeding the peppers, and then slicing into strips. Halve the onion and slice it, and peel the garlic cloves. Add all ingredients to a roasting pan and coat with olive oil. Roast for 1 hour at 375 degrees, until the veggies are soft and starting to brown a bit.

Add all ingredients to a food processor and blend until they achieve a perfect consistency, slightly chunky, but without any major pieces hanging out.

Sofrito can be used to flavor rice and beans, chicken, and many other dishes.

Sofrito in the early morning light.

A Moment To Pause and Reflect

This past Monday, I had the honor of being present for the signing of the bill that will license naturopathic doctors in the state of Maryland. It has been a long, hard road in pursuit of this goal, but the moment has finally arrived, and in March of 2016, God willing, I will be among the first few NDs to be licensed in the newest licensed state, and this has given me pause for thought.

As a naturopathic doctor actively involved in lobbying efforts on behalf of my profession, I've come to value the following motto, originally said by Robert Baden-Powell, the founder of the Boy Scouts: "Leave this world a little better than when you found it." More than any other motto, I think this captures the spirit of naturopathic doctors' legislative efforts. Be they attempting to gain licensure to better serve their patients, gain insurance reimbursement so they can provide services to a broader portion of the population, or work on public health efforts, the naturopathic doctors I know and have worked with are committed to leaving their campground cleaner than when they found it.

That the battle would be hard was to be expected. Any time a new profession seeks licensure, there is inevitable opposition, and of course it was the same in Maryland as anywhere else. Additionally, while many medical doctors in the state supported the licensure of naturopathic doctors, the organizations who claim to represent them are often staunchly conservative in their position. Such organizations count on the ignorance of consumers, doctors, and legislators to make their positions hold sway; those who have actually become educated through talking with or working with naturopathic doctors often give up their opposition. In the end, the NDs were simply telling the truth and looking to be better able to serve the people of Maryland, and legislators knew this. A bill was ultimately passed, and while it isn't perfect, it's a first step on the path.

It will be almost two years until the first licenses are issued to naturopathic doctors, and probably many more years until naturopathic doctors are able to bill insurance here in Maryland, major efforts are under way. There are plans to start a school of naturopathic medicine here in Maryland, and some of the more forward thinking medical institutions in the area are looking to bring naturopathic doctors into the fold. Additionally, the upcoming licensure means that there are likely to be many more NDs coming to the state soon, which means that a lot more Marylanders will start being a lot healthier. This campground is already starting to look a lot nicer.

Antibacterial Soaps May Have Unintended Effects

Most of us know about the so-called 'superbug' MRSA, or methcillin-resistant Staphylococcus aureus, and the health problems it causes. Our history of overusing antibiotic drugs has resulted in strains of bacteria that have adapted defenses against those same antibiotics, leaving us in quite a quandary.

There have also been concerns that antibacterial soap may contribute to antibiotic resistance. The conventional line of thinking has been that, like antibiotic drugs, antibacterial soap kill off most bacteria, leaving only a few resistant strains behind, which then multiply and spread. However, a new study has shown something completely unexpected: Some antibacterial soaps may actually promote bacterial colonization.

Triclosan is a common ingredient in antibacterial soap, and is the main one responsible for killing bacteria. It's so common, in fact, that it has begun showing up in the human body and human secretions. In a study published yesterday, researchers found that triclosan is present in the nasal secretions of healthy adults, but that, against expectations, the presence of triclosan in the nasal passages is associated with an increased incidence of Staph aureus colonization, not a decreased incidence.

One might reasonably expect that presence of triclosan in the nasal secretions might help keep out bacteria through antibacterial action, but such is not the case. Instead, the triclosan was present only at nonlethal levels, which, rather than killing the bacteria, simply stressed them and caused them to react. What was their reaction, you ask? Their reaction was to attempt to adhere to local proteins within the nasal passages, forming what bacteriologists call a "biofilm." When bacteria form a biofilm, they're hunkering down for good. The findings of the study show that rather than keeping us squeaky clean, antibacterial soaps actually encourage bacteria to take up residence on our bodies.

It's an old adage that cleanliness is next to godliness. While I won't argue with that, antibacterial cleanliness may be a lot closer to unwanted Staph aureus than any deities. When washing, it's the mechanical action of scrubbing and a mild detergent effect that we need most, not "bacteria fighting power." So go for natural soaps, or at least conventional soaps without added antibacterial agents.

A Listening Assignment

I've written extensively about smoking in the past, and so I'm returning to the topic again today. However, instead of composing a long argument about the evils of tobacco for you to read, I'm offering a listening assignment.

Freakonomics Radio is a program on NPR that looks into the economics of various phenomena, such as the costs and benefits of learning foreign languages, problematic trends in the Japanese housing market, and 'reasons not to be ugly'. In the wake of the 50th anniversary of the US Surgeon General's report on smoking, they've tackled smoking this week. They investigate efforts to cut smoking in both the US and abroad, and take a good hard look at what has worked and what hasn't.

So tonight, perhaps while you're cooking a simple fish recipe or my favorite Spanish rice, tune in and take a listen.

Freakonomics: How to Make People Quit Smoking

Belief in Medical Conspiracy Theories Is More Common Than You Think

When most of us think of conspiracy theories, we think of aliens, JFK, the CIA, and other nefarious government agents acting in secret, but a surprising number of conspiracy theories involve modern medicine. Few of us think of these as conspiracies per se, because they are typically presented a conflict between science and pseudoscience. Nonetheless, the list of said conspiracies includes many that may be familiar to readers, such as:

• The FDA is suppressing important information about natural cures for cancer.
• Medical doctors still want to vaccinate children despite knowing that vaccines cause autism.
• Health officials know that cell phones cause cancer, but aren't doing anything because powerful companies won't let them.
• Public water fluoridation is a way for companies to dump hazardous chemicals into public water.

These theories are derided day in and day out in some online sources, but despite the amount of time spent combatting them, little is understood about why people believe them. The result is that they are addressed as nonsense at best and very dangerous ideas at worst. It's my contention that this approach is failing to change opinions, and in fact is galvanizing opposition. A change is needed.

As a naturopathic doctor, I can understand why the fight against conspiracies can be so vehement. Science simply doesn't support these theories, there's evidence to back up this position, and there are the real-world consequences of some of these conspiracy beliefs. At the same time, the aggressive stance against these ideas is not productive. It creates an adversarial relationship between patient and physician or citizen and government, and that itself has negative effects. It is far more important, I believe, to understand the opinions and why people hold them, so as better to address the concerns. People who subscribe to these theories are not fools, they are attempting to grapple with major problems and make sense of them, and should be addressed as having legitimate concerns.

Enter into this discussion a letter to the editor that was published in the Journal of the America Medical Association Internal Medicine. The two authors, from the University of Chicago's Department of Political Science, found that, in a population of 1351 adults, nearly half subscribed to one so-called 'medical conspiracy theory' or another, and a full 18% subscribed to three or more. This is a surprisingly large number. They also correlated these beliefs with other behaviors and found that those who believed the highest number of conspiracy theories were also much more likely to shop at farm stand, buy organic foods and use herbal medicines. These we might view as health-promoting behaviors. On the contrary, however, they were also less likely to get flu shots, use sunscreen, or get an annual checkup.

What is interesting is the author's conclusion that those who believe the theories were not necessarily less health-conscious, a position they reinforced in an interview with NPR. Conspiracy theorists, they argued, were grappling with all of the same health problems as everyone else, but using different sources for health information. Rather than trusting conventional sources for medical information, these individuals were more likely to listen to friends and family in questions about healthcare, along with 'celebrity doctors' such as Dr. Andrew Weil and Dr. Mehmet Oz. It's not that these individuals were unconcerned with health; it's that they were pursuing alternate sources, which they held to be more reliable.

Now, as you might expect, I'm going to bring this back to naturopathic medicine. The United States needs to make healthcare a priority for all of its citizens. I've often argued that NDs offer an additional route into the healthcare system for those who are mistrustful of the conventional medical system or otherwise feel alienated by it. This includes racial and ethnic minorities, as well as those who, for their own reasons, are mistrustful of the system. These findings suggest that this group, who are actively seeking healthcare answers but less involved in the conventional healthcare system, is far larger than could have been anticipated. If this research is correct, those who would be classified as 'high conspiracists', because they believe in 3 or more of these medical conspiracy theories, constitute 18% of the US population, or just over 57 million people. This is a very large number. The US needs to actively engage these people, recognize the fact that they want a different way to address healthcare, and consider that they may be more willing to work with an ND as a primary health care provider.

We've made major steps towards expanding healthcare to all Americans, but we're not there yet. Health insurance coverage isn't the end of the story. We also need to sell the system, and actively engage populations who have not been involved in healthcare in the past. For some, the barrier has been strictly economic, and the conventional system will meet their needs entirely. For others, there's a different barrier in place, and it's personal, cultural and maybe religious. This population needs service as well, and providing healthcare options is an important step towards reaching them.

Vaccines and the Return of Preventable Illness

The New York City Department of Health recently issued a warning that there was an active measles outbreak in Upper Manhattan and the Bronx, and urged citizens to get measles vaccines if they were unvaccinated. If this had taken place several decades ago, it might not be out of the ordinary - occasional increases in infectious disease rates would happen and public health officials would renew their calls to parents to make sure their children were vaccinated. But in 2014, a decade after measles was declared eliminated in the US, an outbreak and the subsequent call for vaccination is out of place.

Measles has seen a surge in recent years, so much so that in 2013 there were 175 cases of measles, as compared to 60 cases in previous years. Figures don't exist for 2014 yet, but this outbreak in New York City is troubling. The measles vaccine became available in 1963, and the last great peak in measles incidence was in 1990. Prior to the vaccination becoming available, nearly every child in America caught measles, with several hundred dying from the illness every year and several thousand suffering severe symptoms, such as seizures and nervous system damage. Now, about 90% of Americans are vaccinated against measles.

So what then of this recent outbreak? Well, the suspicion has naturally fallen on increasing resistance to vaccination by those who are concerned about the potential dangers. The debate about a connection between vaccination and autism has been discussed to such a great extent elsewhere that I'm not going to venture into it here. Instead, I'm going to address the reasons people are concerned about vaccines, and the way we should approach these concerns. Regular readers of this blog will remember my past posts about vaccination (1, 2), so my opinion here should come as no surprise.

To kick it off, let me propose something. Let's stop using the term 'anti-vaxxer'. In dealing with parents that have concerns about vaccines, confrontational positions only serve to perpetuate the problem. As healthcare professionals, we know that vaccines are important and that failure to vaccinate has very serious personal and public health consequences. However, patients still have concerns. Firing these patients or labeling them as problematic only pushes these people out of the healthcare system and into a potentially dangerous situation. Compassion and concern are important with these patients, perhaps even more so than many other cases, and it's though compassion that we can keep them in our practices at least, and hopefully convince them of the importance of vaccination.

I also want to address the reason that people are concerned, because there's legitimate concern here. Put simply, people want to protect their children, and mandatory shots that make children scream and cry touch on that intrinsic desire. Unfortunately, vaccines have been a victim of their own success in this regard. In 2014, there is no imminent threat to speak of - these illnesses have largely been eradicated, and while American parents 50 years ago would gladly vaccinate their children to avoid measles, nowadays, their likelihood of a screaming child is higher than their likelihood of one with measles. Likewise, there's no apparent benefit either - as with all preventive medicine, if a vaccine works perfectly, absolutely nothing happens. As a result, they're a hard sell.

Even so, sell we must. For a treatment used nearly universally in America, vaccines have a massively strong safety record. And, unlike some conventional treatments, vaccines have proven remarkably successful as well. Despite major efforts in heart disease, cancer, diabetes, arthritis, and any number of other illnesses, none of these have been declared eliminated, while diphtheria, polio and smallpox (and until recently, measles) are considered illnesses of bygone era.

The recent outbreak, then, is not a call to arms to fight the 'anti-vaxxers' - it's an opportunity to welcome them back into our practices and again reach out to communicate with them, and at least to keep them under medical supervision.

Uses For Bacteria Abound

Bacteria are everywhere, especially on our bodies. It's an oft-repeated fact that there are more bacterial cells in our intestines than there are human cells in the rest of our body, but it doesn't end there by any means. The mouth, sinuses, and skin are also covered with bacteria, and there are even a few brave souls that live in the human stomach.

This is pretty much a discovery of the past two decades, and it's radically different than the prior belief that bacteria are something we only occasionally encounter, and when we do encounter them, we get sick. Rather, bacteria are something we live with every moment, and their role in the normal functioning of the body is probably enormous, though this is something we are only now coming to understand. In fact, the study of the human microbiome is just over 10 years old - the term was coined in 2001 by biologist Joshua Lederberg to describe the sum total of the bacteria that coexist with human hosts. The Human Microbiome Project, meant to mirror the Human Genome Project, was founded in 2008, making this a serious investigation for only about six years. In that time, however, thousands of symbiotic bacteria have been identified.

Of course, as this research is being done by Americans, it hasn't simply stopped at observing and cataloguing the range of bacteria present. Instead, we've begun to look at practical applications for bacteria. Some have suggested deliberately infecting children with Helicobacter pylori to prevent development of allergies in childhood, and then selectively killing off the bacteria later in life to prevent ulcers in adulthood. Others have proposed using Oxalobacter formigenes to prevent stone formation in patients who have recurrent kidney stones. Others have begun developing mouthwashes that selectively kill Streptococcus mutans to prevent dental cavities. As soon as we discover something, we immediately start fiddling with it. We're Americans, and we can't help it.

As an ND, I take the perspective that selectively killing some bacteria isn't as likely to be helpful as promoting other bacteria, with the intention that they arrive at a balance between multiple bacteria. This has long been my approach to digestive health, and it's been a pet theory of mine that something similar would prove true about oral health as well. Rather than kill the 'bad' bacteria, why not promote the 'good' bacteria? I haven't developed an oral probiotic mouthwash, but perhaps I should have, because I recently read that probiotic mouthwashes are indeed being explored as an approach to halitosis (bad breath). It turns out that some are taking my approach and looking to promote the use of 'good' bacteria to promote oral health, rather than just killing the 'bad' bacteria. 

Perhaps I missed the boat on probiotic mouthwashes, but the future is teeming with possible applications for probiotic bacteria. Will nasal bacteria be used to fight chronic sinus infections? Will they be used to break down harmful substances in the digestive system? Will they perhaps even be used in wound-healing to prevent infection by pathogenic bacteria? This field is still brand new and we're learning about it very rapidly, so I wouldn't cross any of these off the list. Stay tuned.

We Can Do Better Than This (And Maybe We Are)

Just a few weeks ago, a study was released that demonstrated something shocking. Truly shocking. Of course, we know that overweight and obesity are problems in modern America, and we're beginning to realize exactly how large a problem it is. But one thing we may not fully realize is just how much a poor lifestyle contributes to it.

We know that poor dietary choices and low levels of exercise contribute to obesity, but for consumers, the question is, "What does a poor diet really look like?" and "How much exercise is too little?" Well, we now have a number for how much exercise is too little.

Researchers at the University of Alabama have found that, on average, an obese American man gets 3.6 hours of vigorous exercise. Per year. An average obese American woman gets less. 1 hour per year. Without even addressing dietary choices, this pinpoints low physical activity as a major contributor to obesity.

Some readers have questioned the ability of the researchers to accurately measure exercise levels this low, but even taking margin of error into account, the research clearly shows that obese Americans are getting shockingly low levels of exercise. It's really no wonder that obesity results with activity levels this low.

Is it any wonder, then, that we're seeing the growth of drastic weight loss therapies, such as bariatric surgery, near-starvation diets, and more? Adult Americans have developed dietary and exercise habits that are nearly impossible to break, and have no other option other than drastic solutions. The guideline of 30 minutes of exercise five times a week is well-accepted as a threshold for adults looking to maintain weight and reduce risk of disease, but for obese Americans, this is not nearly enough.

However, at the same time as this shocking result was published, more encouraging news also hit the newspapers. Obesity rates in children dropped a stunning 43% over the past decade. Obese children are many times more likely to be obese adults, and this decline was seen as a massive reversal of a decades-long trend in obesity. In 2012, 8% of 3-5 year olds were obese, as opposed to 14% in 2004, and while this is a dramatic drop, 8% obesity prevalence is still a high percentage, and we'll need to see further drops in the future.

The point is that, despite decades of terrible health habits, including smoking, low levels of exercise, and poor diet, Americans may be starting to change their ways, and are teaching those habits to their children. Here's hoping.

Fish and Potatoes

It's been several weeks since I've put a recipe on the blog, my time having been consumed with medical topics, and so I'm returning today with a recipe, a simple one that reveals the natural goodness of the ingredients used. Simplicity is undervalued in cooking, especially in modern American with its fetish for complicated flavors and heavily spiced foods. Simple foods, prepared well are often the most delicious because they allow us to really pay attention to what we are eating.

As is well documented, fish can be a tough sell. We know we should eat more, but we don't know how to prepare it. I've offered recipes in the past, but it's been a while since then, so I'm returning with a guaranteed sell. If the prior recipes were strongly flavored, this one is far, far from it. It's simple and allows the natural flavors of the fish to be presented - I recommend a mild, meaty white fish for this, like mahi mahi or corvina.

2 medium onions, sliced thin

3 tbsp olive oil

2 lbs waxy potatoes (such as Yukon gold), peeled and sliced in thin rounds

1/4 cup water

1 tsp salt

1 lb white fish fillets

1 tbsp lemon juice

Use a large, oven-worthy pan for this. Saute the onions in 2 tbsp olive oil until very soft and caramelized. Add the potatoes, the water, 1/2 tsp salt and gently stir to mix. Cover and cook at medium low temperature for 10 minutes, until the potatoes begin to soften.

Meanwhile, drizzle the fish with the remaining 1 tbsp olive oil and sprinkle on 1/2 tsp salt.

Add the fish to the cooking potato/onion mixture, along with the lemon juice - don't mix, just place it on top. Cook covered for at least 20 minutes, until the fish is fully cooked.

Finish the dish by putting the pan in the oven to broil for 3-4 minutes. The broiler will put a nice brown on the fish and potatoes.

Delicioso! 

Naturopathic Medicine Saves Money

Last summer, a landmark study was published in the Canadian Medical Association Journal. It found that naturopathic medicine reduced the risk of cardiovascular disease when added to conventional medical care. In the study, the group that received naturopathic care saw its incidence of metabolic syndrome fall nearly 50%, and their likelihood of suffering a cardiovascular event (a fancy word meaning heart attack, stroke, clot, or other issue) was about a third lower than the group that received only conventional care. To put this in plain English, Naturopathic Medicine makes people healthier and saves lives.

However, the study authors weren't done there. In addition to investigating the healthcare benefit, the authors wanted to answer the question: Does naturopathic medicine save money?

Specifically, the researchers were asking this question: If an employer invests in naturopathic medicine, do they see a return on their investment? To find out, the full cost of the naturopathic program was assessed, and this was then compared against total per employee healthcare spending and differences in employee productivity.

The results were published recently, and they are clear: Employers who invest in naturopathic medical care for their employees see significant healthcare cost savings, as well as increases in productivity. You can read the exact figures in the article itself, but the rough findings were that naturopathic care helped employers save about $1000 dollars per employee in healthcare costs, and that those employees were more productive, to the tune of about $1400 per year. As a per-employee benefit, that's notable, and it scales up very quickly into even more significant cost savings in a large company.

While this is only one study, it does accord with earlier unpublished findings that naturopathic medicine reduced healthcare costs and improved productivity at the Vermont Auto Dealers' Association (VADA). The findings were so significant in Vermont, in fact, that the VADA changed its position on insurance coverage for naturopathic services, and helped Vermont to pass legislation that mandated insurance coverage for naturopathic care.

Whether the new study will push insurance coverage in any states is not clear, but in any case, employers should strongly consider providing naturopathic care to their employees, not only to help their employees live healthier lives, but to save money as well. I'm even imagining a slogan: Go Green To Save Green With Naturopathic Medicine.

Let's get out there and make this happen.

How Many Mets Is That?

About a month ago, the Freakonomics radio show asked the question "What's The 'Best' Exercise?" in their weekly episode. This is a tough question, because there are many criteria you could use to assess this question. Does "Best" mean the one that works the largest variety of muscles? The one that we can do starting when we are young and continue until we are very old? Is it the one that provides the most cardiovascular benefit? Is it the one that provides optimal health benefit for the least input? Or is it the most enjoyable? As you can see, this is a hard question to answer.

In some ways, the answer to this question is: The "Best" form of exercise is the one that you will do regularly. Exercise is a habit, and hard work and persistence are more important than scientifically proven results. A "beach-ready" body that you have one summer when you are 24 is less valuable than the more moderately toned one you maintain for decades. Thus, the exercise that you find enjoyable enough to engage in regularly is the "Best" one. By far.

That said, there is some interesting research out there on the "value" of some forms of exercise as opposed to others, and the best way to quantify this is by using the MET as a unit of measure. MET stands for Metabolic Equivalent, and is a way to quantify the amount of energy burned by a given activity. 1 MET, for example, is roughly equivalent to sitting quietly, whereas walking at a slow pace has a MET value of 2, or twice that of sitting quietly. The higher the MET value, the greater the energy expenditure for a given activity.

But how do we use this information? What are various activities "worth"?

Well, Freakonomics would direct you to this document, produced by the CDC, which gives some examples of moderate and vigorous activity. You might find this helpful, or you may find it a bit difficult to navigate. I'd refer you instead to this website, which provides lists of all kinds of activities, grouped into categories such as Bicycling, Dancing, Home Repair, and Sports. Just about any activity you can think of has been measured and updated over the past 20 years.

While some of this information is what you already know - e.g. basketball requires more energy than billiards - it's still helpful for those who are considering picking up a sport for health benefits. But again we come back to the important question of what kind of exercise you will stick with. Running at a 10 minute/mile pace has a higher MET value than basketball, but the social reinforcement of a team sport is likely to keep you engaged over a long period of time. So take the information with a grain of salt. One form of exercise may burn more calories than another, but if you won't do it, is it worth investing in?

After all, what do you want to do to keep active?

Old Wive's Tales?

The legislative effort continues in Maryland, and in the past week, I have testified to both the Maryland Senate Education, Health, and Environmental Affairs Committee, and the Maryland House Health and Government Operations Committee on the topic of naturopathic licensure. What a week it's been! If you're a Maryland resident and are interested in contacting your representatives about naturopathic licensure, click this link and you'll be brought to a page with simple instructions.

Meanwhile, I was sent this charming infographic by a friend of mine. I can't say I agree with everything it presents (the lack of citations makes it hard to verify info), but this is a great starting point for a conversation. Naturopathic medicine is often maligned as a collection of "old wives' tales," but nothing could be further from the truth. Naturopathic doctors are actively involved in research efforts, and of course pay attention to the latest news from around the scientific world. So which of the following are old wives' tales? Ask a naturopathic doctor to find out!

The Legislative Effort Continues

This week, naturopathic doctors from around Maryland came to Annapolis to talk with legislators about the importance of licensing and regulating the practice of naturopathic medicine. This is the fourth year that the MDANP has been at work in its legislative effort, and in honor of the effort, I'm posting a map showing the US states and territories that currently license naturopathic doctors (in green) and those that will be debating the issue in 2014 (in yellow). Currently, a third of states license naturopathic doctors, and many more will consider doing so in 2014. While I work in a profession characterized as fringe, I hope this map makes clear the fact that naturopathic medicine has moved into the mainstream. And really, why wouldn't it? With a clear focus on prevention, treatments that offer cost savings, and an extremely low incidence of malpractice or harm, naturopathic doctors offer the nation something important at a time when it's needed more than ever before. If you haven't before, take a minute this week to find out what the naturopathic professional organization in your state is up to; you might even pitch in!

Simple Pleasures

Simple recipes are often the most difficult. While large ingredient lists are imposing and can offer the logistical challenge of managing a massive number of ingredients and preparation, a long list of spices often brings with it a strong-enough flavor that it can cover up sub-par technique and preparation. It's ironic, but true. It's easier to get results with complicated recipes. In contrast to that, I'm offering a simple but sublime recipe adapted from Claudia Roden's The Food of Spain. Rather than a curry with a list of 15 spices alone, this is a simple dish prepared from a few ingredients and spiced only with garlic and paprika, and yet the results are fantastic.

1 cup dried chickpeas soaked overnight or 1 15 oz can chickpeas
Salt
1/4 cup olive oil
A whole head of garlic
1 cup dried raisins, soaked in water for 20 min
1 teaspoon sweet paprika
5 cups chicken stock
2 1/2 cups arborio rice

Drain the chickpeas, and bring to a boil in fresh water. Reduce heat to low and simmer for 1 hour, adding 1 tsp salt.
Preheat your oven to 400 degrees.
Peel and chop the garlic cloves, and drain the raisins.
Heat the oil in a medium size pot or casserole that can go in the oven. Stir fry garlic and raisins in the oil for 2-3 minutes, until the aroma arises from the garlic. Add paprika and stir well, then add chickpeas, stock and another teaspoon of salt. Bring the mixture to a boil and add the rice. Stir well to achieve a consistent mixture.
Bake in the oven for 30 minutes, until the rice is al dente.

Simple, yes. Wholesome, yes. Sublime, yes as well. This is a great, filling Spanish delight that will surprise you with its fantastic taste and elegance. It's as well suited to a dinner party as it is a simple family meal. Enjoy.

The 50th Anniversary of an Important Moment

Fifty years ago this week, the Surgeon General of the United States, Luther L. Terry, released Smoking and Health: Report of the Advisory Committee to the Surgeon General, an important milestone in the effort to control tobacco as a public health hazard. While studies from the early 1950s had already indicated that smoking caused lung cancer, and prior studies had shown correlations between smoking an risk of premature death, the report of the Surgeon General made it the opinion of the United States government that smoking was a significant health hazard, and should be controlled by legal means. In that time, we've seen efforts to restrict the purchase of tobacco, the act of smoking, and many, many taxes levied on tobacco, all in an effort to reduce smoking and tobacco consumption.

I won't belabor the point here, so I'll simply point out that the Journal of the American Medical Association has devoted its entire issue to the anniversary of this important event, and also note two studies published in JAMA this month.

The first study found that since the publishing of the Surgeon General's report in 1964, an estimated 8 million smoking-related premature deaths have been prevented in the United States. While lifespan has increased overall since 1964, smoking restriction has added 2.3 years to life expectancy for men, and 1.6 years to life expectancy for women. My own conclusion is that it's been no small potatoes.

The second study found that global smoking rates have decreased for men from 41% in 1980 to 31% in 2012, and for women from 11% in 1980 to 6% in 2012. While this is excellent news - it means that global smoking rates have decreased by over a third - the total number of smokers has actually increased as the global population has increased, so we still have lots of work to do.

As we move forward into the second 50 years of tobacco restriction, and especially as we now see the rise of legalized marijuana consumption, let's not ignore the important work that still must be done, while we celebrate that this global effort has had excellent success.

Vitamin E Surprises Me

Most of the articles written here are meant to be free-standing, so that anyone who happens across them will be able to benefit, but regular readers of my blog will benefit from their experience in reading my blog post today.

To set the scene: Three weeks ago, I made an off-hand comment about the rise and fall of vitamins, mentioning specifically vitamin E. Vitamin E was the focus of a lot of attention many years ago, when it was believed that use of high doses of the antioxidant vitamin might prevent cardiovascular disease. Since then, however, it has fallen out of favor, and is now believed by many to have been over-hyped. Further studies of vitamin E have failed to verify the benefit, and so I tend not to recommend it much, or at least not to patients with cardiovascular disease. In my most cynical moments, I dismiss vitamin E as a fad of a prior time.

Then, two weeks ago, an editorial in the Annals of Internal Medicine came out slamming vitamins in general and vitamin E in particular. I deconstructed that article and argued that it was riddled with problems, but as it relates to today's posting, the editorial suggested that vitamin E was ineffective for, just about anything, and was also probably unsafe.

It turns out that I was wrong to dismiss vitamin E, and so was the Annals of Internal Medicine. Just two days ago, an article was published in the Journal of the American Medical Association that found that vitamin E may provide benefit as an adjunct treatment in Alzheimer's disease. Further confirmation is necessary, but the findings were significant and worthy of attention because of their clinical utility - researchers posited that vitamin E delayed progression of symptoms by about 19% per year in Alzheimer's patients. Additionally, no ill effects were noted over a mean follow-up time of about two years.

I'm not going to discuss the results of the study here, however. Rather, I'm going to make an important point about research. The editorial published in the Annals of Internal Medicine was rash in its suggestion that physicians stop recommending supplements, consumers stop buying supplements, and researchers stop investigating supplements. I argued that broad, blanket statements like this one rarely, if ever, hold up to scientific scrutiny, and less than two weeks after publication, we've already started chipping away at the editorial by way of a peer-reviewed study published in a major medical journal. Broad statements that do not take into account nuances, or indeed evidence, are bound to fail, though they may be partnered with major media campaigns.

The second point is this - clearly I was wrong too. Medicine, despite its attempts to pursue neutrality and evidence, is subject to fads - treatments of all kinds come in and out of favor, and it's not uncommon for clinicians to discount older therapies in favor of newer ones. And lo, I was guilty as charged. Though the evidence for vitamin E in cardiovascular disease remains weak, I was wrong to dismiss the supplement altogether as a fad that lost favor. Vitamin E may indeed hold promise as an effective treatment for other conditions, and I'll now continue to keep an eye out for research.

The point is this: It does no one any favors to close doors in medicine. When we do so, we're inevitably proven wrong. While evidence may lead us away from going to a certain treatment for a certain condition, we should never discount that treatment entirely. I hope we've all learned our lesson today.