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.)