From time to time, I get to recommend to a motivated new patient with mildly elevated blood pressure that he or she try the “DASH” diet prior to considering medication.  The DASH diet, which stands for “Dietary Approaches to Stop Hypertension,” and has been recommended by the National Institutes for Health, the National Heart, Lung, and Blood Institute, and the American Heart Association, lowers blood pressure within 2 weeks.  You can check it out yourself at dashdiet.org.

The DASH diet is based on 1) increasing fruits and vegetables, whole grains, nuts, and dairy; and 2) decreasing fat and sugar.  Specifically recommended for lowering blood pressure, it also lowers weight, and the risk of stroke and heart disease.  Combined with exercise, it improves insulin resistance, which decreases your risk of developing diabetes.  The benefits have been seen in people of all ages, from teens to the elderly.

You can see that there is significant crossover between my four recommendations and the DASH diet, although we do part company on the amount of grain it recommends and the preference for low-fat dairy.  Let’s just say I respect the fact that everyone is different, and that some folks seem to tolerate grain (whole-grain only) better than others.  If the low-fat dairy recommendation confuses you, I recommend that you do your own little experiment:  Follow the DASH diet as written for a month or two, and then switch to full-fat dairy.  If your pants get tight or your weight (or blood pressure) rises, then you’ll have your answer.  But just for the record, I don’t believe that will happen.  I don’t believe that the fat in dairy and meats is unhealthy.  In fact, I believe those fats are nutritious.  It’s the fats in fast food, snack foods, and commercial baked goods that are the big problem.  All fats are not the same (see “Butter is better.”)

A new study shows that the DASH diet plus regular exercise improves not only blood pressure, but brain power as well.  In a March 2010 study published in Hypertension: Journal of the American Heart Association, 124 men and women were divided into 3 groups.  Over 4 months, one group followed the DASH diet and exercised for 30 minutes three times a week, a second group followed the DASH diet without exercise, and a third group changed neither their eating patterns nor their level of activity. At the beginning and end of the study, participants underwent a series of tests that assessed mental skills such as manipulation of ideas, concepts, and planning.  The people who combined aerobic exercise with the DASH diet experienced a 30% improvement in brain function, improved their cardiovascular fitness, lost 19 pounds on average, and lowered their systolic blood pressure (top number) by 16 points and diastolic blood pressure (bottom number) by 10 points.  Wow.  That’s the group I want to be in.

High blood pressure is epidemic in our country.  It affects at least one-half of adults aged 60 and older and increases the risk of heart attacks, strokes, kidney disease, and dementia.  So why don’t we all eat the DASH diet?  Why don’t all newly diagnosed hypertension patients get referred to a nutritionist to learn to eat this way?  Come to think of it, why should you have to wait until you’re diagnosed with high blood pressure?  Why aren’t school lunch programs based on the DASH diet?  And why don’t children learn these basics in their science and nutrition classes?  I am more than ready to spend my days teaching people how not to become hypertensive and diabetic.  Any takers?

How to start improving your nutrition?  Since the average American gets only 2-3 servings of fruits and vegetables each day in total, the DASH diet involves a significant increase in the amount of produce consumed.  As usual, I don’t recommend jumping in all at once.  Instead, pick something from the list below.  In a few weeks, add another choice, and then another a few weeks later.  At some point, you will notice that you feel a lot better.  Then, if you’re like most people, you’ll go back to your old habits.  Don’t worry, it’s temporary.  You just need to see if it’s really the dietary changes that are responsible for the fact that you feel better.  That’s human nature, and it’s how we convince ourselves which investments are worth it.  Don’t take my word for it — take all the time you need, and figure it out for yourself.

Here are some ways to get started:
.Add a serving of vegetables to lunch and dinner.
.Bring a piece of fresh fruit to work for midday snack.
.Switch to butter, and make your own salad dressing (see “What’s in that salad dressing?”).
.Use vinegar, herbs, and spices instead of salt.
.Have a glass of milk or a piece of cheese or a serving of yogurt three times a day.
.Limit meat to 6 ounces a day.  Be aware of portion size; we all need to know what an appropriate serving size looks like.
.Change from white rice and conventional pasta to brown rice and whole-grain pasta.
.Eat more beans (see “The Lovely but Lowly Bean“).
.Choose cheese sticks, nuts and nut butters, raisins and other dried fruits, yogurt (see “Everything You Always Wanted to Know About Yogurt But Were Afraid to Ask“), fresh fruits and vegetables for snacks.

Bon appetit!

Many commercial salad dressings drown your fresh, delicious and nutritious food in water and corn syrup.  Not only do they waste your money, but they convert your salad to a wolf in sheep’s clothing. 

This morning, I stopped at the local supermarket to look at the ingredient lists on four popular brands of salad dressing.  You will be very interested to learn what I discovered.  The first product I picked up was Wishbone Italian dressing.  Its first ingredient is water.  Seems like a very expensive way to buy water.  And surprising, too, given that Italian dressing is traditionally made from olive oil and vinegar.  Not this Italian dressing, though.  After the water, its ingredient list contains soybean and canola oil, distilled vinegar, sugar, salt, dehydrated garlic and onion and red bell pepper, maltodextrin, xantham gum, spices, autolyzed yeast extract, EDTA, natural flavor, lemon juice concentrate, caramel color, and annatto, which colors the dressing yellow, more like olive oil, which it does not contain.

The second product I picked up was Hidden Valley Fat-Free Ranch.  Like the Wishbone Italian, the ingredient list starts with water, followed by corn syrup, maltodextrin, sugar, and modified food starch (usually made from corn or wheat, whichever is cheaper at the time of purchase).  These are four different ways to say “sugar,” which, of course, significantly raises the amount of insulin required to metabolize your food.  The 6th ingredient is protein-rich buttermilk, of which there must be very little since the nutrition information lists 0 grams of protein.

Next I checked Kraft Catalina, a sweet, French-style dressing.  The first ingredient was high-fructose corn syrup, followed by water and tomato paste (called “tomato puree”), soybean oil, vinegar, salt and 12 more ingredients that constitute less than 2% of the total.  These include red dye 40, yellow dye 6, and blue dye 1, which probably account for the unusually deep orange color of the product.  Two tablespoons of Catalina salad dressing contain 10 grams of carbohydrate, most of which (9 grams) is sugar.  It’s a lot like pouring pancake syrup on your salad.

The last dressing I examined was Kraft Balsamic Vinegar.  Once again, the first ingredient was water.  Then came “vegetable oils” (further defined as “canola, soybean, extra virgin olive oil”),  followed by “balsamic vinegar” (wine vinegar, grape juice, water), and the usual long list of ingredients each of which constitutes less than 2% of the total.  I  have a much better, simpler recipe.  Mix 3 tbsp. of olive oil with 2 tbsp. balsamic vinegar.  Toss over washed lettuce greens just before serving.

So what’s the alternative?  I picked out a few of my favorite salad dressing recipes for you to try.  The directions for all of them are the same:  Combine ingredients in a small bowl, mix or whisk until blended, and refrigerate.  All of these dressings are flavorful and nutritious.  If you are sensitive to salt, just skip it.  There is plenty of flavor with or without the salt.

1) Balsamic Vinaigrette (a bit more involved than the very simple recipe above) is made with 1/4 cup balsamic vinegar, 1/4 cup extra-virgin olive oil, 2 tbsp lemon juice, 2 tsp soy sauce, and 3 garlic cloves mashed to a pulp with 1/2 tsp coarse salt (use a fork or a mortar & pestle), and fresh ground pepper to taste.

2) Tahini Salad Dressing (one of my long-time favorite salad dressings, and really delicious on a Lebanese salad composed of 2 small diced cucumbers, 2 small diced tomatoes, 3 diced radishes, 1 sliced green onion, 10 sliced mint leaves, and 1/3 bunch parsley, chopped) is made with 1 minced clove of garlic, 3/4 cup tahini (sesame seed paste, available everywhere), 1/4 cup lemon juice, and 2 tbsp olive oil, with salt to taste.  This dressing will only stay fresh for a few days.

3) Classic French Vinaigrette is made with 1/2 cup white vinegar, 1 tbsp honey, 1 tbsp prepared Dijon-style mustard, 1/2 tsp ground black pepper, 1 tsp salt, 2 tsp minced garlic, and 1 cup olive oil.  Adding 2-4 drops hot sauce is also an option, although it will no longer be a classic french vinaigrette.

Try one or more of these and let me know what you think.

Last summer, egg production was way down.  Soon after our 3 beautiful Hamburg chickens arrived, we went from 1 or 2 eggs a day to maybe 1 egg a day to sometimes no eggs.  Then a whole week went by without a single egg.  It soon became clear that something was not right.  They looked okay, at least at first.  Friendly, healthy, happy.  The dappled sun shone down through the leaves of the oak tree under which their coop was situated, and flattered their beautiful black and white feathers.  Every morning they looked forward to the delivery of their breakfast, and they chirped eagerly as I crossed the lawn to the coop.  But there were no eggs. 

I checked the inventory:  fresh water, laying mash, oyster shell, plenty of leftover fresh produce.  What was missing?  The girls’ feathers were starting to fall out.  And their bright red combs were starting to fade.  They were starting to look a little drawn.  Now what?

Whereas I usually take to the books for answers, my husband takes to the road.  Sure enough, in short order he had made a new friend, an elderly gentleman who had spent decades raising racing pigeons in, of all places, the same town we live in!  His flock had once numbered upwards of 300 birds, and he had had ducks and chickens as well.  He knew his birds, and he was pleased to help.  He emphasized that he would have to see the coop. 

The following Sunday the birdman and his young assistant pulled up in a small truck.  The assistant hopped out, leaving the knowledgeable birder in the driver’s seat.  From his truck’s location at the bottom of our driveway, the birder could just barely see the corner of the coop peaking out from behind the great oak.  He explained that the weather had kicked his arthritis into high gear, so he would have to stay put while his assistant took a look around.  The assistant returned to report that the coop itself looked great.  Our carpenter’s father-in-law’s old clothes pole made a perfect roosting post.  The nesting boxes were just right.  The water was clean.  So what was the problem?

The birder listened to his assistant, nodding carefully, and then leaned forward.  He raised up his nose, and drew his eyes in toward the center of his face as he focused in the direction of the birds.  He could not actually see them from where he sat.  We waited.  I didn’t breathe for a few seconds.  Then he delivered the verdict :  There’s not enough light.  That perfectly protected little spot under the oak was not so perfect after all. 

We spent a few days assessing our options.  We let the girls out to run around and hoped they would stay near the coop.  They did not.  We admitted the obvious, and drove to Lowe’s.  Twenty-one metal stakes and 150 feet of chicken wire later, we had expanded the girls’ playground into the bright sun.  We flung open the coop door, and they jumped out, eager to explore their newly extended surroundings.

So here is what we learned:  Chickens need sunlight.  This makes me think about the epidemic of Vitamin D deficiency in Cleveland and elsewhere.  I read once that Nordic moms bundle their infants and place their carriages outside while they sleep so their tiny pink faces are exposed to the sun.  I already knew that people and vegetables need sun to grow.  I didn’t realize that birds need sun, too.  Vitamin D isn’t just good for your bones.  It strengthens your immune system.  It makes your insulin work more efficiently.  Make your insulin work better, and you will lower your risk of becoming diabetic.

I belong to a terrific gym, and I really enjoy going there with my family.  But it does not take the place of a walk in the light of the day, even if it isn’t exactly sunny.  Barring blizzards, floods, tornadoes, and temperatures in the single digits, I try to get out for a walk every day.  It makes an enormous difference in my waistline, my outlook, and my overall health. 

I encourage patients to commit to a 5-minute walk every day, outside if at all possible.  Maybe 10 minutes, depending on how sedentary they are — the last thing I want is for folks to start walking 30 minutes a day, get shin splints, and then have to sit still and heal for 3 months.  So I say, “Start slow.”  Maybe in a month or two you can increase to 7 minutes, or 15, depending.  If the weather is not to your liking, walk in hallways, or at the mall, if there is one nearby.  The closest mall to where I live is filled with brisk walkers every morning. 

The key to exercising is to do it at the same time every day.  To illustrate why, allow me to ask you a couple of silly questions:  “Do you brush your teeth?”  Of course you do.  “What time?”  “In the morning,” or “Morning and night.”  So now we’ve established that you brush your teeth every day at the same time. 

What if I were to tell you that the research now shows that you get the same benefit if you brush your teeth just 3 times a week (not true, but stick with me…)?  But here’s the rub — it has to be on Tuesdays at 10 am, Thursdays at 7:30 pm, and Saturdays at 4 pm.  We would never brush our teeth!  But that’s how we expect ourselves to exercise, and then we get frustrated with ourselves when we don’t.  So the key is to exercise at the same time every day, seven days a week.  Then you don’t have to think about it.  You just do it. 

Next scoop:  Golden Buffs arrive to share the coop, grow up, and start laying eggs.

     Recently, my old friends and neighbors, Marc & Suzanne, sent me this note about the blog:  “We love it!  Thank you for sending it.  We are not doing so well, weight wise.  We cook the healthy food, eat it, eat it again, eat it all, and then have dessert.”  This week’s post is about portion control.

     Yesterday I sat on a cozy couch with a group of friends, and we worked on a few recommendations to help people with portion control.  The first recommendation was to divide food into single-size portions right when you bring it home from the store.  In my house, I empty 2 large bags of peanuts into a bowl, then measure 1/4 cup of peanuts into each of about 18 baggies, knot each one, and then toss them all into a tin can for retrieval later, one at a time.  I am not a big fan of pre-portioned foods like granola bars and cereal bars, because they contain way too much refined carbohydrate and way too little nutrition.  If the ingredient list contains items not normally found in my kitchen, it’s not really food.  If it’s something my great-grandparents would not have recognized as food, it’s not.  But slicing up an apple or a grapefruit in advance, or grabbing a bag of nuts, ready to eat, is a great idea.

     Recommendation #2 was to serve meals on smaller plates.  Dinner plates, like our expectations about the size of a normal portion, have gotten larger over the past few decades.  You can fix that simply by using plates that are called “salad size.”  Or you can cover that large dinner plate (formerly the size of a typical serving plate) with a large amount of greens or salad, and place your other delights on top.  Of all the commercial diet programs, Weight Watchers does the best job helping adherents to learn to eat appropriate amounts of food.  In part, this is because they teach people to eat real food, and not prepackaged foods and supplements.  Teaching portion control is Weight Watchers’ greatest strength.

     Recommendation #3 was to serve food plated instead of family-style, and even to place the leftovers in the refrigerator before the meal begins.  A related recommendation, one that I’ve seen in action especially in my skinny friends’ homes, is to serve buffet style in the kitchen while guests eat in the dining room, necessitating that the diner rise and leave the table to get a second or third helping.  One variation on this theme would be to bring items like salad, pickles, and olives and so forth to the table, but to keep the other foods on the buffet. 

     Recommendation #4 was to savor the flavor, let chocolate melt on our tongues, eat at the table instead of in front of the television set, and be “in the moment.”  My friend Joe calls this “food consciousness.”  This morning for breakfast, I cracked a golden-orange yolked egg into hot butter, cooked it “sunny-side-upside-down,” slid it onto a small plate, and carried it to the kitchen table to be eaten in the light of the early morning sun.  I made sure to appreciate and enjoy the flavor of each bite.  I allowed nothing to disturb my concentration.  The egg was delicious.  How do I know?  I tasted every bit.   

     Recommendation #5 was to serve soup first.  It’s satisfying and flavorful, fills the belly with a volume of liquid, and gives the brain time to receive the message of satisfaction.  That way, hopefully, you will be less likely to overeat the next course.

    There are any number of reasons why people overeat.  The first and most obvious reason is hunger.  After we eat, it takes about 20 minutes for the signal to reach our brains.  So that’s how much time you need to wait to know if you are satisfied.  Before 20 minutes goes by, you can’t tell if you have had enough to eat.  So if you keep eating during those 20 minutes, you will end up feeling uncomfortably full.  Assuming your insulin levels are normal, that is.  Remember that high insulin levels coat the satiety centers in your brain and make it very difficult to tell whether or not you are full. 

     All kinds of cultural rules have evolved to help individuals regulate their appetites.  The French generally do not take seconds, nor do they snack between meals.  That’s much easier when you’ve eaten a tasty, satisfying, and enjoyable meal.  Parents in a community in the southeast Pacific teach their children to stop eating when they are 80% full.  That gives their brains time to catch up with their stomachs. 
 
     My friend asked me to talk about emotional eating, especially after dinner.  Oprah says that stopping eating at 7 p.m. each night was the single most constructive improvement she made to her eating patterns.  The importance of eating breakfast in this situation cannot be overemphasized.  If you have not eaten the amount of fuel (i.e., food) you need by the time you get up from the dinner table, you will eat the rest after dinner.  And then you won’t be hungry when you wake up in the morning.  To help you out of this vicious cycle, eat some protein for breakfast.  Cereal does not count.  This may not solve the problem entirely, but it will help.  For more help with emotional eating, read Dr. Sara Stein’s very special new book, Obese From The Heart.

     We are programmed to eat when there is food.  Only recently, evolutionarily speaking, have we become absolutely sure when we will be eating our next meal.  Only recently have large numbers of people found themselves in the midst of endless plenty.  So only recently have we needed to learn how to stop eating.  It goes against our natures, and this is why it is so challenging.  Nevertheless, I strongly believe that if we work WITH our metabolism, instead of AGAINST it, we will find it much easier to defer that second helping until it’s time for our next meal.  Then it won’t be a second helping.  It will be dinner.
 
     At the end of the meal comes dessert.  Dessert in our home consists of fruit.  Not fruit cups, or fruit roll-ups, or Fig Newtons.  Fruit.  A bowl of blueberries or strawberries.  Sliced kiwi or oranges.  Sometimes with a few squares of dark chocolate.  When company comes, we may go all out and serve ice cream, or my husband’s delicious banana-chocolate-chip cake.  Or both.  One serving, for special occasions.  Eaten slowly and savored for its unbelievably satisfying flavor.  Then I carefully wrap and freeze the remainder for another special day.  There will always be another special day, and another opportunity to enjoy a treat.  I promise.

“We know there is a deep reservoir of food wisdom out there, or else humans would not have survived to the extent we have.  Much of this food wisdom is worth preserving and reviving and heeding.”  
                                   — Michael Pollan in Food Rules: An Eater’s Manual.  

    It occurs to me that there is a great deal of wisdom in the advice we receive at the dinner table, and I’ve been collecting it for years.  I heard some of these aphorisms at home, and I heard others elsewhere: “Eat your vegetables,”  “Chew your food,”  “Breakfast is the most important meal of the day,” “Eat slowly,” “Don’t eat standing up,” and — my favorite —  “The more colors on your plate, the better.” 

    There is more to these sayings than meets the eye.  We have a lot of innate knowledge about food.  For example, it now appears that chicken fat has antiviral properties.  That makes a lot of sense to me.  Why else would my medical school classmate, Xenia, have brought me chicken soup when I had a cold?  Everyone knows that you’re supposed to drink chicken soup when you’re sick.  Now it turns out that it’s not just about the steam. 

    Then there are beans.  Beans are the only food in the universe that are high in both protein and fiber, and that makes them delicious, nutritious, and satisfying.  We teach our children that beans are magic.  Every culture has its “Jack & the Beanstalk” story.  Beans are on the list of foods that prevent diabetes and obesity.  Yet considering they’re so good for us, we don’t eat very many.  People aren’t even sure what to do with them anymore.  Over the past 100 years, home-based food wisdom has been a major casualty of the industrialization of food, and beans are a good example.  

    Recently, I found a 1991 article from the NYTimes, “To Reclaim Their Health and Heritage, Arizona Indians Reclaim Ancient Foods,”  http://www.nytimes.com/1991/05/21/science/to-preserve-their-health-and-heritage-arizona-indians-reclaim-ancient-foods.html?scp=2&sq=chia+seeds&st=nyt about native Americans learning methods of food preparation traditionally used by their ancestors.  A return to a diet consisting primarily of beans, greens, whole grains, and high-fiber plant foods will normalize digestion, hunger, blood sugar, and weight.  For all of us.  Beans can be grown, soaked, sprouted, slow-cooked, and dried. 

    I’ve collected a few beanpot recipes for you to try.  They all have in common the same approach.  Collect a bunch of ingredients, throw them into a covered pot, and cook them over low heat for a pretty long time.  You will not be sorry.  These recipes are delicious.  If you’d like to add a meat bone or a piece of flank steak as well, then go right ahead.  And if you have another favorite recipe, please send it in.  We can start a collection.

1. Black-eyed peas with vegetables and pasta

Ingredients:  1/2 lb. dry black-eyed peas; 1 large onion, finely chopped; 2 large carrots, finely chopped; 1 red bell pepper, seeded and chopped; 1/4 c. tomato paste dissolved in 1/2 c. water; 4 garlic cloves, minced; 1 bay leaf; 1 dried hot pepper or 1/2 teaspoon hot pepper flakes; 1/4 c. extra virgin olive oil; 1/2 c. elbow macaroni or small square Greek egg noodles; 1 c. chopped cooked spinach or greens; 2 tbsp. red wine vinegar.

Directions:  On the stove, boil the black-eyed peas in a large soup pot for 5 minutes, and drain.  Add onion, carrots, pepper, pasta, tomato paste, garlic, bay leaf, hot pepper and 1/4 cup olive oil to soup pot.  Cover with water by 2 inches, cover the pot, and place it in a 300 degree oven for 2-3 hours.  Taste and adjust seasoning.  Stir in the greens, 2 more tbsp. olive oil if desired, and vinegar.  Allow to cool for about 10 minutes before serving.

2. White baked beans

Ingredients: 1 heaping c. dry white navy beans, 1/4 c. dry chick peas, 1 large onion, chopped; 4 carrots, peeled and sliced in small rounds; 3 tbsp. hot sauce; 2 tbsp. brown sugar, 1 t. salt, 4-5 c. water, and  4 whole raw eggs, in the shell.

Directions:  Start this the night before, if you plan to eat it for lunch.  Or before 8 a.m. if it’s going to be dinner.  Place ingredients in a deep casserole dish.  Add enough water to cover the ingredients by two or three inches.  Cover the bean pot and place into a 250 degree oven.  Turn it down to 200 degrees after a few hours.  Check it a few times to make sure there is enough water just to cover the beans.  The eggs absorb flavor across the shell and become the most amazing hard-boiled eggs you’ve ever eaten. 

3. Exotic white beans (Thank you, Jean!)

Ingredients: 1 c. dry white beans; 1 large red onion, chopped; ¼ c. sundried tomatoes; 2 tbsp. brown sugar; 1 t. salt, 1 tbsp. thai roasted red chili paste, 5 c. water.  Directions identical to #2, although Jean said that somehow she cooked the beans at 350 for 3 hours, and then 250 for a couple more hours, and then accidentally turned off the oven overnight.  The beans were soft and delicious anyway.  These recipes are very forgiving.

4. Black beans

Ingredients: 1 c. dry black beans; 1 large onion, chopped; 4 cloves garlic; 3 tomatoes; 2 oranges, peeled and chopped into small pieces; 1/2 t. red pepper flakes; 3 tbsp. molasses; 1 t. salt; 5 c. water.  Directions identical to #2.

    Many years ago, my then-vegetarian sister had a boyfriend whose mother served her “bean loaf” on her first visit to their home.  Its dreadfully unappetizing name was nothing like its flavor.  We renamed it “chickpea pie,” and it stuck around for much longer than the vegetarianism (and the boyfriend).  Here’s to the lowly but lovely bean.  And here are a few more of my favorite sayings.  “Eat close to the garden.”  “Don’t buy products whose ingredients you can’t pronounce.”  “Don’t buy products with more than four ingredients.”  “Choose foods that have been through as few machines as possible.”  These are all different ways of saying the same thing: Eat food, not manufactured calories. 

Lately quite a few people have asked me to explain how I became interested in nutrition, and in preventing diabetes (type 2) and obesity.  Some time ago, after I had been practicing medicine for a few years, I noticed something very odd.  Not only had I recently diagnosed more than the usual number of cases, but they were mostly in a select group of new patients.  This select group consisted almost entirely of spouses of my diabetic patients.  Now I had learned in medical school that the tendency to develop diabetes is genetic.  That means you would be more likely to become diabetic if one or especially if both of your parents were. 

But none of my professors had said anything about spouses.  Spouses are not generally related to one another.  But here it was.  One after another, the spouses of diabetic patients were arriving at my office with diabetes.  What did these husbands and wives have in common?  It was not their genes, of course.  It was their eating patterns. 

So I started to look at how, what, and when they ate.  They kept food logs.  They checked their blood sugars before meals, after meals, even in the middle of the night on occasion.  They collected nutrition labels and we worked together to make sense of them.  Then they began to make changes, big and small.  These changes developed into the four recommendations that I promulgate for preventing diabetes and obesity. 

There is more to this story.  Years later I, like all of America, watched the people of New Orleans struggle to survive in the aftermath of Hurricane Katrina.  I stared, horrified, at one particular news photograph of a blanket-covered, wheelchair-bound body, flattened over itself as if tying its orthopedic shoes for eternity.  My physician’s eye was seeing a second, deeper layer of tragedy below the surface, but what?  I continued to stare at the photograph until I realized that it symbolized to me the awful consequences of uncontrolled diabetes. 

For the individual in the photograph, Katrina was likely the last in a long series of humiliations.  The disease’s destructive course speeded up by the storm, there was no alternative ending.  Diabetes stole her ability to regulate her fluids, to monitor her sugars, to stand and walk.  Diabetes destroyed her ability to adapt to the environment.  Then came the storm.  Unable to survive the heat, dehydration, starvation and immobility in this inhospitable place from which there was no escape, she died. 

The twin tragedies of Katrina and diabetes became linked in my mind.  As harsh a blow as the storm was to the people of New Orleans, diabetes made it even more difficult to survive.  Diabetes does that.  No matter what your circumstances, it makes it that much harder to survive.  Katrina didn’t make diabetes more destructive, but it did show me how profound that destructiveness is — and how urgent is the need to prevent it.  After Katrina, I became more committed than ever to preventing diabetes.

Annual diabetes costs in the U.S. topped $218 billion in 2007 and are expected to rise to $336 billion by 2034.  Diabetes is devouring our healthcare dollars, felling our workforce, and exhausting the resources of millions of families.  Diabetes affects almost 21 million Americans, an estimated 6 million of whom have not yet been diagnosed.  It is the number one cause of acquired blindness, non-traumatic leg amputation, and kidney disease leading to dialysis.  Two-thirds of diabetic individuals die from cardiovascular disease, the number one cause of death in this country.  Diabetics are two to four times more likely to suffer a heart attack or stroke than non-diabetics.

If we are going to optimize our overall health as a nation, direct public health resources most effectively, and be in the best possible shape to prepare for emergencies if and when they do occur, we must all learn to tell the difference between real food and manufactured calories. 

I tell patients that my goals are a little different from theirs.  My goals include maintaining normal blood pressures, preventing kidney damage, monitoring blood sugars, updating immunizations and screenings.  But you have just one goal — to dance at your grandchildren’s weddings.  That is my wish for you.  To your good health!

This week I received a letter asking how insulin causes us to gain weight and store fat.  “How does too much insulin make one fat?,”  commented the writer.

And the answer is: “We don’t exactly know yet.”  But we’re figuring it out, a little at a time.  The biochemists, who work at the cellular level, appear to be figuring it out first.  The rest of us can tell firsthand that the information we get from TV advertisements and cereal boxes doesn’t help much.  The fact that our epidemic of obesity and diabetes is getting worse all the time shows that this information isn’t accurate.  If things continue to get worse no matter how hard you try, it’s time to reexamine the fundamentals.  If you can’t stop your head from hurting no matter what you do, it’s time to stop banging it against a wall.  There is a name for nutritional claims on food products.  It’s called advertising.
 
OK, so what do we understand?  We understand that insulin (and other enzymes) is released in response to some kind of signal that is sent to the pancreas (and other parts of the gut) when we start to eat.  There is new evidence that this signal is actually sent in anticipation of eating, in other words, BEFORE the food actually enters our mouths.  This is not a surprise to me.  Our own language actually contains evidence of this phenomenon in the expression “mouth-watering.” 

We understand that food causes your blood sugar to rise, as it should, and that the pancreas releases insulin in response to those rising blood sugars.  The insulin escorts the sugar to cells, sugar is thus removed from the bloodstream, and blood sugars return to their pre-meal levels. 

In a previous post, I discussed the fact that the faster you absorb your food, the faster your blood sugar rises, and the more insulin you need to catch the sugar and remove it from the bloodstream.  Insulin is the fat-storage hormone; the more insulin we use, the more fat we store.  Also, there is something about the RATE at which you absorb sugar that dictates how much insulin you are going to need.  If all the sugar shows up at once, you need a load of insulin to catch it.  If the sugar drips in bit by bit, you only need a little bit of insulin to catch it.  You can read more about this at my post, “Eating Toast and Jelly for Breakfast Wastes Your Insulin.”

Where does the sugar go next?  Some sugar molecules get used immediately by working muscles and thinking brains.  Some go to our liver, where they are collected into strands of glycogen.  Glycogen strands are like pearl necklaces whose pearls can be popped off later, one at a time, to keep our blood sugars normal between meals and while we sleep.

The rest of our blood sugar gets stored as fat.  That makes sense.  If you don’t need it now, and you have enough for later, then the rest should go into deep storage.  Fat is deep storage.  We store fat in the form of triglyceride, which is a molecule that consists of three fatty acid chains attached to a glycerol molecule.  Glycerol is made from the sugar that comes from the carbohydrates in our diet.  The more carbohydrate we eat, the more sugar becomes available to form glycerol.  The more glycerol we make, the more triglyceride we make and the more fat we store.  The amount of available glycerol dictates how much triglyceride we can make.  So carbohydrate is an essential component of fat storage.  That’s really important. 

Remember that triglycerides are composed of 1 glycerol plus 3 fatty acids.  The source of fatty acids is dietary fat.  Our brains are designed to be able to use as fuel not only sugar, but also fatty acids.  Interestingly, as far as insulin is concerned, fatty acids are a free ride.  You don’t need insulin to catch fat the way you do to catch sugar.  So after fat (in the food we eat) is digested and broken down into free fatty acids, those free fatty acids can either be used right away, or they can be attached to glycerol molecules to make triglyceride molecules.  Then all those triglycerides are stored in body fat.

Triglycerides are a big molecule.  They are too big to move across a cell membrane, so they must be transported across as individual components, and then reassembled into a triglyceride molecule inside the cell.  This reminds me of the huge breakfront that we inherited from my husband’s grandparents and which has sat in my dining room all the years of my married life.  It’s so big that we can’t get it through doorways, so when we have moved we have had to take it apart.  The top detaches from the bottom in a very clever way that always gets my admiration.  It’s an ingenious design that makes it simple to move what would be an unwieldy piece of furniture, and which would otherwise have been obliged to remain forever in the room in which it was built.  In much the same way, triglycerides circulate in the bloodstream and accumulate in cells, but the fatty acids of which they are composed continually pass across cell membranes, cycling into triglycerides and back. 

Now, let’s talk about insulin again.  A great number of hormones in our bodies help to break down triglycerides and release fatty acids for use (as fuel).  But not insulin.  Insulin is the one hormone that facilitates triglyceride storage.  In the presence of insulin, we will always store fat, and not release it.  Insulin is the stimulus for fat storage.  In order to release fatty acids, the level of insulin must be low.  For fat cells to release their fatty acids, there must be a relative deficiency of insulin in the body.  That makes sense, because our insulin levels should be high only when we have just eaten, and that is the one time when there is no need to break down fat to obtain nutrition. 

Therefore, because the high-insulin state prevents mobilization and use of fatty acids, it becomes impossible to lose weight in the presence of large amounts of insulin.  We store fat independent of our food intake, and we gain weight when insulin exerts its effect on body fat.  More as the story develops…

Yogurt is a food product that results from the fermentation of milk by a couple of specific types of bacteria.  It has been around for at least 4500 years, and is clearly a way to preserve dairy products without refrigeration.  Yogurt is real food.  It is delicious and nutritious.  I strongly recommend whole milk yogurt for the same reasons that I recommend whole milk.  Milkfat contains the widest possible variety of nutrients, including all the fat-soluble vitamins, and it helps to slow the absorption of carbohydrate eaten along with the fat.  The more slowly you absorb your food, the less insulin your body needs to release.  The less insulin you use, the more satisfied you are and the less fat you store. 

Now let’s talk about what’s on the shelves at the supermarket.  They may start as yogurt, but they don’t really end up that way.  They end up more like some kind of sweet pudding.  Very, very sweet pudding.  Well, actually, sweeter than pudding.  As we shall see, they contain signicantly more sugar than pudding. 
 
Yogurt without added flavors could be called “pure” yogurt, but it’s not.  It’s called “plain” yogurt.  That’s interesting. A glance at the yogurt flavors at my local supermarket supports the dessert motif.  Product flavors include amaretto cheesecake, white chocolate raspberry, black cherry cheesecake, chocolate eclair, coconut cream pie, caramel praline.  These make the strawberry flavor sound downright wholesome.  The target audience for other flavors, like “Sprinkl’ins Magic Crystals” and “Sprinkl’ins Rainbow Sprinkles,” is children.  See my posts on breakfast cereals, Most Cereals are Like Eating Candy for Breakfast  and  More on Breakfast Candy,  for more on marketing strategies that target children.

What’s bothering me about the yogurt at the supermarket?  Besides the bogus flavor names, it’s one thing and one thing only: the amount of sugar in each container.  I took pen and paper to the supermarket, and copied down the information from the nutrition labels.  The numbers I quote below were relatively consistent across the many different brands I reviewed.  These numbers held true whether the yogurt was made from skim, low-fat, or whole milk.  So here we go.

A single-sized serving of plain yogurt contains 11-12 grams of carbohydrate. These 11 grams of carbohydrate are from lactose, or milk sugar, which is an intrinsic nutrient in all yogurt.  In contrast, a serving of flavored (lemon, vanilla) or fruit (strawberry, peach) low-fat or skim milk yogurt contains 33-34 grams of carbohydrate.  Because milkfat takes up a little space in the container, whole-milk yogurt has slightly less, 31 grams. 

34 (total grams of carb) minus 11 (lactose) is 23.  That’s the amount of carbohydrate added to each single-serving container in the form of sugar.  Each 5 grams of carbohydrate is equivalent to a teaspoon of sugar.  So 23 grams of carbohydrate is equivalent to almost 5 teaspoons of sugar.  This means that each container of yogurt contains close to 5 teaspoons of added sugar.  By comparison, Swiss Miss’s chocolate and tapioca pudding flavors have 26 and 25 grams of carbohydrate, respectively.  Still a lot, but then no one’s trying to disguise the fact that these are desserts.

Now I like sugar in my tea and oatmeal, and even on a grapefruit half now and then.  But 5 teaspoons of sugar is a whopping amount of sweetener.  I’m not recommending that we stop eating our yogurt sweet, by the way.  I am saying that it would be a very good idea to consider buying plain yogurt, and then to add your own choice of fixings. 

Taste is acquired.  In the United States, we are taught from a very early age to prefer sweet flavors.  In the yogurt aisles, demand is met by Dannon, Breyers, Yoplait, and the like.  But restricting yogurt to sweet choices markedly limits your options.  Sweet is not the only way to eat and enjoy yogurt. 

For example, tsatsiki is a Greek condiment made with yogurt, cucumber, dill and garlic.  Indian raita is similar, though it is spiced instead with toasted cumin seed, cilantro, mint, and cayenne.  The cool temperature and flavor of the raita offsets the heat of the spicy curries and chutneys with which it is served.  Yogurt is also used as a chicken marinade in Indian cuisine.  My own father likes to eat his yogurt with fresh, chopped cucumbers and tomatoes, plus a bit of finely diced sweet onion.  He makes it for me sometimes when I come to visit, and you know what?  It’s delicious.  Bon appetit!

For more interesting facts about yogurt, check out http://en.wikipedia.org/wiki/yogurt.