My mom doesn’t take any diabetes medicine.  She keeps her blood sugars normal through a combination of common sense and careful carbohydrate consumption.  A few months ago, she had to be hospitalized for what she calls a “minor procedure.”  The procedure went fine, but not the food.  The first meal they brought her consisted of breaded fish (frozen), mashed potatoes (instant), corn (canned), a dinner roll (frozen), and tea (2 sugar packets on tray).  “If I ate that, my blood sugars would have gone through the roof!” she told me.  She drank the tea, and called my dad, who arrived shortly with chopped salad, roasted peppers, and meat loaf.  This week’s post is about hospital food, if you can call it that.  You are not going to believe what it’s like to order meals for hospitalized patients.

Let’s imagine, for example, a diabetic guy in the intensive care unit.  His blood sugars have been completely out of control, up and down, up and down.  He is recovering slowly from a very serious pneumonia, and is only now beginning to eat again.  The nurse asks if I’d like to order an 1800 kcal ADA diet, which I do not.

An “1800 kcal ADA” diet means 1800 calories total each day, in accordance with the recommendations of the American Diabetic Association.  Their recommended diet is loaded (and I am not exaggerating here) with processed carbohydrate items guaranteed to make it nearly impossible to control one’s blood sugar.  No thanks.

Instead of an 1800 kcal ADA diet, I order a “low-glycemic diet,” which is not actually one of the approved options in the hospital.  I know I’m setting myself up, but there are no other options I can order in good faith.  Real food?  High fiber and protein?  Low-processed-carb?  I wish.  The kitchen sends fake scrambled eggs (beaters) and a large blueberry muffin.  I kid you not.  This is what Sodexo, which supplies the hospital food where I work, actually sent for my diabetic patient a few weeks ago.

It should surprise no one that his blood sugars spike into the 400’s after lunch.  I ask the nurses if we can just get the patient a hard-boiled egg.  No, we cannot.  The hospital does not actually have eggs.  Just beaters.

Patients aren’t the only people who eat in hospitals.  A few years ago I decided to get a cup of coffee in the hospital cafeteria.  I looked for the milk, but there was none.  There were only single-sized servings of flavored liquid non-dairy coffee whiteners.  I don’t use those; they are not food.  I asked for milk and was told I would have to purchase it.

Patients who are less ill than my intensive care unit patient are permitted to choose their own daily meals.  They are provided with printouts, or “menus,” as the Dietary Department calls them, which are simply lists of all the items available for consumption in the hospital.  Patients choose what they like, and a version is prepared that attempts to meet their dietary restrictions.

A common scenario for me, as a physician, is one in which I work to control a patient’s blood sugars in an attempt to heal a leg infection and avoid an amputation.  High blood sugars interfere with healing because they prevent white blood cells from working correctly.  Now, imagine me walking into a patient’s room and seeing that patient eating a bowl of Raisin Bran (one of the highest sugar-containing cereals) on a tray that also contains a glass of orange juice, tea with sugar packets, and 2 slices of toast with margarine.  I know these options will spike my patient’s blood sugars and make it nearly impossible for me to get them under control.  I am wondering why those options were on my patient’s “menu” in the first place.

If it weren’t so serious, it would be comical.  Like putting a humidifier and a de-humidifier in the same room, and letting them duke it out (thank you, comedian Steven Wright!).  I don’t want to duke it out.  I want to be able to ask for, and receive, the tools I need to do my job successfully.  Assigned the task of healing patients and controlling their blood sugars, I expect to be given the tools to do so.  Different kinds of professionals use different kinds of tools.  My first tool is food.

If you’ve been reading along, you know that my friends and I spent a gorgeous October day at Washington’s Grist Mill, on Dogue Run Creek, 3 miles southwest of Mount Vernon.  The current mill is actually a reconstruction of the mill that Washington built in 1771 to replace one his father built on the same spot forty years earlier. 

At Washington’s grist mill, wheat flour and corn meal were made for the plantation, and a super-fine flour was made for export to Europe and the West Indies.  The mill’s power supply came, then and now, from water that is diverted into Dogue Run Creek from Piney Branch, above the mill.  The additional waterflow significantly increases the mill’s production capacity. 

My friends and I also investigated a nearby threshing building.  The round, two-story building, built into the side of a small hill, was constructed with a central post.  Horses walked up a short ramp to the building’s upper level, where the floors were covered with large amounts of cut wheat stalks.  The horses were tethered to the central post.  As they trotted around the post, the stalks broke apart and the straw and chaff became separated from the grain, which slipped through spaces between the floorboards down to the lower level.  Trotting (instead of walking) kept the grain cleaner by preventing horses from passing waste as they moved.  Behind the building, ground level doors opened to rising mounds of whole grain, which were then collected and brought to the mill for grinding. 

Washington’s grist mill, for which Oliver Evans was awarded U.S. Patent No. 3, is the only operating “Oliver Evans Automated Milling System” in America.  Power is supplied by a 16-foot water wheel whose spinning motion turns the shafts, gears, and belts that propel the machinery.  Elevators move the grain vertically between the floors in small buckets attached to an endless belt running inside a closed shaft.  The small buckets dump their contents into a hopper, or container, which sits directly above two large, horizontal millstones.  Grain drops slowly into a central hole leading to the tiny space between the millstones, where it is ground into flour.  If the operator chooses, the freshly ground flour may then be moved into a long, rectangular sieve that retains the coarser materials and allows only the smallest, finest particles of flour to pass through.

Washington’s mill produced a finer, drier flour than had ever before been made.  Previously, hard-wheat milling produced a coarse, brown flour that retained the bran, with its essential nutrients, but Washington’s new automated mill produced a bran-less, superfine flour that was much lighter.  Unfortunately, without its bran it was also less nutritious. 

Washington’s horse-driven threshing house, combined with Oliver Evans’s extraordinary automatic mill, dramatically increased the availability of grain and flour.  The improved efficiency allowed many more people to be fed with less work.  Bread and flour, both coarse and fine, could now be obtained with comparatively little human energy. 

We were starting down a road whose destination we could not see.  At a certain point, the benefits of increasing the quantity of food are outweighed by compromises to the quality of that food.  It would be a couple of centuries before we would reach that point.

For now, Washington and Oliver Evans had figured out how to substitute horsepower and water power for elbow grease. 
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Last week I talked about my October visit to DC with three old friends, and our visit to George Washington’s grist mill.  You might say that it wasn’t exactly at the top of their list, but they are great sports, and we are still friends!  Actually, they agreed it was pretty interesting, and Ronnie even sent me a copy of The Gastronomica Reader (Darra Goldstein, ed.) yesterday. 

This week we continue talking about how the past 200 years of food-related inventions (which decreased markedly the work of gathering, preparing, and metabolizing food) have finally caught up with us.  Less work means easier to digest, which means more insulin.  That’s not what you want.  The more insulin you use, the hungrier and heavier you get.  If your insulin levels are high, you are more likely to be having problems with your blood pressure, fertility, and triglyceride levels.  And the button on your pants.  Not to mention that your blood sugars begin to rise the minute your insulin supplies start running short, which starts to happen about 10 years before you are actually diagnosed with diabetes.  That’s why diabetics usually have about 10 years worth of damage to their blood vessels by the time they are formally diagnosed. 

The 20th century was a time of mergers, acquisitions, efficiency experts, and assembly lines.  Someday, it will also be remembered as the time when we learned how efficient is too efficient, how big is too big.  Too big is when one company’s failure threatens the stability of an entire economy.  The 20th century was a time of substitutions, when we learned to use Crisco and margarine instead of butter and lard, beaters instead of eggs, soda pop instead of milk and water, boxed cereals instead of breakfast, and TV dinners instead of meals.  In contrast, the 21st century is when we began to realize that, at a certain point, food can be so easy to manufacture, acquire, and eat that it becomes costly in an entirely different way. 

Healthwise, we are now paying a very hefty price for the privilege of being the land of good ‘n’ plenty.  Our bodies and metabolisms were not designed to be spoon fed to the extent that we are.  I’m not saying we should thresh our own grain.  I’m saying that since we don’t, we need to eat less.  How much less?  Well certainly no more than our ancestors, who actually worked very hard for it.  Just because refined (stripped) flour is now available in bulk doesn’t mean we should eat large amounts at every meal.  Remember, everything in moderation.

The 20th century was when we learned to take large-scale advantage of the production efficiency of the combine harvester, one of the greatest labor-saving devices ever invented.  Why is the combine harvester, patented by Hiram Moore in 1834, called a “combine”?  Because it combines several operations (reaping, binding, threshing, and winnowing) in a single machine, and drastically increases the rate and efficiency of harvesting. 

Before the introduction of the combine harvester, wheat was harvested by a group of people, several reapers plus a binder.  The reapers would slice across the ripe grain stalk with hand-held scythes.  Next, the crop would be bound together for drying and storage.  Later, dry grain or seed was separated from the straw and the chaff.  It was laborious as well as inefficient, for a large amount of the grain fell to the ground.  That grain became the equivalent of today’s food banks.

In contrast, a combine harvester first gathers and cuts the standing stalks, and then feeds the cut stalks, with their attached grain, to a threshing unit.  Inside, kernels of grain are separated (threshed) from the straw and chaff, which are blown (winnowed) out the rear of the machine.  Threshed grain is cleaned and collected for storage or transfer. 

Many seeds (soybeans, canola, and flax) and grains (wheat, corn, oats, barley, and rye) are universally harvested in bulk by combine harvesters.  The relatively sudden availability of virtually endless amounts of grains and seeds set the stage for an explosion of processed, food-like, edible products.

Next week:  Washington’s grist mill.
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What does low-carb mean?  Well, the first thing it means is that something else has more carb.  So what are you comparing it to?   Breakfast cereal?  Angel food cake?  The standard American diet (sAd)?  Anything would be low-carb compared to those. 

A whole bunch of folks at the Nutrition & Metabolism Society have been working hard to help people understand that carbohydrate, and not dietary fat, is the main dietary component causing our obesity and diabetes epidemic.  They say we all need to be eating a low-carb diet, and they have the research to prove it.

I agree with a lot of what they say.  But I disagree about what to call it.  I’m sort of saying the same thing as them, because I do believe that carbohydrate [especially refined carbohydrate, manufactured carbohydrate, processed and stripped carbohydrate] is one of the major players in the obesity epidemic.  I just don’t think we should be calling it a low-carb diet.  I admit it; I’m mincing words (instead of garlic).  But if it’s called a “low-carb” diet, that would mean that a high-carb diet is the normal default.

If you call something low-  then there must be a high somewhere.  If you call dessert “blond brownies,” there must be a not-blond type.  And there is.  If you call someone pro-, then everyone else can be presumed to be con-.  So if people advocate a low-carb diet, then what does a high-carb diet look like?  And the answer is — the American diet.  The standard American diet (sAd) consists mainly of illness-producing amounts of refined carbohydrate.  Cereal and toast for breakfast, sandwich and chips for lunch, pasta for dinner.  You want fries with that?  No wonder America has an obesity and diabetes problem.  That diet, the sAd, is profoundly unhealthy.  It causes diabetes, obesity, high blood pressure, arthritis, heart attacks, and strokes.  That’s not okay with me or my patients.  So why would I pick a name that presupposes the sAd is some kind of normal?  I wouldn’t.  That’s my point.

This perspective highlights the difference between absolute and relative comparisons.  Let’s pick an example from something quite familiar to me, the medical industry.  Imagine, for example, that a new medicine came to market that decreased the chance of developing a rare and horrible side effect (say, a severe rash) from 2 in 10,000 to 1 in 10,000.  For every 10,000 people who tried the medicine, the chance of getting the rash would be halved, from two to one.  You could say that the medicine was “twice as safe.”  That’s called a relative comparison.  And while it is true, technically speaking, it’s not the whole story. 

The other way to look at this is that, in fact, the chance of developing the horrible rash is already very small, and it becomes slightly smaller if you switch to the new medicine.  That is the conclusion I reach from evaluating the absolute, or actual, numbers.

When we call smart eating a low-carb diet, we are making a relative comparison.  And relative comparisons are notoriously undependable because they don’t take into account where you started.  They tell you where you landed, but not how far you went. 

I don’t want to call a diet with healthy amounts of carbohydrate “low-carb.”  What then?  Smart-carb?  Natural-carb?  Garden-carb?  Pre-industrial carb?  I’ve heard some people talking about the Paleo [PAY-lee-oh] (short for Paleolithic) or caveman diet, which presumes that the right amount of carbohydrate would be the amount that the average human ate in that pre-agricultural era.  Why pre-agricultural?  Because that’s before humans began to grow and domesticate grain, especially wheat.  Wheat (along with corn and soy) is the grain used to make large amounts of the processed, food-like products that may be found at the American supermarket.  But Paleo doesn’t feel right either, unless I don’t mind eating the Industrial Revolution diet.

It’s important to remember that all carbs aren’t all-bad.  Not for everyone.  It’s certainly true that some folks are so sensitive to carbs that even an apple a day will make their pants too tight.  Practically the only carbs this group of people can eat comfortably are green vegetables.  But there are lots of other people who can eat all the peaches and lima beans they want.  So, instead of low-carb, I’d like to hear people start saying they eat a low-grain diet, or a low-processed-food diet, or even a low-grain and low-fruit diet.  That’s going to tell me a lot more about how well this person understands his or her own metabolic needs. 

When we call a diet “low-carb,” we are making a comparison with the sAd.  And the sAd is so high in processed carbohydrates that virtually every other diet is an improvement.  Low-carb, therefore, doesn’t tell us much.  It doesn’t say whether the recommendations target all grain, or only processed grain, or all grain and fruit, or all four categories of carbohydrate:  grains, fruits, beans and vegetables.  And it presumes that the sAd has a normal amount of carb.  Which it does not.
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     Last month, I spent a few days in Washington, DC, with my three oldest friends.  Growing up together on Long Island, we had sleepovers under Jane’s mother’s grand piano, starred together in the best-ever 5th and 6th grade production of Oklahoma!, and held Game of Life competitions almost every day after school for an entire year.  When we get together we have a lot to talk about.

    As usual, the plans for this year’s reunion were complicated.  Ronnie got us tickets to see the White House from the top of the Washington Monument.  Jane and Lee got us to Georgetown for dinner and shopping.  I got to convince my friends that we had to visit George Washington’s grist mill.  Not exactly your run-of-the-mill tourist stop, but my awesome friends were ready and willing.  Then the grist mill got me thinking about food-related inventions over the past 200 years. 

    This post is the first in a series of three entitled “Food Used to be Hard Work.”  Over the past year, I’ve talked a lot about how the amount of work we do to get our food ready to eat is inverse (opposite) to the amount of insulin we release to catch the food and escort it to our cells.  The more work we do, the less insulin we use.  And the reverse is also true:  the less work we do to prepare and break down the food we eat, the faster we absorb it, and the more insulin we must release to catch it.  The goal is to find the balance. 

    So — where did the obesity and diabetes epidemic come from?  What’s different now compared to 100 years ago?  And what does Washington’s grist mill have to do with obesity and diabetes?  Well, let me tell you a story.  Once upon a time, not very long ago, almost everyone worked in agriculture.  They had to.  Given the limited technology of the day, it was the only way families could hope to raise enough food to get from one growing season to the next without running out.  Every family had its knives, scythes, and wooden plows, the tools that dominated agriculture for thousands of years.

    For 10,000 years, civilizations followed the same annual pattern of plowing in early spring, sowing in late spring, and harvesting in the autumn.  Plowing could be done by a farmer with a horse- or ox-drawn plow, and sowing, or spreading seed, could be done by anyone.  Harvesting, on the other hand, was back-breaking, hard work.  Obesity would be virtually impossible in a world where people worked so hard for their food.

    The past 100 years have been a time of unprecedented industrial growth and change.  Automation in industries of all kinds, including energy, finance, construction, and transportation, introduced us to the concept of “economies of scale,” whereby we learned that the unit costs of production would shrink as a company’s growth permitted it to save money by purchasing its raw materials in bulk.  It was a time of expansion, of testing the limits.  How big could companies get?  What were the consequences of that kind of growth?  In every industry, revolutionary inventions were increasing automation and improving efficiency.

    In the food sector, that meant a few things.  Some brilliant inventors built machines that would harvest crops more efficiently that ever before.  Next week I’m going to talk about the combine harvester, one of the greatest labor-saving devices ever invented.  The following week, I’ll get back to Washington’s grist mill, which revolutionized the milling process and, for the first time, allowed a single person to convert large amounts of whole grains into flour.  Other inventors figured out how to remove the bran fiber coat and the germ to make the flour look cleaner and increase its shelf life.  Lastly, new edibles like breakfast cereals, chips, instant soups, and granola bars, made with manufactured products such as partially hydrogenated oils, textured soy vegetable protein, and high-fructose corn syrup, were being developed.  These manufactured products cost substantially less than traditional foodstuffs, and soaring profits provided a significant inducement to develop more of the same. 

    All of these inventions had one important feature in common: They decreased the work of food gathering, preparation, and metabolism.  That means they increased the amount of insulin we used to break down our food.  And that high insulin state became the norm across America.

    The 21^st century is a different kind of time.  At least with regard to food, it is the time when we begin to understand and address the limits of making food easy to eat.  There is such a thing as too easy.  Too easy is what causes diabetes and obesity.

    Next week:  why is a combine harvester called a “combine”?

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Early one morning, now decades ago, I looked far down a hallway and saw two very obese women walking toward me.  Backlit by the rising sun, the two women appeared only in outline; all I could see of them was the dark shapes of two large bodies surrounded by golden rays.  I stood, transfixed, watching their movements as they walked.  Their arms swung far out from their shoulders like ribbons on a maypole.  Instead of swinging easily to and fro with each step, their upper extremities flew back and forth like propeller blades.  The force of their arm rotations supplied energy to fling their hips and torsos forward, while their legs, stiff and straight, worked to catch up with each step.  It looked like hard work, and I forced myself to look away. 

Then, a couple of years ago, having arrived early to a large celebration, I saw a woman, clearly an organizer of some sort, crossing the still empty party room on some urgent last-minute mission.  What I saw astounded me.  Though of normal weight, she was flinging her arms back and forth like propeller blades.  Immediately, I knew.  She had not always been this size.  I also knew something else, and it troubled me greatly: Part of her brain still thought she was heavy.  Despite the many hours she had invested in her health and recovery, and despite her obvious success, not all of her had healed. 

Last week I saw it again.  This time it was a young woman walking along briskly on the sidewalk. 

Gastric bypass operations have become commonplace, and many individuals who thought they were consigned to a life of obesity, diabetes and knee pain have found a way out.  It’s not enough, though.  We seem to be making some headway treating the physical part of the disease.  We need to do a much better job treating the mental and emotional part.  I’m sure that Dr. Sara Stein, the renowned bariatric psychiatrist and author of Obese from the Heart, would agree.

This past summer I had the pleasure of reading The Body Has a Mind of Its Own, by the  mother-son neuroscience writing team of Sandra Blakeslee and Matthew Blakeslee.  Rated one of the top science books of 2007 by the Washington Post, it explains how our minds create networks of body maps that are exquisitely related to how our bodies interact with the environment.  Like a tree that grows new limbs while others are pruned, body maps change over time, shrinking and expanding in response to changes in our bodies and the environments within which we function. 

Doctors, and occupational and physical therapists, are now using the new research about body maps to develop methods to heal phantom limb pain, anorexia nervosa, and other body map distortions.  I look forward to its application for all those whose minds could use some help learning that the bodies they inhabit are no longer obese.
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This afternoon I went to the Cleveland Botanical Garden’s RIPE! Food and Garden Festival.  The advertising said that RIPE! celebrates the edible gardening revolution and our region’s thriving commitment to local food.  Boy, oh boy, if anyone doubts that the culture of food is undergoing a real revolution, just show up next year.

I watched the folks from Snowville Creamery make vanilla ice cream using an old fashioned churn whose paddle was attached to a stationery bike.  The result was truly extraordinary.  I also drank a glass of their creamy milk, a gift from 235 Jersey cows who spend their days grazing on a farm down in Pomeroy.   

Meadow Maid  was sampling a wide variety of their delicious cheeses, also from grass-fed cows.  I met Andrew, of Kitchen Basics’ Real Cooking Stocks (beef, chicken, vegetable, seafood, veal), and learned that all their stocks are made locally.  Who knew?  I love that stuff; I buy it by the case and use it all the time.  I also ran into Green Pastures Poultry‘s owner, Ariella Reback, whose poultry I’ve purchased and enjoyed in the past.  The name says it all.

I sampled 12-year-old balsamic vinegar and Coratina Marcinase extra virgin olive oil at The Olive Tap‘s  (Medina) booth.  I drank an exquisite elixir made from Andean Fire Orchid, courtesy of Nora Egger and her company, the Lounging Gourmet.  There were gorgeous tomato and vegetable pizzas being grilled on a huge outdoor oven, and my friend bought herbal tea from a local vendor whose granola is sold at Heinen’s under the store brand name. 

I met Jody Lathwell, who runs the Tremont Farmers’ Market , and we revelled in the large number of markets that have been established in the past few years, including the Downtown Farmers’ Market at Public Square (Fri), the mid-week market on the grounds of the Cleveland Clinic, the Coit Road Farmers Market (Mon, Wed, Sat), the Chagrin Falls Market (Sun), Kamm’s Corners (Sun), Lakewood (Sat), and Shaker Square Market (Sat), the granddaddy of them all.  I am filled with joy to know that almost none of these markets existed just a few short years ago.  And I know that there are many more.

I had the good fortune to meet, from Kent, Lucky Penny Farm‘s Abbe Turner, whose business cards advertise her as CEO, cheesemaker, entrepreneur and optimist!, to taste honey from Bedford Heights’s Beecology, and to eat three different kinds (pumpkin, black truffle and garlic chive) of artisanal goat cheese (chevre) brought in by MacKenzie Creamery  from nearby Hiram.

I saw trucks advertising grass-fed milk shakes and burgers for sale, butternut squashes, apples, heirloom tomatoes, herbs, flowers, homemade chocolate chip cookies, displays of sculpted vegetables and an expert pumpkin carver hard at work.  All well and good.  But what’s for dinner?  So, now, the moment we’ve all been waiting for — a couple of interesting recipes for your enjoyment:

#1 Mexican cucumbers.
Sprinkle a cucumber with chili powder, salt, and the juice of 2 limes.  Enjoy.

#2 Pickled Red Sandwich Onions with Mustard Seed (from Jess Thomson)
Combine 1 c. sugar, 5 c. vinegar, and 1 T. kosher salt in a large pot and bring to a simmer, stirring occasionally as the sugar dissolves. Place 2.5 lb. sliced onions in a large bowl (or two), pour the vinegar mixture over the top, and let sit for 30 minutes, stirring occasionally.  Into squeaky-clean canning jars, place a few dill blossoms, a few peppercorns, and a big pinch of mustard seeds. When the onions have softened and turned bright pink, stuff each jar full. Add brine until it comes to 1/4” from the rim, wipe rims, add lids, and process in a water bath for 20 minutes after the water returns to a boil.  The onions are ready to eat as soon as the jars cool.  Yield: 4 pints pickled onions

P.S. Instead of throwing away the extra leftover brine, return it to a boil and pour it over fresh, clean baby carrots, green or yellow wax beans, or cooked, sliced beets.  Refrigerate for a few days.  These are called refrigerator pickles.

Hope to celebrate real food with you at RIPE! next year.  Hearty appetite!

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