Friday, February 26, 2010

The grapefruit--one way to battle winter

As the snow keeps drifting down, the wind keeps a blowing, and the gray skies ever make me desire a personal psychiatric consult, the citrus aisle of the grocery store is a welcomed reminder that there are palm trees and sanity in blessed parts of the United States of America.  As you can tell from repeated posts and reminders, I’m not really a fan of winter.  I particularly disdain the bleak species where the snow turns black and there’s no topographic variation to permit skiing or mountainous exploration.***

I have employed a variety coping mechanisms for the seasonal blahs.  Tactics have included the evasive, fleeing the northern hemisphere in December for summery South America for six months; the illuminating, having my fiancé design and build me a “happy lamp” as a sun substitute; and the caloric, particularly baking.

A less proud moment of winters past may have involved an entire chocolate layer cake topped with toasted walnuts and about a pound of homemade buttery caramel that I ate—alone.  (At least I completed an Olympic distance triathlon that summer.)  Now I moderate a bit better, but I still love to bake during the winter.  Benefits of winter baking include, admittedly, the cold weather allowing the oven to steam the windows Titanic style, and of course, the citrus.  Not only are the lemons and oranges beautiful, but the grapefruits are brilliant in baked goods.

The grapefruit, the beloved seemingly benign diet food of America also has a more mischievous side.  Grapefruit juice can be a bad player when taken with a variety of medications.  This discovery, like many scientific discoveries was hobbled upon coincidentally.

 In the 1980s in attempts to study the interaction between ethanol and a popular blood pressure medication, scientists decided on a Saturday night to make a felodipine Cosmopolitan with grapefruit juice to help the booze go down a bit better [1].  When they ran the experiment, they found that patients who took the drug with the cocktail had significantly lower blood pressures than those who had no alcohol.  Somebody astutely suggested it was the juice, not the liquor that caused such drastic changes in the drug metabolism.

Since this time, the grapefruit juice/medication interaction has been further explored.  [2,3].  Many medications are metabolized through an enzymatic pathway.  It appears that grapefruit juice reduces the prevalence of the enzyme CYP3A4 part of the cytochrome P450 in both the gut and the liver.  This allows for more medicine to be absorbed in the intestine and allows for medicines to linger in greater concentrations.  This can exacerbate toxic effects of  multiple drugs. 

A list of common medications that interact with grapefruit are listed here.  If you are concerned, please talk to your doctor.  If you are not taking any of these medications, feel free to participate in the construction and destruction of a luscious grapefruit lemon bar.  The benefit of the grapefruit is a complex sweetness with a less harsh tartness that I find many lemon bars have.  The crust is a modified shortbread recipe, so it is crisp, crumbly and light, with a bit of sour cream to echo the acidity in the filling.  The filling is more of a curd than a sturdy baked custard, so these treats are best eaten with a fork after refrigerated overnight.  The curd would also work great on toast or as a filling for cakes or cookies so feel free to separate the elements and work with what pleases you.

Grapefruit lemon bars

Shortbread Crust
Adopted from Joy of Cooking
¾ cup unsalted butter (1 ½ sticks) softened
2 tbsp sour cream
¼ cup confectioner’s sugar (powdered sugar)
2 tbsp granulated sugar
¼ tsp salt
1 ½ cups all purpose flour

Preheat oven to 300 degrees.  In large bowl beat all ingredients minus flour.  Stir in flour.  Light knead until blended.  In 8x8 baking pan with fingers press dough into bottom and up around the edges about ¾”.  Bake for about 35 minutes or until lightly browned and darker at the edges.  While baking, make the curd filling.  Allow to cool slightly for about 5 minutes and add the curd.  Refrigerate for 4-5 hours or until cool and set.  Sprinkle with powdered sugar and enjoy!

Grapefruit Curd
Adopted from James Peterson’s Baking

Juice and zest from one ruby red grapefruit (about 1 cup juice)
Juice and zest from one lemon
4 eggs
¾ cup granulated sugar
1/2 cup plus 2 tbsp unsalted butter cut into tablespoon pieces

Set a saucepan of water over medium heat and bring to a simmer.  In a heatproof bowl that will fit over pan, whisk together eggs and sugar for about 2 minutes until pale.  Then whisk zests and juice.  Set the bowl over the saucepan.  Stir constantly with a whisk for about 8 minutes or until the mixture starts to thicken.  Add the sliced butter, one piece at a time and stir constantly.  Cook for about 2 minutes longed.  Remove from heat.

***On a side note completely unrelated to the core of this essay, I have just undergone the most unbelievable ritual to prove that winter is evil.  Coincidentally, my car and my fiancé’s car break simultaneously.  Our lovely repair shop lends us a loaner.  After spending an hour driving through blustery conditions to drop him off and then drive to the hospital, I roll down the window to take a parking ticket. The window falls into the door with impressive speed and doesn’t come out.  I then proceed to drive through downtown with no window while it snows into the car.

1. Bailey D et al.  Ethanol enhances the hemodynamic effects of felodipine.  Clin Invest Med 1989: 12: 357-362.
2. Dahan A et al.  Food Drug interaction: grapefruit juice augments drug bioavailability—mechanism, extent and relevance.  2004.  European journal of Clinical Nutrition.  58, 1-9.

3.  Bailey D et al.  Grapefruit Juice-Drug Interactions.  1998.  British Journal of Clinical Pharmacology.  46: 101-110.

Tuesday, February 23, 2010

Why Chai?—caffeine as medicine

Believe it or not, I got through medical school without a caffeine dependency.  While a lot of my friends have an IV drip straight from the espresso machine, I try and keep my intake to a minimum.  Most people feel better after a rich morning coffee.  I’m already wired. You’ve seen me dancing post-call doing backflips down the hall (I wish I could do backflips).  Coffee makes me want to jump out of my skin. 

Even though I am caffeine averse, this psychostimulant has a variety of therapeutic purposes.  For all the joking and wishing, there actually is an intravenous form of caffeine in the hospital.  Overworking residents is not one of the indicated uses. 

One of my most vivid memories from medical school was when I learned how to do electroconvulsive therapy on my psychiatry rotation.  Caffeine is sometimes given during ECT because it lowers the seizure threshold and increases seizure time.  When a psychiatrist hands you two electrical probes and tells you to press the button, you have to comply!  ECT has been developed into a humane, extremely effective treatment of refractory depression and has helped many people that medicine doesn’t touch.  Thankfully, it’s nothing like the old movies like One Flew Over the Coo Coo’s Nest where the batty psychoanalyst straps the patient down and vigorously shocks him into prolonged convulsions.   

Caffeine also plays an interesting role in headaches and pain.  When in combination with either acetaminophen (Tylenol) or aspirin, the amount of analgesic needed to relieve headaches is reduced by about 40% 1.  Caffeine also works as an adjuvant to acetaminophen and aspirin and provides greater relief when in combination than alone; this is why people love Excedrin. 

The relationship between headaches and caffeine is complex, considering the most common symptom of caffeine withdrawal is headache 2.  A recent study of over 50,000 Norwegians found that zinged up Scandinavians were more likely to have infrequent headaches than those that did not drink coffee, although causality cannot be establish and there are many confounding factors 3

If you have a headache, a caffeinated treat might just do the trick.  Homemade chai is easy, rich and delicious.  Mine has a huge punch from loose leaf Darjeeling tea so it is definitely powerful stuff.  It lacks the cloyingly sweet and overpowering cinnamon kick that the boxed stuff has, and it makes your apartment, barn, trailer, home, abode or dwelling smell unbelievable.  If you still don’t feel better, throw some Advil in for some crimson chai. 

PS, this stuff is REALLY strong because I just drank it.  My hands are shaking from the caffeine overload.  What's on TV at 2am? 

Chai (makes about 6 cups)

15 black peppercorns
8 green cardamom pods
15 cloves
2 medium cinnamon sticks (plus more for serving)
2 inches ginger root peeled
1 bay leaf
4 cups water
2 cups milk
4 tablespoons loose-leaf Darjeeling tea (about 8-10 teabags or 0.8 oz)
3 tbsp honey
1 tbsp sugar

Add peppercorns, cardamom, cloves, cinnamon, ginger and bay leaf to mortar and pestle and give a couple of good pounds.  If you don’t have one, you can put everything in a plastic bag and smash with a frying pan or something else heavy.  Put spices in water on high and bring to boil, after boils, reduce heat to low, simmer, covered for about 20 minutes.

Add milk and tea, simmer for another 5 minutes.  Strain with mesh strainer or cheesecloth add honey and sugar.   Serve with cinnamon stick and enjoy.

Shapiro, RE. 2008. Caffeine and headaches. Current Pain and Headache Reports 12, no. 4:311-5.

Juliano, LM. and RR Griffiths. 2004. A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features. Psychopharmacologia 176, no. 1:1-29.

Hagen, K., et al. 2009. High dietary caffeine consumption is associated with a modest increase in headache prevalence: results from the Head-HUNT Study. The Journal of Headache and Pain 10, no. 3:153-9.

Saturday, February 20, 2010

The chicken and the egg. They came together.

Raw eggs make great food.  If you’ve ever been to my house for dinner, or eaten something I brought to a party, you’ve probably eaten raw eggs.  Yes, I know, I’m a horrible friend because I didn’t tell you, and now I’m announcing it on the internet.  You may never come back.

But before you decide that you’d rather not acquaint with me, let me just say this.  Yes, salmonella infection is a risk if you eat raw eggs, and yes, I put you at risk.  Even so, according to the CDC, 1 in 10,000 eggs are currently contaminated with salmonella 1.  The highest rate of egg contamination is in the Northeastern region of the US, which, thankfully (not to off-put the lovely inhabitants of New England) I do not live in. 

A risk is a risk.  Let’s put this risk into perspective.  As a human dweller of North America, you have about a 40% lifetime risk of getting cancer, a 4/10,000 risk of having a pulmonary embolus if you take birth control pills, and if you were born in 2000, which obviously you weren’t, you have a 35% lifetime risk of developing diabetes! 2,3,4. So, one in ten thousand? I’ll take my chances on a creamy, yolky, tiramisu and work on becoming that one in three with “a touch of sugar”.  I guess my risk of salmonella is actually higher since I probably eat 200 plus eggs a year, but even so, most of them are cooked.*

Salmonella can dwell in the ovary of the chicken, and thus the egg becomes infected before the shell is formed.  Proper washing of the egg does NOT prevent salmonella, even though when I was sheepishly watching Rachel Ray the other day, she said her husband told her to put the eggs in warm water and whatdyaknow it’ll go away!  Check your sources, lady.  Even so, using fresh eggs and keeping them refrigerated can prevent the bacteria from multiplying. 

Eggs and chickens are not the only foods that put you at risk of salmonella.  Vegetables, peanut butter and other “safe foods” are contaminated with some nasty pathogens.  In a 2009 report analyzing food related bacterial illnesses in 2006, 21% of cases were related to poultry, 17% were related to leafy vegetables and 16% were related to fruits and nuts 5.  One multi-state outbreak was attributed to “baked goods contaminated by floor sealant”.  Maple syrup is not the same as polyurethane.

Raw egg yolks make a beautiful base for a salad dressing.  They emulsify the fat and water based ingredients to make a rich, creamy dressing.  In this salad, which is my punchy version of a Caesar salad, I like to add poached chicken thighs which are moist and flavorful, boiled new potatoes for starch, radishes for a strong bite, and red chilies for a kick.

Elizabeth’s Caesar-ian Section Salad

For the dressing:
One egg yolk (I like to separate eggs with my hands)
Juice of one lime
1 tbsp white wine vinegar
One clove of garlic smashed and finely chopped
¼ cup finely (and freshly) grated parmesan cheese
Lots of black pepper
1 tbs finely chopped fresh cilantro
1 tbs finely chopped fresh mint
medium shallot diced finely
½ tbs salt
¾ cup olive oil

1 lb chicken thighs
1 lb new potatoes boiled until tender
Radishes, finely sliced
½ pound of romaine washed, dried and chopped
½ red chili seeded diced finely
1 yellow pepper chopped
2 green onions chopped

For the dressing:
Separate the egg yolk from the white, add the garlic, lime and vinegar, whisk together. Add the parmesan, pepper, salt.  Add ½ cup of olive oil in a steady stream whisking constantly.  Add the shallots and herbs, add remaining ¼ cup oil.  Refrigerate for 1-2 hours for flavors to blend if you have the time.

To poach the chicken:
In a pan with lid, fill with water about ½ inch-1 inch, season with salt, add chicken.  On medium-low heat simmer chicken, covered for 10 minutes and then flip.  Cook for 10 more minutes.  If you are using chicken breasts instead, reduce the cooking time to about 7 minutes on each side.

To assemble salad, slice up chicken and potatoes.  Add veggies and toss dressing (you might have extra dressing).  I’m assuming people know how to put things in a bowl.




3. Farmer, RD., et al. 1997. Population-based study of risk of venous thromboembolism associated with various oral contraceptives. The Lancet 349, no. 9045:83-8.

4. Narayan, KM., et al. 2003. Lifetime risk for diabetes mellitus in the United States. JAMA : Journal of the American Medical Association 290, no. 14:1884-90.

5. 2009. Surveillance for foodborne disease outbreaks - United States, 2006. MMWR: Morbidity & Mortality Weekly Report 58, no. 22:609-15.

* Disclaimer: if you are pregnant or immunosuppressed in any way, don’t eat raw eggs.

Thursday, February 18, 2010

A shout out to kraut

For all you science geeks out there, remember when we used to sit in the lab looking at things under the microscope?  My junior year of college in my microbiology class, my lab group of three decided that we would isolate a virus from a bacterial strain that grew from sauerkraut.  Thinking back on this, attempting to isolate a virus FROM an isolated bacterium in a basic science lab was probably not a smart idea, and the experiment most definitely failed.  So did the sauerkraut.  What started out as about 5 lbs of raw shredded cabbage in an industrial bucket with salt dumped on it turned into a smelly, moldy, microbiologic disaster.

While most people find gross memories scarring and unappetizing, for me they ignite my hunger.  (This does not include any foods that have actually made me sick.  I will never eat Hot Sauce Williams again…or drink lemon-lime Gatorade.)  I always came out starving from gross anatomy class the first year of medical school, and the operating room reminds me of BBQ—in a good way.  Probably, I’m just hungry all of the time and it can be challenging to carve out lunch time in the hospital. Grossness becomes a regular part of life, and I just eat around it. 

The sauerkraut incident should have turned me off from fermented salty, acidic cabbage, but alas, it only made me want more.  Of course, we all know that I love bitter vegetables.  Sauerkraut has its health benefits too.  The brining of cabbage brings out cancer fighting compounds that are vitamin C derivatives.  A recent study shows that cabbages grown in winter have the highest concentration of ascorbigen, one of these cancer fighting compounds 1.  Who knew that winter could actually provide health benefits?   

On a slightly more disturbing note, I also found this study titled “Use of human urine fertilizer in cultivation of cabbage—impacts on chemical, microbial and flavor quality.”2  Supposedly, peeing on your plants is an excellent and delicious way to fertilize them.  This might just be the motivation to go organic (although urine is probably organic anyway).  Maybe I’ll just start eating pesticides.

Nothing about this post should convince you to eat sauerkraut.  If you have read this far, you are probably gagging, nauseated, or revolted.  Eat it anyway!  In this recipe I make a whole chicken cut up and cooked in sauerkraut, beer and veggies.  It’s a hearty winter dinner just for you, and your friends, and your drunken downstairs neighbors.

Chicken with sauerkraut and beer

One onion diced
One carrot diced
One pound sauerkraut drained (I rinsed mine but I wish I hadn’t…I like the acidic kick)
2 slices bacon chopped (if you don’t eat pork just use butter or olive oil instead)
¼ tsp red pepper flakes
¼ tsp fennel seeds
¼ tsp salt
¼ tsp ground allspice
¼ tsp ground cloves
1 ½ tbsp brown sugar
Pepper to taste
One whole chicken cut into thighs, wings, and breasts (to cut up a chicken look here, or just buy whichever pieces of chicken you like…this recipe is better for chicken with bones)
One 12 oz bottle of stout beer
Sour cream to top

Cook bacon over medium high heat in dutch oven or other large cooking vessel.  Put bacon on paper towels and drain excess fat.  Leave about 2 tablespoons.  Over medium high heat, sauté onions and carrots until translucent and soft, about 8 minutes.  Add red pepper, fennel, allspice and cloves.

Add sauerkraut and saute for another 1-2 minutes.

Add brown sugar, bacon, salt and beer and allow to cook for about 5 minutes.  Meanwhile, preheat cast iron pan with about 2 tbsp canola oil and brown chicken for about 8 minutes.  If you are using a whole chicken, cook the thighs and legs first, add the wings and breasts a few minutes later.  Add chicken to dutch oven, cover, and simmer over medium heat until chicken is cooked through about 12 minutes.  Serve over brown rice, noodles or mashed potatoes and top with a generous dollop of sour cream.

Martinez-Villaluenga, C., et al. 2009. Influence of fermentation conditions on glucosinolates, ascorbigen, and ascorbic acid content in white cabbage (Brassica oleracea var. capitata cv. Taler) cultivated in different seasons. Journal of Food Science 74, no. 1:C62-7.

Pradhan, SK., et al. 2007. Use of human urine fertilizer in cultivation of cabbage (Brassica oleracea)--impacts on chemical, microbial, and flavor quality. Journal of Agricultural and Food Chemistry 55, no. 21:8657-63.

Tuesday, February 16, 2010

A salute to air travel

I am recently returning from a short jaunt to New Hampshire. Since embarking on my approximately 30th flight since September, I’ve been thinking a lot about flying. The turbulence exacerbates my irregular pulse, the turbid air recycling makes me nauseous, and the company on the plane can sometimes be exceedingly obnoxious (quoting entire choruses of Jimmy Buffet songs while professing the pathetic level of your love life and talking about your bankrupt houseboat casino to unsuspecting strangers is never a good idea). But none of these things bothers me as much about flying as the fact that in May, I will be a doctor.

Only at 30,000 feet could it really mean so much to be a physician. For example, if there were a medical emergency at the Cleveland Symphony, there are probably between 300 and 500 physicians of various specialties ready to run to the rescue before the patient was carted off to the hospital approximately 500 feet away. Contrast that to the isolating altitudes of the airplane, where there may not be any health care providers at all and the presenting pathology could range from heart attacks to labor to seizures.

“Are there any doctors on the plane?” as I sheepishly raise my hand…am I really (or will I really be) that person? Even though in the hospital as a new intern my life will be extremely challenging and exact responsibilities such as writing orders, performing procedures, and signing my own notes (no co-sign!), never will I be without some sort of supervision within earshot. But in a few months, I will take the Hippocratic Oath and with that oath, it will be my duty to at least try to do no harm.

Unfortunately, there is not much good data on the topic as airlines have variable reporting standards for medical incidents. According to a recent review paper, a medical emergency occurs in about 1 out of 10,000-40,000 passengers, and on overseas flights there is a doctor on the plane about 85% of the time1. (Yay, doctors get to travel!) The most common presenting complaints are fainting, followed by abdominal symptoms, followed by cardiac problems 2. Doctors are not legally required to offer assistance in the US or Canada, but are in Europe. Regardless, they are well protected on flights by Good Samaritan laws, and thus should volunteer unless they feel that they for some reason are unable or exceedingly inebriated.

This is a salute to all my friends who will also soon be doctors. Let’s hope we were well trained enough to at least give it a go. Let’s also hope that there’s a well seasoned emergency room doctor sitting next to us. And I’m sorry to produce anxiety for all of you by writing this.

Not to worry however. There are cookies on the plane to give you energy (at least on some airlines). I leave you all with a recipe for chewy molasses cookies as a substitute for the better-than-peanuts, crunchy spice cookies offered on Delta, the worst airline in the world. May everybody have safe travels and until then…eat chewy, spice laden, richly colored cookies.

Chewy Molasses Spice Cookies Adopted from The Martha Stewart Living Cookbook

2 ½ cups all-purpose flour
2 ¼ teaspoons baking soda
½ teaspoon kosher salt
1 tbsp freshly grated ginger
½ tsp ground allspice
¼ tsp ground cloves
½ tsp ground black pepper (sounds weird but SOOO delicious)
2 sticks plus 2 tbsp unsalted butter
½ cup granulated sugar (plus more for dusting)
1 large egg
¼ cup plus 2 tbsp molasses (or if you run out of molasses as I did, sub a couple of tbsp of maple syrup)

In a medium bowl, whisk together flour, baking soda, salt, allspice, cloves and pepper, set aside.

In the bowl of an electric mixer, cream the butter, ginger, brown sugar, and white sugar until light and fluffy, about 5 minutes.

Beat in the egg and molasses. Add the flour mixture, mix until combined. Form into flat disc, wrap in plastic wrap, and chill the dough at least 2 hours. (Chilling dough is annoying but it helps shape the cookies). Preheat the oven to 350. Pour sugar into a bowl. Form the dough into 1 inch round balls (although I like them a bit bigger), roll each ball in the sugar. Place the cookies on a baking sheet, spaced about 2 inches apart. Flatten each ball with the palm of your hand into a disc. Bake the cookies until browned about 10-12 minutes.


Cocks, R. and M Liew. 2007. Commercial aviation in-flight emergencies and the physician. Emergency medicine Australasia : EMA 19, no. 1:1-8.

Sand, M et al. 2009. Surgical and medical emergencies on board European aircraft. Critical Care. 13 (1).

Thursday, February 11, 2010

And the beet goes on

So I know there aren’t a lot of beet lovers out there. I’m asking a lot to get you to like brussel sprouts AND beets. Let me say, however, that I am a fanatic. A freshly cooked beet tossed up with some lemon is the epitome of richness, sweetness and deliciousness. And not to get too grossly personal, but every time I eat beets, I think I have a urinary tract infection. My pee turns bright red. Does this happen to anyone else?

Studies show that yes, beeturia, as it is so lovingly referred to in the medical world, occurs in approximately 14% of the population. (On a side note, I just love how they named it beeturia. When you pee blood this is called hematuria; hemat- for blood and –uria for urine. I guess the medical term for beet…is beet!)

While having beeturia might seem of minor consequence, and the majority of the time it is, in some cases it can indicate something more serious. Back in the 60s when beets were groovy, British scientists studied the incidence of beeturia in patients that had no known medical problems, those with iron deficiency anemia, those with pernicious anemia (this is anemia from the inability to absorb vitamin B12 in the gut), and those with malabsorption syndromes1. They found that the incidence of beeturia was only about 14% in healthy people but around 40% for anemic or malabsorptive patients.

This phenomenon was further explored. After a group of scientists experimented on 100 impoverished grad students, starving them, feeding them liquid beets and collecting their pee in a jug, it was found that high stomach acidity and long stomach emptying time can greatly impede absorption of beet pigments2. The rest of this data was gathered through rat models. Other things that stop beet pigment absorption include intestinal iron compounds, which explain why anemia can cause beeturia3.

So, if you eat beets and you have beeturia should you freak out? Probably not; most people with beeturia have a genetic predisposition to it. If you are concerned however, you could go to your doctor and say that you read something on the internet written by a medical student that you might have anemia. Doctors love that. (Like the time in my second year of medical school that I was convinced that my fiancé had this horrible autoimmune disease ankylosing spondilitis which causes your back to fuse together and gives you horrible arthritis, just because he had back pain. He went to the doctor all freaked out, and of course he just had some muscular strain. He did two stretches and felt better.)

And if you’re not sure if you have beeturia, there’s only one way to find out. Only through experimentation of consumption can the truth be gained. So, I challenge you to make this colorful, fragrant beet recipe which is citrusy, nutty and creamy, and report back to me. Even if you hate beets, do it for the name of science.

4-5 medium beets
Juice of one lime and one lemon
2 tbs unsweetened almond butter (you can buy this at Trader Joe’s it’s like peanut butter but with almonds; if you can’t find it you could just use a couple of tablespoons of finely chopped up toasted almonds)
1 medium clove of garlic
2 tbsp olive oil
1 tsp salt (plus salt to cook the beets)
One ripe medium avocado

Rinse the beets (or scrub that) if they are particularly dirty. Fill a medium to large pot halfway with water. Salt the water. Cut beets in half and boil over medium high heat with covered lid for about 40 minutes or until beets are tender when pierced with a sharp knife. When beets are ready, rinse with cold water and peel with hands. Beets should peel easily and your hands will turn a beautiful crimson color (if they don’t peel easily use a vegetable peeler). Dice beets into medium sized cubes.

Dice avocados into medium sized cubes. To make dressing, mix lemon and lime juice with almond butter, garlic and salt in small bowl or glass. Then add olive oil. Dress salad and toss gently (don’t make too much fuss or the avocados will get mashed up). Enjoy!

1) WATSON, W., LUKE, R., & INALL, J. (1963). BEETURIA: ITS INCIDENCE AND A CLUE TO ITS MECHANISM. British Medical Journal, 2(5363), 971-3.

2) Watts, A., Lennard, M., Mason, S., Tucker, G., & Woods, H. (1993). Beeturia and the biological fate of beetroot pigments. Pharmacogenetics, 3(6), 302-11.

3) Eastwood, M., Nyhlin, H. (1995). Beeturia and colonic oxalic acid. QJM : monthly journal of the Association of Physicians, 88(10), 711-7.

Tuesday, February 9, 2010

Artery boosting chocolate/Artery busting brownies. Chocolate for your heart. Happy Valentine’s Day!

Ladies (and gentlemen), it is the week of love.  With Valentine’s Day coming soon, and (PS it’s still winter), there’s nothing better than a good chocolate brownie, or a whole pan of them.  Even if you don’t have someone to love, YOU are the most important person in your life.  So, love yourself and make some brownies, pour a glass of wine, and watch a pleasantly cheesy movie.

We ladies are genetically/culturally engineered to love chocolate.  Did you know that chocolate is the most craved food in North America, especially by women1? The proposed theory is both cultural and hormonal.  In a recent study, more pre-menopausal women craved chocolate compared to post-menopausal women, suggesting that menstruation can make us crave chocolate2.  Even so, in this study, hormones do not fully explain a woman’s love for chocolate.  Perhaps it is simply delicious.  Besides, guys love chocolate too!

Maybe our collective love of chocolate isn’t such a bad thing.  There is copious research that shows that certain compounds in cocoa powder called plant derived flavanols can improve cardiovascular health and lower blood pressure3.   A recent Journal of Food Science study shows that these compounds can be retained in baked goods as long as a low pH is maintained 4.  Baking soda, which alkalinizes the cocoa powder and raises the pH, should be avoided.  While making buttery, gooey brownies is probably not as beneficial as pure dark chocolate for your health, there’s a good side to everything with moderation.

Before, brownie recipes were the bane of my existence.  I tried so many.  I tried the fudgy, the cakey, the ones with whipped egg whites, the cocoa powder, the unsweetened, the cheesecake-topped, everything, but they all sucked.  I just want a delicious, moist, chocolaty brownie.  Like the box.  I know I shouldn’t be saying this, but until I whipped up this recipe, the boxed brownies were the best I ever made.  The combination of unsweetend chocolate, oil, butter, plenty of eggs, a bit of flour, and the secret ingredient, Nutella is a great combination.

Since this is a week of love, my dear fiancé tested this recipe which I composed a few months ago and recreated the brownies from my written directions.  In this exercise of not dominating the kitchen, I tried to relax, and together we found the flaws hidden in my instructions.  They turned out delicious. I have repaired these errors, and the recipe is reproducible, so the everyman and woman can enjoy these tasty treats as much as we do. 

Elizabeth’s Nutella Brownies

5 ounces unsweetened chocolate
1 stick butter
¼ cup vegetable oil
¼ cup nutella
1 cup dark brown sugar
1 cup granulated (white) sugar
1 tsp vanilla extract
¼ tsp salt
4 eggs
¾ cut flour

Preheat oven to 350 degrees F.  Grease 9X13 inch baking pan.  Melt butter and chocolate over medium low heat on stove.  When melted, turn off heat, add Nutella and oil, and whisk until smooth.

Allow to cool.  In a large bowl, whisk sugar, cooled chocolate mixture, vanilla and salt until smooth.  One at a time, whisk eggs into mixture.  Whisk in flour until most large chunks are gone and pour into greased baking pan.  Bake for approximately 20 minutes or until sharp knife in center of brownies comes out almost clean.  Allow to cool and enjoy!

1) Weingarten, H., & Elston, D. (1990). The phenomenology of food cravings. Appetite, 15,

2) Hormes, JM. and P Rozin. 2009. Perimenstrual chocolate craving. What happens after menopause? Appetite (APPET) 53, no. 2:256-9.

3) Desch, S., et al. 2010. Effect of cocoa products on blood pressure: systematic review and meta-analysis. American Journal of Hypertension 23, no. 1:97-103.

4) Stahl, L., et al. 2009. Preservation of cocoa antioxidant activity, total polyphenols, flavan-3-ols, and procyanidin content in foods prepared with cocoa powder. Journal of Food Science 74, no. 6:C456-61.

Saturday, February 6, 2010

Pregnancy Pudding

I love to eat (clearly). And, I love working with pregnant women and delivering babies. Unfortunately, these two passions do not coincide. Sure, pregnant women love to pack on the pounds and devour thousands of calories of delicious treats everyday. But, the second they go into labor, they are banned from consuming anything but clear liquids in almost every labor and delivery suite in America.


The story goes back to 1946 when Mendelson wrote a ground-breaking paper showing that pregnant women are at high risk of aspirating their stomach contents into their lungs if they required emergency surgery and intubation (when a breathing tube is placed in the airway for safety during anesthesia) 1. Since the time that Mendelson’s groundbreaking paper was published, the fear of aspiration has permeated the minds of all OB/GYNs and anesthesiologists, banning food from the labor suite. Aspiration is an absolutely devastating outcome which can cause significant morbidity and can be fatal. Aspiration rarely occurs in the modern day L&D ward, but it should be prevented at all costs.

Can prohibiting oral intake actually prevent aspiration? This has never been proven, and is extremely difficult to study based on the rare occurrences of aspiration. In order to study this properly, there is a need for a very high study volume to detect a difference in aspiration rates for those that eat versus those that don’t. Even so, there is limited data on the effects of labor outcomes for fasting versus eating women.

Recently, an article was written in the NY Times discussing an analysis by the Cochrane Review2. The Cochrane Review is a database of meta-analyses of randomized control trials of high quality, and is an excellent, unbiased source of information. This particular review compiled 5 studies looking at studies of eating or consuming sports drinks during labor. They concluded that “there is no justification for the restriction of fluids and food in labor for women at low risk of complications.”

The analysis is complemented by a study recently published in the British Medical Journal3. This study was a randomized trial of 2426 low-risk, non diabetic subjects randomized to clear liquids or a low residue diet. The low residue diet group did not have a statistically significant difference in Cesarean rate, APGAR scores, or vomiting, and thus seemingly did not greatly affect birth outcomes. 
I do NOT make any recommendations to eat during labor. The American College of Obstetrician Gynecologists recently published guidelines recommend to not change any rules4. Thus, we will continue to fast. Even so, this is an area that needs more well designed, strongly powered studies, especially since many women are so miserable during labor and simply want something to eat. Anesthesiology has advanced incredibly since 1946 and has many new techniques and medicines to prevent aspiration. Beyond this, less than 1% of people require intubation for emergency surgery because epidural and spinal anesthesia are used for C-sections the majority of the time. 

Hopefully, for my sake and the sake of everyone around me, by the time I get pregnant and have babies, the rules will have changed and I can gobble it up. (I didn’t eat during my triathlon, and pooped out in the run coming in 5th from last!) In preparation, I will make some pregnancy pudding, because what could be better to eat during labor than homemade chocolate peanut butter pudding (maybe toast, but I can dream)? It’s filling, delicious, and easy on the stomach, with carbohydrates and proteins to give you energy for the long push. Most homemade puddings have raw eggs in them (not good for the pregnant ladies), but you can make a great pudding with just milk and cornstarch (and peanut butter and chocolate). And if you’re not gestating currently, feel free to partake as well.

Recipe adopted from Bon Appétit January 2009:

Chocolate peanut butter pregnancy pudding
½ cup sugar
5 teaspoons cornstarch
1/8 teaspoon salt
2 ¼ cups whole milk (honestly, you can do it with skim or 1% and I eliminated the heavy whipping cream from the recipe and replaced it with milk. This is not meant to give you massive indigestion)
1/2 cup creamy peanut butter
4 oz (about 2/3 cups) semi-sweet chocolate chips
1 tsp vanilla
Whisk first 3 ingredients in large saucepan to blend.

Gradually whisk in milk. Whisk over medium heat until mixture comes to boil.
Then boil until thick, whisking constantly about 30 seconds (this step can sometimes take longer, but you’ll be able to see it thickening).
Whisk in peanut butter; boil until thick again, whisking often, about 1 minute.
Remove from heat, add chocolate chips and stir until melted, add vanilla.

Cover and chill at least a few hours ahead of time.

1. Mendelson CL. The aspiration of stomach contents into the lungs
during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.
2. Singata M et al. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev 2010; 1:CD003930.
3. O'Sullivan, G., et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ: British Medical Journal 2009; 338:784.
3. ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and Gynecology 2009. 114(3): 714.

Wednesday, February 3, 2010

a fortifying post--why cast iron is good for you

For my birthday this year, I proclaimed to my family "No more kitchen supplies!". It seems that when you develop a hobby, be it cooking, or knitting, or biking, then all of the sudden, that's all you get for Christmas, birthdays, or any other celebration. No longer is the longed for sweater, a good novel, or a funny DVD. Well thankfully, my sister didn't listen to my birthday demand, and in the mail (thank god for free shipping from Amazon) came a brand new cast iron pan. And bless her soul! Cast iron is genius.

If you don't have a cast iron pan, I strongly recommend that you get one. They are extremely affordable, they cook very evenly, you can put them in the oven without the handle melting off, and if you take care of them they will last forever. They do require a little more maintenance than your regular kitchen utensil. You have to season them which means initially scrubbing the pan with hot soap and water, heating the pan, and smoking hot oil into layers, but this makes a natural non-stick layer. There are many methods for seasoning and this and this are good instructional videos.

When my pan had gotten a little out-of-control sticky, I went on a search of how to re-season it. I stumbled upon resources mentioning that cast iron cooking can contribute to iron intake because elemental iron leaches into the food that we cook. They go even further to suggest that cast iron could be part of the treatment for anemia. Fascinating. Time to scour the evidence. Unfortunately, a lot of the original papers that discuss the amount of iron in different foods from cast iron cooking are from the 80s and not available online. It would seem a little overkill to go to the library and find the original articles for a blog that five people read (but thank you if you are one of them). Even so, the abstracts suggest that cast iron does contribute significantly to the iron concentrations in various foods (1,2).

Interestingly though, are more recent studies that use cast iron as an attempted treatment to prevent iron deficient anemia in underdeveloped countries, since anemia is endemic in many parts of the world. A study completed in Ethiopia in the 1990s distributed cast iron or aluminum pots to families of children with iron deficiency anemia and measured the difference in hemoglobin concentrations after 12 months(everybody in the study also took oral iron supplements) (3). They also measured the amount of iron available in Ethiopian foods cooked in various vessels. The findings showed a significant difference in hemoglobin concentrations in those children that received cast iron-cooked food versus aluminum or clay. Vegetables and meat best extracted iron from the food into a digestible form. Beans for some reason, did not do as good of a job. Similar experiments repeated in other countries have yielded similar results, showing an excellent and easy way to combat low blood counts (4,5)

Fortunately, we do not live with the daily threats of malaria, hookworm and starvation. Even so, iron deficient anemia is prominent in our population especially in women of menstrual age, pregnant women, and those that do not get enough through their diet. In attempts to perfuse your vital organs with rich, red blood built with the powerful iron element, I leave you with this recipe. (Caution: do not eat steak with butter everyday. That is NOT good for your blood)

New York Strip Steaks with Balsamic Glaze

2 thick NY strip steaks
1 tbsp butter
1 medium shallot
1 tbsp balsamic vinegar
salt and pepper to taste

1. Preheat your oven to 400 F
2. Preheat your cast iron pan to a medium-high/high heat
3. dry your steaks on a paper towel (the drier they are, the better sear you will get)
4. salt and pepper steaks generously on both sides
5. put half of the butter in the preheated pan and allow to melt
6. add steaks to pan
5. put steaks in pan; cook for about 4 minutes on each side
6. put steaks in oven for 2-5 minutes depending on how done you would like them
7. take steaks out of oven (be careful because the handle is very very hot) and put on a plate to rest, put the pan back on the stove over medium heat
8. with the pan drippings, put other half of butter (or if it too greasy for you already don't) and then saute shallot until transluscent
9. deglaze pan with balsamic vinegar. If the sauce is too dry add a bit of sherry or water
10. pour over steaks and serve


1.Burroughs, AL.; Chan, JJ. “Iron content of some Mexican-American foods. Effect of cooking in iron, glass, or aluminum utensils.” Journal of the American Dietetic Association, v. 60 issue 2, 1972, p. 123-6.

2.Brittin, HC.; Nossaman, CE. “Iron content of food cooked in iron utensils.” Journal of the American Dietetic Association, v. 86 issue 7, 1986, p. 897-901.

3. Adish, A., Esrey, S., Gyorkos, T., Jean-Baptiste, J., & Rojhani, A. (1999). Effect of consumption of food cooked in iron pots on iron status and growth of young children: a randomised trial. The Lancet, 353(9154), 712-6.

4. Borigato, E., & Martinez, F. (1998). Iron nutritional status is improved in Brazilian preterm infants fed food cooked in iron pots. The Journal of nutrition, 128(5), 855-9.

5. Geerligs, P., Brabin, B., Mkumbwa, A., Broadhead, R., & Cuevas, L. (2003). The effect on haemoglobin of the use of iron cooking pots in rural Malawian households in an area with high malaria prevalence: a randomized trial. Tropical Medicine and International Health, 8(4), 310-5.