Saturated Fat, Glycemic Index and Insulin Sensitivity: Another Nail in the Coffin

Insulin is a hormone that drives glucose and other nutrients from the bloodstream into cells, among other things. A loss of sensitivity to the insulin signal, called insulin resistance, is a core feature of modern metabolic dysfunction and can lead to type II diabetes and other health problems. Insulin resistance affects a large percentage of people in affluent nations, in fact the majority of people in some places. What causes insulin resistance? Researchers have been trying to figure this out for decades.*

Since saturated fat is blamed for everything from cardiovascular disease to diabetes, it's no surprise that a number of controlled trials have asked if saturated fat feeding causes insulin resistance when compared to other fats. From the way the evidence is sometimes portrayed, you might think it does. However, a careful review of the literature reveals that this position is exaggerated, to put it mildly (1).

The glycemic index, a measure of how much a specific carbohydrate food raises blood sugar, is another darling of the diet-health literature. On the surface, it makes sense: if excess blood sugar is harmful, then foods that increase blood sugar should be harmful. Despite evidence from observational studies, controlled trials as long as 1.5 years have shown that the glycemic index does not influence insulin sensitivity or body fat gain (2, 3, 4). The observational studies may be confounded by the fact that white flour and sugar are the two main high-glycemic foods in most Western diets. Most industrially processed carbohydrate foods also have a high glycemic index, but that doesn't imply that their high glycemic index is the reason they're harmful.

All of this is easy for me to accept, because I'm familiar with examples of traditional cultures eating absurd amounts of saturated fat and/or high-glycemic carbohydrate, and not developing metabolic disease (5, 6, 7). I believe the key is that their food is not industrially processed (along with exercise, sunlight exposure, and probably other factors).

A large new study just published in the American Journal of Clinical nutrition has placed the final nail in the coffin: neither saturated fat nor high glycemic carbohydrate influence insulin sensitivity in humans, at least on the timescale of most controlled trials (8). At 6 months and 720 participants, it was both the largest and one of the longest studies to address the question. Participants were assigned to one of the following diets:

1. High saturated fat, high glycemic index
2. High monounsaturated fat, high glycemic index
3. High monounsaturated fat, low glycemic index
4. Low fat, high glycemic index
5. Low fat, low glycemic index

Compliance to the diets was pretty good. From the nature of the study design, I suspect the authors were expecting participants on diet #1 to fare the worst. They were eating a deadly combination of saturated fat and high glycemic carbohydrate! Well to everyone's dismay except cranks like me, there were no differences in insulin sensitivity between groups at 6 months. Blood pressure also didn't differ between groups, although the low-fat groups lost more weight than the monounsaturated fat groups. The investigators didn't attempt to determine whether the weight loss was fat, lean mass or both. The low-fat groups also saw an increase in the microalbumin:creatinine ratio compared to other groups, indicating a possible deterioration of kidney function.

In my opinion, the literature as a whole consistently shows that if saturated fat or high glycemic carbohydrate influence insulin sensitivity, they do so on a very long timescale, as no effect is detectable in controlled trails of fairly long duration. While it is possible that the controlled trials just didn't last long enough to detect an effect, I think it's more likely that both factors are irrelevant.

Fats were provided by the industrial manufacturer Unilever, and were incorporated into margarines, which I'm sure were just lovely to eat. Carbohydrate was also provided, including "bread, pasta, rice, and cereals." In other words, all participants were eating industrial food. I think these types of investigations often run into problems due to reductionist thinking. I prefer studies like Dr. Staffan Lindeberg's paleolithic diet trials (9, 10, 11). The key difference? They focus mostly on diet quality, not calories or specific nutrients. And they have shown that quality is king!


* Excess body fat is almost certainly a major cause. When fat mass increases beyond a certain point, particularly abdominal fat, the fat tissue typically becomes inflamed. Inflamed fat tissue secretes factors which reduce whole-body insulin sensitivity (12, 13). The big question is: what caused the fat gain?

Guest Commentary: The Promise of Earlier Palliative Care

Laura Kimberly, MSW, MBE
Director of Special Projects
Jefferson School of Population Health


It is well established that palliative care is typically introduced far too late in the course of treatment for a patient with a terminal or life-limiting diagnosis to achieve the optimal benefit. Sadly, palliative care is often regarded as an option of last resort once all other options have been exhausted and further aggressive treatment has been deemed futile. However, palliative care can (and often should) be integrated into a patient’s care far earlier.

In an article published last week in the New England Journal of Medicine, researchers studied a sample of patients newly diagnosed with metastatic non-small cell lung cancer who were randomized either to standard oncologic care, or to a palliative care intervention begun at the time of diagnosis.

The study found that the patients who were randomized to receive early palliative care experienced a better quality of life and improved mood as compared to the control group and survived, on average, approximately 2 months longer than the group receiving standard oncologic care. In addition, patients randomized to palliative care received less aggressive treatment at the end of life with a reduction in utilization of services.

The Western medical model trains physicians to provide the best possible treatment for their patients, making use of every available cutting edge technique and treatment. However, all too often this translates to aggressive, perhaps even futile, care at the end of life that may, in fact, lead to poorer outcomes. Accepting palliative care as an element of an integrated model of care for the end of life requires a shift in treatment paradigm, and these types of culture shifts certainly do not happen over night. However, studies such as this can help to clear up some of the misconceptions that persist regarding the appropriate use of palliative care, with the ultimate goal of enabling patients to approach the end of life with a minimum of distress and suffering, and with dignity and, hopefully, a measure of peace.

I look forward to reading more such studies, and I hope that future studies will also seek to measure improvements in quality of life and mood in caregivers who suffer in their own way alongside their loved ones. If you are doing work in this area, I would love to hear about it and encourage you to contact me by leaving a comment on the blog.

To read this study, please click here.

hee hee

Can you find the picture of me in this post from diseaseproof?

I'll give an update this weekend about how my meal prep is going with my new gone-all-day-and-night schedule. I just had to make a few tweaks to the plan.

Tropical Plant Fats: Coconut Oil, Part II

Heart Disease: Animal Studies

Although humans aren't rats, animal studies are useful because they can be tightly controlled and experiments can last for a significant portion of an animal's lifespan. It's essentially impossible to do a tightly controlled 20-year feeding study in humans.

The first paper I'd like to discuss come from the lab of Dr. Thankappan Rajamohan at the university of Kerala (1). Investigators fed three groups of rats different diets:

1. Sunflower oil plus added cholesterol
2. Copra oil, a coconut oil pressed from dried coconuts, plus added cholesterol
3. Freshly pressed virgin coconut oil, plus added cholesterol

Diets 1 and 2 resulted in similar lipids, while diet 3 resulted in lower LDL and higher HDL. A second study also showed that diet 3 resulted in lower oxidized LDL, a dominant heart disease risk factor (2). Overall, these papers showed that freshly pressed virgin coconut oil, with its full complement of "minor constituents"*, partially protects rats against the harmful effects of cholesterol overfeeding. These are the only papers I could find on the cardiovascular effects of unrefined coconut oil in animals!

Although unrefined coconut oil appears to be superior, even refined coconut oil isn't as bad as it's made out to be. For example, compared to refined olive oil, refined coconut oil protects against atherosclerosis (hardening and thickening of the arteries) in a mouse model of coronary heart disease (LDL receptor knockout). In the same paper, coconut oil caused more atherosclerosis in a different mouse model (ApoE knockout) (3). So the vascular effects of coconut oil depend in part on the animals' genetic background.

In general, I've found that the data are extremely variable from one study to the next, with no consistent trend showing refined coconut oil to be protective or harmful relative to refined monounsaturated fats (like olive oil) (4). In some cases, polyunsaturated oils cause less atherosclerosis than coconut oil in the context of an extreme high-cholesterol diet because they sometimes lead to blood lipid levels that are up to 50% lower. However, even this isn't consistent across experiments. Keep in mind that atherosclerosis is only one factor in heart attack risk.

What happens if you feed coconut oil to animals without adding cholesterol, and without giving them genetic mutations that promote atherosclerosis? Again, the data are contradictory. In rabbits, one investigator showed that serum cholesterol increases transiently, returning to baseline after about 6 months, and atherosclerosis does not ensue (5). A different investigator showed that coconut oil feeding results in lower blood lipid oxidation than sunflower oil (6). Yet a study from the 1980s showed that in the context of a terrible diet composition (40% sugar, isolated casein, fat, vitamins and minerals), refined coconut oil causes elevated blood lipids and atherosclerosis (7). This is almost certainly because overall diet quality influences the response to dietary fats in rabbits, as it does in other mammals.

Heart Disease: Human Studies

It's one of the great tragedies of modern biomedical research that most studies focus on nutrients rather than foods. This phenomenon is called "nutritionism". Consequently, most of the studies on coconut oil used a refined version, because the investigators were most interested in the effect of specific fatty acids. The vitamins, polyphenols and other minor constituents of unrefined oils are eliminated because they are known to alter the biological effects of the fats themselves. Unfortunately, any findings that result from these experiments apply only to refined fats. This is the fallacy of the "X fatty acid does this and that" type statements-- they ignore the biological complexity of whole foods. They would probably be correct if you were drinking purified fatty acids from a beaker.

Generally, the short-term feeding studies using refined coconut oil show that it increases both LDL ("bad cholesterol") and HDL ("good cholesterol"), although there is so much variability between studies that it makes firm conclusions difficult to draw (8, 9). As I've written in the past, the ability of saturated fats to elevate LDL appears to be temporary; both human and certain animal studies show that it disappears on timescales of one year or longer (10, 11). That hasn't been shown specifically for coconut oil that I'm aware of, but it could be one of the reasons why traditional cultures eating high-coconut diets don't have elevated serum cholesterol.

Another marker of cardiovascular disease risk is lipoprotein (a), abbreviated Lp(a). This lipoprotein is a carrier for oxidized lipids in the blood, and it correlates with a higher risk of heart attack. Refined coconut oil appears to lower Lp(a), while refined sunflower oil increases it (12).

Unfortunately, I haven't been able to find any particularly informative studies on unrefined coconut oil in humans. The closest I found was a study from Brazil showing that coconut oil reduced abdominal obesity better than soybean oil in conjunction with a low-calorie diet, without increasing LDL (13). It would be nice to have more evidence in humans confirming what has been shown in rats that there's a big difference between unrefined and refined coconut oil.

Coconut Oil and Body Fat

In addition to the study mentioned above, a number of experiments in animals have shown that "medium-chain triglycerides", the predominant type of fat in coconut oil, lead to a lower body fat percentage than most other fats (14). These findings have been replicated numerous times in humans, although the results have not always been consistent (15). It's interesting to me that these very same medium-chain saturated fats that are being researched as a fat loss tool are also considered by mainstream diet-heart researchers to be among the most deadly fatty acids.

Coconut Oil and Cancer

Refined coconut oil produces less cancer than seed oils in experimental animals, probably because it's much lower in omega-6 polyunsaturated fat (16, 17). I haven't seen any data in humans.

The Bottom Line

There's very little known about the effect of unrefined coconut oil on animal and human health, however what is published appears to be positive, and is broadly consistent with the health of traditional cultures eating unrefined coconut foods. The data on refined coconut oil are conflicting and frustrating to sort through. The effects of refined coconut oil seem to depend highly on dietary context and genetic background. In my opinion, virgin coconut oil can be part of a healthy diet, and may even have health benefits in some contexts.


* Substances other than the fat itself, e.g. vitamin E and polyphenols. These are removed during oil refining.

Tropical Plant Fats: Coconut Oil, Part I

Traditional Uses for Coconut

Coconut palms are used for a variety of purposes throughout the tropics. Here are a few quotes from the book Polynesia in Early Historic Times:

Most palms begin to produce nuts about five years after germination and continue to yield them for forty to sixty years at a continuous (i.e., nonseasonal) rate, producing about fifty nuts a year. The immature nut contains a tangy liquid that in time transforms into a layer of hard, white flesh on the inner surface of the shell and, somewhat later, a spongy mass of embryo in the nut's cavity. The liquid of the immature nut was often drunk, and the spongy embryo of the mature nut often eaten, raw or cooked, but most nuts used for food were harvested after the meat had been deposited and before the embryo had begun to form...

After the nut had been split, the most common method of extracting its hardened flesh was by scraping it out of the shell with a saw-toothed tool of wood, shell, or stone, usually lashed to a three-footed stand. The shredded meat was then eaten either raw or mixed with some starchy food and then cooked, or had its oily cream extracted, by some form of squeezing, for cooking with other foods or for cosmetic or medical uses...

Those Polynesians fortunate enough to have coconut palms utilized their components not only for drink and food-- in some places the most important, indeed life-supporting food-- but also for building-frames, thatch, screens, caulking material, containers, matting, cordage, weapons, armor, cosmetics, medicine, etc.

Mainstream Ire

Coconut fat is roughly 90 percent saturated, making it one of the most highly saturated fats on the planet. For this reason, it has been the subject of grave pronouncements by health authorities over the course of the last half century, resulting in its near elimination from the industrial food system. If the hypothesis that saturated fat causes heart disease and other health problems is correct, eating coconut oil regularly should tuck us in for a very long nap.

Coconut Eaters

As the Polynesians spread throughout the Eastern Pacific islands, they encountered shallow coral atolls that were not able to sustain their traditional starchy staples, taro, yams and breadfruit. Due to its extreme tolerance for poor, salty soils, the coconut palm was nearly the only food crop that would grow on these islands*. Therefore, their inhabitants lived almost exclusively on coconut and seafood for hundreds of years.

One group of islands that falls into this category is Tokelau, which fortunately for us was the subject of a major epidemiological study that spanned the years 1968 to 1982: the Tokelau Island Migrant Study (1). By this time, Tokelauans had managed to grow some starchy foods such as taro and breadfruit (introduced in the 20th century by Europeans), as well as obtaining some white flour and sugar, but their calories still came predominantly from coconut.

Over the time period in question, Tokelauans obtained roughly half their calories from coconut, placing them among the most extreme consumers of saturated fat in the world. Not only was their blood cholesterol lower than the average Westerner, but their hypertension rate was low, and physicians found no trace of previous heart attacks by ECG (age-adjusted rates: 0.0% in Tokelau vs 3.5% in Tecumseh USA). Migrating to New Zealand and cutting saturated fat intake in half was associated with a rise in ECG signs of heart attack (1.0% age-adjusted) (2, 3).

Diabetes was low in men and average in women by modern Western standards, but increased significantly upon migration to New Zealand and reduction of coconut intake (4). Non-migrant Tokelauans gained body fat at a slower rate than migrants, despite higher physical activity in the latter (5). Together, this evidence seriously challenges the idea that coconut is unhealthy.

The Kitavans also eat an amount of coconut fat that would make Dr. Ancel Keys blush. Dr. Staffan Lindeberg found that they got 21% of their 2,200 calories per day from fat, nearly all of which came from coconut. They were getting 17% of their calories from saturated fat; 55% more than the average American. Dr. Lindeberg's detailed series of studies found no trace of coronary heart disease or stroke, nor any obesity, diabetes or senile dementia even in the very old (6, 7).

Of course, the Tokelauans, Kitavans and other traditional cultures were not eating coconut in the form of refined, hydrogenated coconut oil cake icing. That distinction will be important when I discuss what the biomedical literature has to say in the next post.


* Most also had pandanus palms, which are also tolerant of poor soils and whose fruit provided a small amount of starch and sugar.

Ninth National Quality Colloquium from Boston

We will finish the Ninth Annual Quality Colloquium here in Boston tomorrow morning. It has been a spectacular three days from the special pre course on quality and safety to the plenary talk from ATUL GAWANDE, to the closing panel today on the role of Governance in Quality. The leaders of the nation's three Masters Degree Programs in Quality were also all here from Jefferson,Northwestern and the Univ of Illinois. The panel on curricular innovations in quality featured these three leading groups and the challenges that they face today in creating new materials for the classroom---both in person and on line.We also talked about the scholarship of quality featuring the editors of the four leading journals in the field. They discussed the future of medical publishing, finding skilled peer reviewers,and the impact of health reform. We also heard from experts in connecting with the empowered patient on line,ranging from the now famous "e-patient Dave" to the leader of the Center for Connected Health at Harvard. To top it all off, the CMO of CMS came to Boston to promote the accountability agenda. To me, it all means NO OUTCOME---NO INCOME....we better get used to this new era of accountability and transparency. Wish you were all here!!Learn more about this amazing conference at www.qualitycolloquium.com. DAVID NASH

weekend cooking

I started a new job on campus (doing the same thing as before, just not working from home anymore); and I'm gone from 7 am until 9 pm every weekday. yikes! (Don't worry, that includes fun in addition to work). So I'm trying to work out my food prep. I think it involves a lot of weekend cooking. Here's what I tried out this weekend.

First I had a snack because I was hungry after yoga:

These are some of my favorite foods: frozen mangos, romaine lettuce, carrots, and sugar snap peas.

Then I made housemate's smoothies. Here's a gigantic bowl of fruit, mostly frozen, with a bunch of fresh grapes. I kinda went overboard on the fruit but that's okay, it just turned into 13 smoothies instead of 10. We have a visitor coming this week so I made extra.

Next I assembled yummy beans in carrot juice. I tried out my new juicer. Housemate was irritated with me for getting a new juicer since I already had a good one. But I sure like this one. It's easy to use, smaller than the old one, and easy to clean up. Here's the juicer in action:

Then I couldn't resist playing some more so I tried out an apple. First slice (using an apple corer/slicer):

Then juice. Here's the juice from one apple. The apples are local, fresh, and yummy:

This is just a treat. Whole apples are healthier because they have all the fiber.

Okay, that was Saturday. Sunday morning I put the beans on to cook and went to church. Sunday afternoon, the weather was too nice, so I went biking. Then Sunday night it was time to make the veggies. The garden is overflowing with collards so that was the main ingredient, but it also included kale, swiss chard, eggplant, lots of herbs, onion, and garlic. Here's some of the produce left, after most was processed in the food processor:

I seriously used a ton of collards, so the only way to fit them in was to chop them tiny with the food processor. I just chopped everything with the food processor, because it was fast and it compressed the food more. This was a ton of veggies! At left is my big pot and at right is housemate's---she has much fewer veggies, and some potatoes added in. Oh, and this was before all the greens were added to my pot:

While these were cooking I made tomorrow's salads. I forgot to take a picture: romaine lettuce, yummy fresh strawberries, raspberries, blackberries and kiwi, and a few pumpkin seeds. I'll add D'angou pear vinegar when I'm ready to eat them.

Now time to assemble the veggies: the cooked greens&veggies, the cooked beans, some canned tomatoes (from the garden), and just a bit of date syrup (leftover from the smoothies):

Put them in the freezer (joining the smoothies):

Here's tomorrow's food in the fridge:

oh yeah, that's housemate's spritzer in the back. Ignore that. For brekky and lunch I'll have salad, cooked greens, and my favorite raw veggies: carrots, sugar snap peas, and kohlrabi. For dinner, sweet corn & mashed avocado and salad. I'll have something similar every day. The salads and raw veggies I'll prepare every night for the next day, and the cooked stuff will come out of the freezer. We'll see how this works.

Can a Statin Neutralize the Cardiovascular Risk of Unhealthy Dietary Choices?

The title of this post is the exact title of a recent editorial in the American Journal of Cardiology (1). Investigators calculated the "risk for cardiovascular disease associated with the total fat and trans fat content of fast foods", and compared it to the "risk decrease provided by daily statin consumption". Here's what they found:

The risk reduction associated with the daily consumption of most statins, with the exception of pravastatin, is more powerful than the risk increase caused by the daily extra fat intake associated with a 7-oz hamburger (Quarter Pounder®) with cheese and a small milkshake. In conclusion, statin therapy can neutralize the cardiovascular risk caused by harmful diet choices.

Routine accessibility of statins in establishments providing unhealthy food might be a rational modern means to offset the cardiovascular risk. Fast food outlets already offer free condiments to supplement meals. A free statin-containing accompaniment would offer cardiovascular benefits, opposite to the effects of equally available salt, sugar, and high-fat condiments. Although no substitute for systematic lifestyle improvements, including healthy diet, regular exercise, weight loss, and smoking cessation, complimentary statin packets would add, at little cost, 1 positive choice to a panoply of negative ones.

Wow. Later in the editorial, they recommend "a new and protective packet, “MacStatin,” which could be sprinkled onto a Quarter Pounder or into a milkshake." I'm not making this up!

I can't be sure, but I think there's a pretty good chance the authors were being facetious in this editorial, in which case I think a) it's hilarious, b) most people aren't going to get the joke. If they are joking, the editorial is designed to shine a light on the sad state of mainstream preventive healthcare. Rather than trying to educate people and change the deadly industrial food system, which is at the root of a constellation of health problems, many people think it's acceptable to partially correct one health risk by tinkering with the human metabolism using drugs. To be fair, most people aren't willing to change their diet and lifestyle habits (and perhaps for some it's even too late), so frustrated physicians prescribe drugs to mitigate the risk. I accept that. But if our society is really committed to its own health and well-being, we'll remove the artificial incentives that favor industrial food, and educate children from a young age on how to eat well.

I think one of the main challenges we face is that our current system is immensely lucrative for powerful financial interests. Industrial agriculture lines the pockets of a few large farmers and executives (while smaller farmers go broke and get bought out), industrial food processing concentrates profit among a handful of mega-manufacturers, and then people who are made ill by the resulting food spend an exorbitant amount of money on increasingly sophisticated (and expensive) healthcare. It's a system that effectively milks US citizens for a huge amount of money, and keeps the economy rolling at the expense of the average person's well-being. All of these groups have powerful lobbies that ensure the continuity of the current system. Litigation isn't the main reason our healthcare is so expensive in the US; high levels of chronic disease, expensive new technology, a "kitchen sink" treatment approach, and inefficient private companies are the real reasons.

If the editorial is serious, there are so many things wrong with it I don't even know where to begin. Here are a few problems:

1. They assume the risk of heart attack conveyed by eating fast food is due to its total and trans fat content, which is simplistic. To support that supposition, they cite one study: the Health Professionals Follow-up Study (2). This is one of the best diet-health observational studies conducted to date. The authors of the editorial appear not to have read the study carefully, because it found no association between total or saturated fat intake and heart attack risk, when adjusted for confounding variables. The number they quoted (relative risk = 1.23) was before adjustment for fiber intake (relative risk = 1.02 after adjustment), and in any case, it was not statistically significant even before adjustment. How did that get past peer review? Answer: reviewers aren't critical of hypotheses they like.
   
2. Statins mostly work in middle-aged men, and reduce the risk of heart attack by about one quarter. The authors excluded several recent unsupportive trials from their analysis. Dr. Michel de Lorgeril reviewed these trials recently (3). For these reasons, adding a statin to fast food would probably have a negligible effect on the heart attack risk of the general population.
   
3. "Statins rarely cause negative side effects." BS. Of the half dozen people I know who have gone on statins, all of them have had some kind of negative side effect, two of them unpleasant enough that they discontinued treatment against their doctor's wishes. Several of them who remained on statins are unlikely to benefit because of their demographic, yet they remain on statins on their doctors' advice.
   
4. Industrial food is probably the main contributor to heart attack risk. Cultures that don't eat industrial food are almost totally free of heart attacks, as demonstrated by a variety of high-quality studies (4, 5, 6, 7, 8, 9). No drug can replicate that, not even close.
   

I have an alternative proposal. Rather than giving people statins along with their Big Mac, why don't we change the incentive structure that artificially favors the Big Mac, french fries and soft drink? If it weren't for corn, soybean and wheat subsidies, fast food wouldn't be so cheap. Neither would any other processed food. Fresh, whole food would be price competitive with industrial food, particularly if we applied the grain subsidies to more wholesome foods. Grass-fed beef and dairy would cost the same as grain-fed. I'm no economist, so I don't know how realistic this really is. However, my central point still stands: we can change the incentive structure so that it no longer artificially favors industrial food. That will require that the American public get fed up and finally butt heads with special interest groups.

high-calorie foods

I had a guest stay with me for a week, and he's a skinny young guy, and I worried I wasn't feeding him enough. I realized I wasn't giving him any grains so I went and bought some manna bread (sprout wheat grains with raisin and carrots to sweeten it up). This is rich and sweet and delicious---it's like a muffin or cake only better (at least to a nutritarian). Here's what the package looks like:

I thought this would be good with a nut butter of some sort but I didn't have any, so I tried my hand at making some out of walnuts. I used the "dry-blender" container that goes with my vita-mix blender. It looks like a regular container but the blades are backwards so it blends the stuff upward rather than downward. That seems to work pretty well for nuts along with the plunger. I found I needed to add a lot of nuts to make it blend well. I used 2 cups of walnuts. This compacted down to probably only 1/2 cup of walnut butter! Talk about calorie-dense! It was a bit crunchy but I actually liked that. Here's the nut butter:

As it gets ground up, the oils release and it becomes, well nut butter.

It was great on the toasted manna bread. I also made this fun treat to take to work with me:

That's a banana walnut-butter sandwich! ha. it was yummy. and the peel keeps it protected until ready for eating.

The nut butter was also really good on (sweet) corn on the cob. Oh my gosh. decadent.

But now my guest is gone and the nut butter won't re-appear for a while because that is some rich food.

Guest Commentary: Healthcare Quality Calls for Visionary Leadership

Laura Kimberly, MSW, MBE
Director of Special Projects
Jefferson School of Population Health


Do you ever wonder what it takes for a health system to win NQF’s prestigious annual National Quality Healthcare Award? On Friday morning, JSPH had the honor of hosting Michael Dowling, President and CEO of North Shore-Long Island Jewish Health System, this year’s winner of the NQF award. It became clear to everyone present that Mr. Dowling is a truly visionary leader, and his transformative approach to creating a culture of quality at NSLIJ is remarkable. Over the course of the morning, Mr. Dowling shared numerous pearls of wisdom, including his take on the essence of the quality movement – “quality is a value, it is the DNA of an organization, and every employee is a quality professional.”

During his tenure as CEO, Mr. Dowling has promoted a quality agenda through radical changes to the structure and organization of the primary hospitals, long term care facilities, community hospitals, and ambulatory sites that now make up the NSLIJ Health System. The health system owns each entity, and all primary administrative and clinical functions are centralized for maximum efficiency, communication, and integration. In addition, the health system has a single board of directors, enabling effective decision-making with a constant eye to the health system’s big picture.

Mr. Dowling faced enormous challenges to bring about the massive systems changes required to create NSLIJ. Nearly every entity within the health system was operating at a deficit at the time of purchase – the health system is now profitable, generating over $6 billion in revenue and employing 42,000 people.

As an example of Mr. Dowling’s paradigm-shifting approach to leadership, he attends NSLIJ’s Monday morning orientation sessions and personally meets every single new hire, on average 70-90 people each week. In another example of his commitment to integration, teamwork and transparency, he has established protected time on Fridays during which all administrative and clinical staff attend patient safety rounds.

Mr. Dowling identified 6 key areas that underlie NSLIJ Health System’s accomplishments:

1) Employee Development
2) Teamwork and Collaboration
3) Commitment to Transparency
4) Commitment to Innovation and Continuous Improvement
5) Focus on Accountability
6) The Big Picture – Manage for the Short Term, Lead for the Long Term

There is a great deal to be learned by studying NSLIJ’s approach to quality, and to organizational culture and leadership more broadly, particularly within the context of the current health care reform efforts.

Guest Commentary: College for Value-Based Purchasing of Health Benefits

Marlon D. Satchell, MPH
Project Director
Jefferson School of Population Health

Martha C. Romney, MS, JD, MPH
Project Director
Jefferson School of Population Health


There is a growing recognition that the healthcare system in the United States is in an unhealthy state due to a number of factors, including uncontrollable and unsustainable costs, disparate and inequitable access and quality of care, unaccountable waste, errors, and misaligned incentives.

Employers and employees are facing growing challenges in covering the costs of healthcare, disease management, and preventive care.The public and private sectors are in search of methods to bend the cost curve and have identified value-based purchasing (VBP) as a powerful strategy. VBP has been defined as “a strategy employed by purchasers of health insurance and healthcare services to maximize the benefits received at lower costs.”1

The Jefferson School of Population Health (JSPH) has taken on an integral role in educating employers, benefit managers, insurers and human resource professionals about the principles, application, and measurement of VBP initiatives through its College for Value-Based Purchasing (CVBP). From July 19-22, JSPH – along with the National Business Coalition on Health, and the Healthcare 21 Business Coalition – offered an intensive program focusing on benefit purchasing techniques and skills, which emphasize improvement in the value, quality, cost, and effectiveness of health care services purchased on behalf of employees.

A faculty of national multi-disciplinary experts, including healthcare business coalition CEOs, legal, medical, business, human resource and healthcare research industry leaders, led 12 instructional modules on concepts such as improving and measuring quality of care and paying for performance. Other modules included methods for holding payers and providers accountable for quality care, while empowering and rewarding employees for achieving and maintaining their health through wellness programs, health risk assessments, lifestyle behavioral changes, and disease management.

Attendees included employee benefit managers from academia, health care, real estate, biotechnology, pharmaceuticals, public safety, and more, who learned about the need for VBP and the VBP paradigm from the employers/payers, providers, consumers, business and healthcare coalitions’ perspectives. Additionally, attendees created customized action plans for their own institutions to conceptualize strategies for engaging senior and line management, creating supportive work environments, negotiating with suppliers, and implement change through a systematic, comprehensive, collaborative approach.

1. Slen J, Bailit M, Houy M. Value-base purchasing and consumer engagement strategies in state employee health plans: a purchaser’s guide. Academy Health. 2010.

Saturated Fat Consumption Still isn't Associated with Cardiovascular Disease

The American Journal of Clinical Nutrition just published the results of a major Japanese study on saturated fat intake and cardiovascular disease (1). Investigators measured dietary habits, then followed 58,453 men and women for 14.1 years. They found that people who ate the most saturated fat had the same heart attack risk as those who ate the least*. Furthermore, people who ate the most saturated fat had a lower risk of stroke than those who ate the least. It's notable that stroke is a larger public health threat in Japan than heart attacks.

This is broadly consistent with the rest of the observational studies examining saturated fat intake and cardiovascular disease risk. A recent review paper by Dr. Ronald Krauss's group summed up what is obvious to any unbiased person who is familiar with the literature, that saturated fat consumption doesn't associate with heart attack risk (2). In a series of editorials, some of his colleagues attempted to discredit and intimidate him after its publication (3, 4). No meta-analysis is perfect, but their criticisms were largely unfounded (5, 6).


*Actually, people who ate the most saturated fat had a lower risk but it wasn't statistically significant.

summer meals

We have this every day from about July 4 - Sept. 4. We get it fresh picked from a local farm, and they are nice enough to locate their stand a few blocks from our house.

I am sorry to have to tell you that there is nothing better than Wisconsin sweet corn. I'm sorry you don't get to experience it. We don't eat much else at this meal since the corn is filling and we require two ears to satisfy our desires. We might have some cooked veggies with it. Notice the avocado at upper right in the picture. That is a mashed avocado, nothing else. It is our "butter", only better. Our SAD (Standard American Diet) guests agree. The tomato is fresh picked from the garden. I also make a rockin' collards dish from the garden too. I'll post that soon. And oh my god, the eggplant from our garden is fabulous. It's our first time for eggplant. When you pick it fairly small, it is almost sweet. There is no bitter taste! Yes, we are enjoying our summer produce!

quick meals

This took all of 5 minutes to make:

Notice I hardly even chopped the lettuce. I ate a lot of it with my fingers, heh heh. The ingredients were: whatever was in the fridge, which was lettuce, cabbage, orange bell pepper, musk melon (local version of cantaloupe), blackberries, pumpkin seeds, and D'angou pear vinegar (my absolute favorite).

I must have liked it because I had a similar one a few days later. This time I chopped the lettuce. I must have decided the previous one was a bit messy with the fingers. The musk melon was gone, but kiwi arrived on the scene to replace it. yum.

no-coffee no-cream yummy "latte"

Okay, anyone want to come up with a name for this? It's really good. You do need a high-speed blender, sorry. Okay, it's not so good that you will be missing it if you can't make it. It's just an occasional psychological-mostly treat.

Ingredients:

few tsp Chicory root (ground)

1 Tbsp hemp seeds

1 date, pitted (optional)

I get my chicory root from the herbal section at my co-op. any of those coffee-substitude drinks would probably work too. Teeccino makes one.

I steep the chicory root for a minute or less, just like tea. Here's the chicory root and the tea bags I use:

Here it is after steeping. I'm not sure how long 30 sec, 1 minute. It gets strong fast.

Next, remove the tea bag, put everything in the blender and blend on high, for 30-60 seconds. This makes a smooth drink with a nice froth, just like a latte or espresso. I usually don't have dates, but I tried one today and it was good. It tastes good either way.

Use of Bananas for better health

As we all know that 'An Apple a day keeps the doctor away!' but after read this article,may be you will change this phrase like, 'A banana a day keeps the doctor away!'

Two bananas provide enough energy for a strenuous 90-minute workout. No wonder the banana is the number one fruit with the world's leading athletes.

Bananas contain three natural sugars - sucrose, fructose and glucose combined with fiber. A banana gives an instant, sustained and substantial boost of energy.Energy isn't the only way a banana can help us keep fit. It can also help overcome or prevent a substantial number of illnesses and conditions, making it a must to add to our daily diet.

Depression :- People suffering from depression, many felt much better after eating a banana. This is because bananas contain tryptophan, a type of protein that the body converts into serotonin, known to make you relax, improve your mood and generally make you feel happier.

PMS :- Forget the pills - eat a banana. The vitamin B6 it contains regulates blood glucose levels, which can affect your mood.

Anemia :- High in iron, bananas can stimulate the production of hemoglobin in the blood and so helps in cases of anemia.

Blood Pressure :- This unique tropical fruit is extremely high in potassium yet low in salt, making it perfect to beat blood pressure. So much so, the US Food and Drug Administration has just allowed the banana industry to make official claims for the fruit's ability to reduce the risk of blood pressure and stroke.

Constipation :- High in fiber, including bananas in the diet can help restore normal bowel action, helping to overcome the problem without resorting to laxatives.

Hangovers :- One of the quickest ways of curing a hangover is to make a banana milkshake, sweetened with honey. The banana calms the stomach and, with the help of the honey, builds up depleted blood sugar levels, while the milk soothes and re-hydrates your system.

Heartburn :- Bananas have a natural antacid effect in the body, so if you suffer from heartburn, try eating a banana for soothing relief.

Morning Sickness :- Snacking on bananas between meals helps to keep blood sugar levels up and avoid morning sickness.

Mosquito bites :- Before reaching for the insect bite cream, try rubbing the affected area with the inside of a banana skin. Many people find it amazingly successful at reducing swelling and irritation.

Nerves :- Bananas are high in B vitamins that help calm the nervous system.

Ulcers :- The banana is used as the dietary food against intestinal disorders because of its soft texture and smoothness. It is the only raw fruit that can be eaten without distress in over-chronicler cases. It also neutralizes over-acidity and reduces irritation by coating the lining of the stomach.

Temperature control :- Many other cultures see bananas as a 'cooling' fruit that can lower both the physical and emotional temperature of expectant mothers. Pregnant women eat bananas to ensure their baby is born with a cool temperature.

Seasonal Affective Disorder (SAD) :- Bananas can help SAD sufferers because they contain the natural mood enhancer tryptophan.

Smoking &Tobacco Use :- Bananas can also help people trying to give up smoking. The B6, B12 they contain, as well as the potassium and magnesium found in them, help the body recover from the effects of nicotine withdrawal.

Stress :- Potassium is a vital mineral, which helps normalize the heartbeat, sends oxygen to the brain and regulates your body's water balance. When we are stressed, our metabolic rate rises, thereby reducing our potassium levels.These can be rebalanced with the help of a high-potassium banana snack.

Strokes :- Eating bananas as part of a regular diet can cut the risk of death by strokes by as much as 40%!

Warts :- Those keen on natural alternatives swear that if you want to kill off a wart, take a piece of banana skin and place it on the wart, with the yellow side out. Carefully hold the skin in place with a plaster or surgical tape!

So, a banana really is a natural remedy for many ills. When you compare it to an apple, it has four times the protein, twice the carbohydrate, three times the phosphorus, five times the vitamin A and iron, and twice the other vitamins and minerals. It is also rich in potassium and is one of the best value foods.

Use of Lemons for Healthy Body

Lemon is one of those super foods with a myriad health and cosmetic benefits.There are a few persons for whom it is an allergen,so make sure you are not allergic to this natural product,before you start enjoying the many benefits.

(1) Lemon being a citrus fruit, fights against infection.It helps in production of WBC’s and antibodies in blood which attacks the invading microorganism and prevents infections.

(2) Lemon is an antioxidant which deactivates the free radicals preventing many dangerous diseases like stroke,cardiovascular diseases and cancers.

(3) Lemon lowers blood pressure and increases the levels of HDL (good cholesterol).

(4) Lemon is found to be anti-carcinogenic which lower the rates of colon, prostate, and breast cancer . They prevent faulty metabolism in the cell, which can predispose a cell to becoming carcinogenic. Also blocks the formation of nitrosamines in the gut.

(5) Lemon juice is said to give a glow to the skin.

(6) A few drops of lemon juice in hot water are believed to clear the digestive system and purify liver as well.

(7) The skin of lemon dried under the sun and then ground to make powder can be applied to the hair for a few minutes before bath which relieves head ache and cools the body.

(8) Applying lemon juice to acne dries the existing ones and prevents from getting more.

(9) Lemon juice acts as a natural hair lightener and skin bleach which reduces the pigment melanin and prevents the risk of chemical allergic reactions which is common with hair dyes and bleaches.

(10) Lemon juice is given to relieve gingivitis, stomatitis, and inflammation of the tongue.

(11) Lemon juice is given to prevent common cold.

(12) Lemon juice is given to prevent or treat urinary tract infection and gonorrhea.

(13) Lemon juice is applied to the sites of bites and stings of certain insects to relieve its poison and pain.

(14) Lemon juice relieves colic pain and gastric problems.

(15) Lemon juice soothes the dry skin when applied with little glycerin.

(16) Lemon juice used for marinating seafood or meat kills bacteria and other organisms present in them, thereby prevents many gastro-intestinal tract infections.

(17) Lemon juice with a pinch of salt (warm) every morning lowers cholesterol levels and brings down your weight.

(18) Lemon juice is the best drink to prevent dehydration and shock in case of diarrhea.

(19) Lemon juice can also be used as a mouthwash. It removes plaque, whitens the teeth and strengthens the enamel.

(20) A table spoon on thick lemon syrup everyday relieves asthma.

(21) Lemon juice relieves chilblains and itchy skin.

(22) Gargling lemon juice relieves throat infection and also used as a treatment for diphtheria .

(23) Lemon Juice is an excellent treatment for dandruff and gresy hair.

(24) Lemon applied over the face removes wrinkles and keeps you young.

(25) Lemon juice helps to prevent and cure osteoarthritis.