Saturday, 28 July 2012

Jekyll and Hyde in Medical Practice

 I've written many times about how doctors who exploit patients sexually can provide excellent care to and be idolized by their other patients. I just learned from my friend Dr. Brian Hurwitz that the same can be true for doctors who murder their patients!

I first met Brian when I spent three months at the King's College London Centre for Medical Law and Ethics in 1992. He was doing an MA at the Centre, and allowed me to spend a fascinating day with him in his general practice surgery. For the past ten years he's been D'Oyly Carte Professor of Medicine and the Arts and Director of the Centre for the Humanities and Health at King's College.

Brian sent me a not-yet-published chapter he's written about Dr. Harold Shipman, the GP who was ultimately found to have been a serial killer who murdered more than 250 of his patients. The chapter included this remarkable quote from the son of one of the patients Dr. Shipman was found to have murdered:
I remember the time Shipman gave to my Dad. He would come around at the drop of a hat. He was a marvellous GP apart from the fact that he killed my father.
Shipman never admitted his guilt and refused to talk with psychiatrists, as did his surviving family. He committed suicide in prison in 2004. Although many colleagues and members of the community where he practiced noted strange occurrences in Dr. Shipman's practice, no one was prepared to draw the retrospectively obvious conclusion - a trusted, beloved physician was killing his  patients!

I think the best comment about people like Shipman comes from "The Shadow," an old time radio detective whose adventures I followed as a child. (The Shadow had the gift of invisibility.)
Who knows what evil lurks in the hearts of men? The Shadow knows!

Tuesday, 24 July 2012

Who's taking care of Mom?

The July Journal of the American Geriatric Society has a disturbing article - "Hiring and Screening Practices of Agencies Supplying Paid Caregivers to Older Adults."

Researchers at Northwestern School of Medicine posing as prospective clients seeking a caregiver for an elderly adult relative, contacted 180 agencies and asked about hiring, screening, and supervisory practices. Their findings aren't pretty!

67% of the agencies required experience, but this was often assessed by self-report. 62% checked references. 92% checked criminal background within the state, but no agencies checked other states, meaning that someone who had been convicted elsewhere would appear to have a clean record. English language proficiency was assessed via the interview, and no agencies assessed health literacy (ability to understand physician recommendations, dosage schedules, and so forth). 31% conducted drug screening. 7% verified citizenship or visa status. Training and supervision were very limited. The researchers conclude:
The screening and training practices in use by caregiver agencies are highly variable and often of poor quality. Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregivers.

Home care for the elderly has the makings of a perfect storm. It brings together vulnerable elderly with a marginalized population of poor, often immigrant, workers. This is a setup for exploitation - sometimes of the elderly by the "caretaker," and sometimes of the caretaker by the agencies that hire them.

When my father, who lived 1,000 miles from where I was, lost his vision and entered the early stage of cognitive decline, my cousin needed a place to live and moved in with him. He provided eyesight, companionship, and driving. My father provided lodging and paid for food. It was a true win/win situation.

But this kind of good luck is the exception, not the rule.  Agencies, like the 180 surveyed in the study, are filling a vacuum in our fragmented society. Unfortunately, as the study reveals, being hired by an agency is not a reliable stamp of approval.

Thursday, 19 July 2012

Ketogenic Diets, Cortisol, and Stress: Part I — Gluconeogenesis

One recent myth, prevalent in the Paleo Diet community, is that the keto diet is stressful to the body ¹. This idea arises from misunderstandings about cortisol — “the stress hormone”. There are two different arguments we know of, and this post will address the first one, the “gluconeogenesis requires cortisol” myth.

This myth comes from a mistaken chain of reasoning with three steps in it, only one of which is correct:
  1. On a keto diet, because you get very little glucose from carbohydrate in your diet, your body makes its own glucose on demand, in a process called gluconeogenesis. (This is correct.)
  2. Gluconeogenesis requires elevated cortisol. (This is not correct.)
  3. Chronically elevated cortisol damages the body. (This is not precisely true. In a subsequent article in this series, we will explore the relationship between cortisol levels and health. Nonetheless, it makes no difference for this argument — because gluconeogenesis does not in fact require excess cortisol.)

In Brief:


  • Gluconeogenesis does not require high levels of cortisol.
  • When blood sugar begins to get low, glucagon — the primary hormone responsible for ensuring adequate blood sugar — is produced. This promotes gluconeogenesis, and it happens before blood sugar gets low enough to trigger increases in cortisol.
  • When blood sugar gets so low that excess cortisol is produced, it is also low enough that symptoms of hypoglycemia (“low blood sugar”) appear — anxiety, palpitations, hunger, sweating, irritability, tremor; or in more extreme cases, dizziness, tingling, blurred vision, difficulty in thinking, and faintness. So hypoglycemic signs are a good way to judge if cortisol is involved.
  • Since keto dieters do not normally appear to suffer from hypoglycemic episodes, especially when eating enough protein and not fasting for long periods (indeed, hypoglycemic episodes appear to be reduced by keto diets), it is unlikely that cortisol comes into play to regulate blood sugar for normal keto dieters.
  • If you are concerned about your blood sugar, and whether cortisol is being called upon to regulate it, we recommend you measure your blood sugar levels with a glucometer such as this one (but any drug store should offer several models). If your blood sugar is sometimes too low, then we recommend that you experiment with increasing your protein or how frequently you eat.


Gluconeogenesis


On a keto diet, your body makes the modest amount of glucose it needs out of protein in a process called gluconeogenesis (GNG). There is a widely-held misconception that for GNG to occur, there must be high levels of the stress hormone cortisol in the blood. This mistake comes out of the fact that cortisol stimulates GNG. Therefore, it is reasoned, whenever you rely on GNG, your body has to produce and circulate more cortisol. This, however, is like arguing that since a reliable way to make people laugh is to tickle them, that every time you hear someone laughing it means they are being tickled. It turns out there are other ways to make people laugh, and there are other hormones that induce GNG.

The usual hormone to stimulate GNG is glucagon. Glucagon is produced when blood sugar gets low, and its primary function is to restore blood sugar to optimal levels. Cortisol levels rise when blood sugar reaches an even lower level. That is, the blood sugar threshold for cortisol production (55 mg/dL) is lower than the threshold for glucagon (65 mg/dL) ². This lower threshold could be reached if GNG was somehow obstructed. There are some rare disorders that prevent GNG, such as Fructose 1,6-Diphosphatase Deficiency or Glycogen Storage Disease, but in most people, GNG is a straightforward, unimpeded process.

In fact, it turns out that the level of blood sugar that has to be reached to significantly increase cortisol is so low that clinical symptoms of hypoglycemia also start to appear at that level ³. Not only are reports of hypoglycemic episodes in studies of keto dieters rare, it has been known since at least 1936 that keto diets with adequate protein help prevent hypoglycemia. (It is reported in that paper that keto diets with lower protein help somewhat, but not enough.) A more recent paper from 1975 asserts that the best treatment for hypoglycemia is a low carbohydrate diet with frequent small meals, though they note that this worsens the condition in occasional cases where the patient has one of the above-mentioned or similar disorders. The only other examples of hypoglycemia we could find referred to the initial fasting or severely calorie-restricted phases of ketogenic diets for epilepsy.

Based on this collection of observations, it appears that in keto dieters, the glucagon response is enough stimulate adequate GNG to restore blood sugar, unless they have rare GNG disorders, are eating insufficient protein, or have been engaging in extended fasting.


What you can do


If you experience symptoms that could indicate hypoglycemia, and you are concerned about the possibility that cortisol is being activated to regulate your blood sugar, we recommend you purchase a blood glucometer. It is an inexpensive device that measures the sugar in a drop of blood you get from your finger. Excess cortisol is not deployed for blood sugar regulation unless your blood sugar drops below about 55 mg/dL. If you notice this happening, you could experiment with increasing your protein intake or the frequency of eating.


Summary:

  • GNG is stimulated by glucagon, and as long as the GNG response to glucagon is enough to restore blood sugar before it goes down to about 55mg/dL, cortisol will not be called upon to regulate blood sugar.
  • By the time blood sugar levels have gotten so low that cortisol is deployed to help fix it, hypoglycemic symptoms also appear.
  • Keto dieters don't appear to experience hypoglycemic symptoms (except in some cases involving inadequate protein or prolonged fasting). In fact keto diets, especially protein-adequate keto diets, have been used to reduce the occurrence of hypoglycemic episodes in susceptible people.
  • Therefore it is not true that because keto diets use GNG for blood sugar regulation, they cause stress to the body.
  • Since blood sugar is easily measured, you can indirectly test for whether cortisol is being used to regulate your blood sugar yourself. If you find it to be low, there are other strategies you can try to alleviate it that don't involve giving up your keto diet.


References:


¹ Statements that imply this argument can be found in quotes like these:
That latter one seems to be a mistaken generalization that came from taking Mat Lalonde's comments out of context. Lalonde was describing his experience of severe hypoglycemia that happened after extremely intense exercise. He said: “Gluconeogenesis gets turned on by cortisol and other hormones and it’s not that fast. In order for gluconeogenesis to ramp up, cortisol has to ramp up.” By “ramp up”, we infer he means ramp up enough to keep up with the excessive intensity he had induced — a situation unlikely to occur in most keto dieters. We hope to return to the subject of keto diets and athletics another time.


² Evidence type: repeated experimental evidence.
Ober, K. Patrick (Ed.) Endocrinology of Critical Disease. 1997 Humana Press.

(Emphasis ours.)
The importance of maintaining a fairly constant level of serum glucose is reflected in the elaborate system for defending against falling glucose concentrations. Four major counterregulatory hormones are of varying importance and effectiveness in counteracting a hypoglycemic threat, and there is a hierarchy of response of the factors that counterbalance the threat of hypoglycemia. Each factor has a somewhat different threshold for activation (39 ³, 40) and the physiological importance of each component in the system of defense against hypoglycemia tends to be reflected by its position in the hierarchy. Small decreases in the plasma glucose concentration to the threshold of 65 mg/dL (3.6 mM/L) are usually sufficient to trigger the secretion of glucagon and epinephrine (40,41), the hormones that are of greater counterregulatory importance. Cortisol levels do not increase until the blood glucose falls below 55 mg/dL.


The single most important counteregulatory hormone is glucagon, which enhances hepatic glycogenolysis and gluconeogenesis; without glucagon, full recovery from hypoglycemia does not occur (1). Epinephrine, which has an additional action of inhibiting insulin secretion, is not necessary for counterregulation of hypoglycemia when glucagon is present, but it becomes essential in the absence of glucagon (a common occurrence in the patient with insulin-dependent diabetes). Growth hormone and cortisol are slower to act as counterregulatory agents, and these hormones do not make any substantial contribution to glucose counterregulation during acute insulin-induced hypoglycemia (42); since growth hormone and cortisol cannot compensate effectively for hypoglycemia in the absence of glucagon and epinephrine, they are of secondary importance in the counterregulatory scheme (34).


The relevant references from that passage are:

³(Ober's 39.) Evidence type: experimental.
Schwartz NS, Clutter WE, Shah SD, Cryer PE. Glycemic threshold for activation of glucose counterregulatory systems are higher than the threshold for symptoms. J Clin Invest 1987;79:777-781.
(Emphasis ours.)
Arterialized venous plasma glucose concentrations were used to calculate glycemic thresholds of 69 +/- 2 mg/dl for epinephrine secretion, 68 +/- 2 mg/dl for glucagon secretion, 66 +/- 2 mg/dl for growth hormone secretion, and 58 +/- 3 mg/dl for cortisol secretion. In contrast, the glycemic threshold for symptoms was 53 +/- 2 mg/dl, significantly lower than the thresholds for epinephrine (P less than 0.001), glucagon (P less than 0.001), and growth hormone (P less than 0.01) secretion.

(Ober's 40.) Evidence type: experimental.
Mitrakou A, Ryan C, Veneman T, et al. Hierarchy of glycemic thresholds for counterregulatory hormone secretion, symptoms, and cerebral dysfunction. Am J Physiol 1991;260:E67-E74.
The glycemic thresholds for increases in plasma growth hormone, glucagon, epinephrine, and norepinephrine were not significantly different from one another (-67 mg/dl) but were significantly higher than that for cortisol (55 t 2 mg/dl, P < 0.004-0.0003) and for the appearance of autonomic symptoms (58 t 2 mg/ dl, P c 0.039-0.001).




(Ober's 41.) Evidence type: experimental.
Bolli GB, Fanelli CG. Unawareness of hypoglycemia. N Engl J Med 1995;333:1771-1772.
In normal humans, small decreases in the plasma glucose concentration to the threshold of 65 mg per deciliter (3.6 mmol per liter) elicit the secretion of the rapid-acting counterregulatory hormones glucagon and epinephrine, which oppose the glucose-lowering effects of insulin in plasma within minutes. Should plasma glucose levels decrease further, to about 55 mg per deciliter (3.1 mmol per liter), the secretion of counterregulatory hormones increases, and autonomic symptoms (anxiety, palpitations, hunger, sweating, irritability, and tremor) appear, as well as neuroglycopenic symptoms (dizziness, tingling, blurred vision, difficulty in thinking, and faintness).

Evidence type: case studies
Jerome W. Conn. THE ADVANTAGE OF A HIGH PROTEIN DIET IN THE TREATMENT OF SPONTANEOUS HYPOGLYCEMIA: Preliminary Report. Published in Volume 15, Issue 6, J Clin Invest. 1936; 15(6):673 doi:10.1172/JCI100819
Waters(5) in 1931 advised strict curtailment of the carbohydrate in the diet, most of the calories being derived from fat. Following this a high fat, low carbohydrate diet with feedings divided into six daily meals was generally adopted. On this regime there was often prompt improvement; but while hypoglycemic attacks were diminished in number, they still occurred with alarming frequency.

...

It was realized, then, that the ingestion of large amounts of protein would supply glucose to the blood stream at a constant, slow rate, without the production of a hyperglycemia.

...

Conclusions

1. The slow rate at which glucose is liberated into the blood stream during the metabolism of protein is of advantage in the treatment of spontaneous hypoglycemia because —

(a) It causes no hyperglycemia and thus avoids excessive production of insulin and secondary hypoglycemia.

(b) It provides a source of glucose over a prolonged period of time.

(c) It allows in severe cases further restriction in carbohydrate than could otherwise be effected.

2. These facts justify the use of a diet high in protein and low in carbohydrate in the treatment of this condition.

Evidence type: experiment.
Hofeldt FD. Reactive hypoglycemia. Metabolism. 1975 Oct;24(10):1193-208.
(Emphasis ours)
The backbone of successful management of reactive hypoglycemia is the diet. A 100-g carbohydrate diet, isocaloric (25 calories per kilogram body weight) with six equal feedings with avoidance of refined carbohydrates will be successful in the majority of cases. Some authors report a beneficial effect by the restriction of caffeine-containing beverages(33,39,53,60,32-134) and alcohol.(33,35) Alcohol utilizes important gluconeogenic NAD substrate (17,136,137) for its metabolism, depresses the activity of important gluconeogenic enzymes,(138,139) limits alanine and substrate availability.(140)

An occasional case may show worsening on the low-carbohydrate, high-protein diet. Since there is an aminogenic influence on insulin secretion, this could potentially aggravate the reactive hypoglycemia in some patients. However, the concurrent protein stimulation of glucagon release could offset the effects of insulin.(18,23,145) Our studies on hepatic gluconeogenesis have shown that in patients with the fructose 1-6 diphosphatase deficiency there is characteristically a worsening of symptoms when stressed with a low-carbohydrate (ketogenic) diet. These patients, in order to maintain blood-glucose levels early in the fasting state, must call on adrenergic mechanisms to release glycogen stores. Similarly, an occasional patient will develop intolerant symptoms while on the low-carbohydrate, weight reduction Stillman or Atkins diet. These patients may well show similar hepatic enzyme defects. In this special low-carbohydrate intolerant subgroup, the stress of any ketotic diet is avoided and dietary carbohydrates are increased to 150 g or greater. We are presently conducting studies on the therapeutic effectiveness of folic acid (15 mg/day) in these patients with beneficial results.

Saturday, 14 July 2012

Teaching Ethics in High School and Middle School

I'm in Vermont at the Bread Loaf School of English, a Middlebury College program in which the students, primarily high school and middle school English teachers, can get a Master's degree in the course of five summers. My wife has been teaching here every summer since 1992 and I've been enjoying the potential for (a) telecommuting and (b) swimming and hiking in Vermont.

This year the Bread Loaf program has a new format for elective workshops, and I'm doing one next Friday on teaching ethics in high school and middle school. I've never taught at that level, but I've taught medical ethics at Harvard Medical School for many years, and I wanted to see whether and how that experience could be extended to pre-college English classes. I hope the participants learn as much as I have in preparing for the workshop.

Since the content of the medical school course isn't relevant for pre-college English classes, I dissected out the underlying goals I have for the medical students. I identified five:
  1. Strengthen ability to identify ethical issues, ideally combined with a zest for tackling these issues – a capacity that can be called “moral imagination” or “moral sensitivity.”
  2. Impart systematic approaches to resolving ethical questions – approaches, not answers.
  3. Enhance skills and attitudes that promote considering the views of others in a respectful manner – listening to those we’re talking with and, imaginatively, to the views of other stakeholders to the issue. 
  4. Cultivate the habit of using our own "gut" reactions as “data” for ethical reflection, not necessarily as “truth.” This doesn’t come naturally to most adults, and is even more challenging for adolescents. 
  5. Enhance capacity to reason to a justifiable conclusion and articulate the rationale for our conclusions.
In preparing for the workshop I came upon the work of Tom Wartenberg, Professor of philosophy at Mount Holyoke college, who teaches a course in which undergraduates (a) examine children's books through the lens of articulating the implicit philosophical content of the stories and (b) train to lead discussions for fifth graders at a nearby charter school. (The website is very worth a visit.) In an interview he described his objectives for elementary school children as essentially the same as my objectives for Harvard Medical students. His aim is to teach children how to "philosophize," not about the content of philosophy per se. The children dove into the discussions with the same gusto that makes teaching the course to medical students such  a privilege and pleasure.

Apart from the specific content focus of ethics education, the attitudes and skills required for reasoning about ethical issues are the fundamental requirements for democratic participation. I'll depend on the teachers who participate in the workshop for ideas on whether and how including ethics in high school and middle school English classes is (or is not) a promising practice in an era dominated by standardized testing.

Wednesday, 11 July 2012

Beyond Breast Reconstruction: 3-D Areola Tattooing


As a leader in breast reconstruction, Penn Plastic Surgery offers comprehensive services for women at every stage of the breast reconstruction process, from the initial surgery to nipple reconstruction and tattooing.

Breast reconstruction is a surgical procedure to recreate the shape and appearance of a woman’s breast. Most commonly, the procedure is done as part of a mastectomy – surgical removal of the entire breast as treatment for breast cancer.

Plastic surgeons perform two types of breast reconstruction. Implant reconstruction uses breast implants or tissue expanders to recreate the shape and appearance of the breast. Autologous tissue reconstruction uses tissue from the belly, back or thighs to reconstruct the breast. Although autologous tissue reconstruction is more extensive, it can provide an emotional benefit for women looking to use their own tissue to reconstruct their breast and is often performed at the same time as the mastectomy.

After breast reconstruction, many women choose to have nipple reconstruction, including nipple tattooing. Nipple tattooing, or micropigmentation, re-pigments the area to make it look more realistic.

Nipple tattooing is performed by Mandy Sauler, a micropigmentation specialist in  plastic surgery at Penn Medicine. Sauler is a skilled tattoo artist who specializes in 3-D nipple tattoos along with tattoos for other cosmetic purposes. Working for more than a decade as a tattoo artist, Sauler now focuses on permanent cosmetics and micropigmentation. She is board certified by the American Academy of Micropigmentation, and is a member of the Society of Permanent Cosmetics.

Polycystic Ovary Syndrome (PCOS) Treatment Options at Penn Medicine


The Penn Polycystic Ovary Syndrome (PCOS) Center assists women in managing their PCOS symptoms and related health conditions. Due to the impact of PCOS on other health conditions, the center works closely with providers from other specialties throughout Penn Medicine. Each case of PCOS is different, which is why the center works closely with every patient to determine the best treatment plan. 

The services offered to help women manage their PCOS include:
  • Hormonal treatment
  • Fertility treatment
  • Weight management
  • Nutrition sevices
  • Lipid management
  • Dermatology/laser hair removal

Females of all ages are seen at the center. The team of health care providers helps women manage their PCOS through every stage of life with regularly scheduled office appointments, guiding them through treatment decisions about their condition.

Penn's PCOS team members include:
  • Physicians
  • Nurse practitioners
  • Clinical dietitians
  • Clinical research coordinators
Learn more:

      Penn Adolescent and Young Adult Medicine Now in Two Convenient Locations


      Penn Adolescent and Young Adult Medicine now sees patients in two convenient locations  – Penn Medicine Radnor, a facility of the Hospital of the University of Pennsylvania, and Penn Medicine Valley Forge.

      Penn Adolescent and Young Adult Medicine focuses on the needs of young men and women between the ages of 12 and 30. The practice offers primary care with a full understanding of the physical and psychological changes associated with the transition from adolescence to adulthood.

      Penn Adolescent and Young Adult Medicine also provides specialty care for patients including:

      • Eating disorders
      • Managing and coordinating care for chronic illness, stress, depression and anxiety 
      • Drug and alcohol use
      • Smoking cessation
      • Managing conflicts with parents, siblings, teachers and peers
      • Reproductive care
      In addition to a second location, Penn Adolescent and Young Adult Medicine welcomes Deepti Thapar, MD. Dr. Thapar earned her medical degree at Bangalore University, India, and trained in family medicine at Cedar Rapids Medical Education Foundation in  Iowa.  She is board certified in family medicine and has a special interest in preventive care, women’s health and adolescent medicine.

      Dr. Thapar is most interested in developing long-term, collaborative relationships with her patients and is passionate about making a meaningful impact on the young adult population. She sees patients at both the Radnor and Valley Forge locations.


      Learn more about Dr. Thapar.




        Tuesday, 10 July 2012

        Sexual Intimacy in the Nursing Home

        The most recent issue of the Journal of Medical Ethics has an excellent article from the Centre for Evidence-Based Aged Care in Australia - "Dementia, sexuality and consent in residential aged care facilities."

        The authors' argue that "while we must abide by laws regarding consent and coercion, in general we [in the West] expect to be able to engage in sexual behaviour whenever, and with whomever, we choose." In their view, nursing homes should allow for sexual intimacy and interfere only for clearly defined reasons, rather than treating sexuality as a special privilege that must be earned by requiring both parties to "prove" decisional competence, and, often, to require permission from families.

        The authors are drawing on the concept of "dignity of risk." Meaningful life entails taking risks. If we agree with John Stuart Mill that as long as individuals are (a) not causing harm to others and (b) understand the nature and consequences of their proposed actions ("decisional competence"), then(c) their liberty should not be constrained. The authors recognize, but do not discuss in depth, the challenge of assessing "competence" in the presence of dementia. To my reading they underestimate the potential risks, as when one party erroneously believes that the other is their spouse or partner. But they're right that we tend towards excessive prudishness with regard to sexuality in our parents and grandparents.

        This was the explicit focus of teaching when I was a medical student. We were in our 20s, so patients in their 70s and 80s were the age of our grandparents. When teaching us how to take a medical history our instructors warned us that we might feel uncomfortable asking about sex with patients in that age range. They reminded us that we were doctors-in-training learning a medical role, not prurient children or grandchildren peeking through keyholes into a bedroom.

        My father was something of a ladies man. He outlived three wives and, over the years, I was aware of a number of his girlfriends. In the final months of his life he suffered from dementia and heart failure, along with blindness, and was in a nursing home. On a visit that turned out to be just two days before his death, we returned to his room to find an elderly woman lying on his bed. I said in what must have been a saccharine-toned voice "this is my father's bed." She responded, with a mischievous smile and a twinkle in her eye, "I know."

        Knowing that flirtation was alive and well so near the end of my father's life is a happy memory for me!

        (The full article is only available by purchase, but a free abstract is available here.)

        Monday, 9 July 2012

        Raw Soft Taco with Fresh Tomato Salsa

        For all of you wanting that "Summer Glow"- now is the time to get it!  I am not talking about the Summer Glow fake self tanner, but the real glow that comes from the inside out.  The radiance that comes from eating right, exercising, getting plenty of rest, and enjoying the sun for a light/real tan. Eating more "Living Foods" help us to have clear eyes, clear skin, shiny hair and a healthy immune system. The flavor of these raw foods is so fresh and alive because they are as nature intended, full of living water and life force", states Matt Amsden. In Matt Amsden's book RAWvolution, he talks about a well-balanced diet of raw plant foods containing the full complement of vitamins and minerals, necessary for good nutrition, while cooking destroys over 80 percent of a food's nutritive value. Cooking also destroys the vital enzymes in food.  In the book Enzyme Nutrition, Dr. Howard Howell explains, "As our enzyme pool diminishes with age, our ability to perform the tasks that keep the body healthy also diminishes.  Aging happens when enzymes decrease in concentration in the body."  Dr. Howell believes that enzyme preservation is a secret to longevity and getting that glow. By eating living plant foods, we keep and even build up our enzyme reserves. Eating more raw foods also enables you to effortlessly shed excess weight. So, stock up on your live foods this summer and try to keep your raw foods to cooked ratio at 80% raw and 20% cooked. Saving your cooked meal for dinner is a great way to stay on track.  Help children by keeping their ratio at 50% raw and 50% cooked.

        Below are a few recipes I love from the book RAWvolution.  They are both so full of flavor and super easy. The first recipe has ground walnut meat seasoned with Mexican spices, encased in a collard green wrap and served with Fresh Tomato Salsa.  The second recipe was inspired by Matt's Fresh Tomato Salsa, but I switched up the recipe to reflect what I like.  I hope you will give them both a try and check out Matt's book.

        Collard greens are similar to kale in many ways.  Like kale, they too contain the phytonutrient sulforaphane which has been shown to stop breast cancer cells from growing in a study published in Drug Discovery Today.  Collard greens are also a very good source of vitamin A, vitamin C and vitamin E and together, these antioxidants disarm free-radicals which may prevent significant damage to life-sustaining molecules such as enzymes, membranes, mitochondria and DNA.  Include collard greens in your green smoothie for an excellent source of calcium, which helps to maintain the strength and density of bones and may also help prevent osteoporosis. Buy your collard greens organic,  because they tend to have a lot of pesticides.


        Soft Taco with Fresh Tomato Salsa
        Serves 3-4
        1 1/2 cups raw walnuts, ground in a food processor
        1 1/2 teaspoons ground cumin
        3/4 teaspoon ground coriander
        2 tablespoons Nama Shoyu
        3 to 4 small or medium collard green leaves
        1 cup shredded romaine lettuce
        1 recipe Fresh Tomato Salsa (below)

        In a small mixing bowl, combine the walnuts, cumin, and coriander, and mix well. (I added all to my Ninja and pulsed until small pieces were formed)  Add the Nama Shoyu and mix well.  Spread approximately 1/3 cup of the walnut mixture along the center stem of each collard green leaf, then add a layer of shredded lettuce.  Top with approximately 1/3 cup of the salsa just before serving and add sliced avocado.  You can roll like a burrito and slice in half, or just eat like a taco. 
        The Ninja processor is great for little jobs like making the nut meat
         Fresh Tomato Salsa 
        Serves 12
        12 medium Roma tomatoes
        1 1/2 cups chopped fresh cilantro
        1 1/2 cup chopped scallions (add some of the green)
        6 Tablespoons lime juice
        4 cloves garlic, minced
        1 medium jalapeno (remove seeds)
        1/2  teaspoon cayenne pepper
        1 1/2  tsp. sea salt
        3 teaspoons ground cumin
        1 1/2 teaspoons ground coriander 
        1 tsp. of sweetener of choice (optional)

        Combine all ingredients, except tomatoes into a food processor and  process for a few seconds.  Add tomatoes and continue to pulse until you have the consistency you like in salsa.

        Friday, 6 July 2012

        Teacher/student sex

        I spent four happy years (9th to 12th grades) at the Horace Mann School in New York, and was startled by a New York Times article in June titled - "Prep School Predators: The Horace Mann School's Secret History of Sexual Abuse." The author, Amos Kamil, had researched the piece for more than a year and had interviewed more the 100 former students and teachers.

        The article describes how several teachers in the 1980s and 1990s were well known for "hitting" on students. The article discusses in detail three who preyed on boys. One, possibly two, committed suicide after finally being dismissed. But the sexual exploitation had gone on for many years. It's hard to believe that the administration was unaware of what was happening. The author himself was invited to the home of Inslee Clark, the head of school, and, although underage, was given alcohol, at a small dinner that included one of the teachers known for hitting on boys.

        In the world of organizational ethics there's a saying: if the CEO isn't "chief ethics officer" as well as "chief executive officer," don't waste your time on organizational ethics. Leaders set the moral tone of organizations by what they practice, not what they preach. Clark's alcohol-laced dinner suggests that he was setting an atmosphere that tolerated what in the medical world is called "boundary violations."

        There's a structural similarity between the doctor/patient relationship and the teacher/student relationship. We give doctors and teachers authority and respect for helping us cultivate our capacities for health and wisdom. We expect them to focus on the needs of their patients and students, and to put their own private desires into the background. Sexual interest isn't a violation of that trust. Overt behavior is.

        Neither I nor my best friends from high school had any knowledge of teacher/student sexual relationships, but we were at Horace Mann 25 years before the period the article discusses. But Tek Young Lin, a new teacher in our days, now 88, acknowledged that he had sexual relationships with students in the 1960s and 1970s. Tek was a Buddhist and a beloved English teacher. I remember him as a charismatic, profoundly educative person. The candor I remember him for was reflected in the interview he did with the New York Times:
         "in those days, it was very spontaneous and casual, and it did not seem really wrong...if I had in any way harmed them, hurt them, I am truly, truly sorry. I hope if they have been hurt, they will overcome that hurt, and I should be very happy to help in any way I can." 
         The fact that a beloved teacher could also be an exploiter is consistent with comments made on this blog by former patients of physicians who'd lost their licenses for boundary violations. It's clear that teachers, like doctors, who violate boundaries with some, may provide superb education to others.

        An article in yesterday's New York Times reports that alumni are unhappy with what to them seems like a "cold" reaction on the part of current leadership. I'd felt the same way. The disappointing public comments probably reflect the misguided legal advice the school administration was given - to say nothing that could be used against the school in court. This is what lawyers used to advise physicians in situations of bad outcomes. That defensive approach is now seen to be (a) inhumane and (b) bad strategy for preventing malpractice litigation.

        I take three lessons from these unhappy stories about my high school. First, we humans are open to a wide range of feelings and fantasies. In relationships like teacher/student and doctor/patient we should expect that the full range of emotions can enter in (on both sides). Professional education should help us become better self-observers and self-managers, so that we can govern ourselves in accord with our professional responsibilities. Second, leadership matters. Inslee Clark set a permissive example. Likewise, in years past, leaders in medicine did the same. Medical leaders hushed up allegations against colleagues, just as bishops did with offending priests. Finally, when a problem hits the fan, respond as Tek Young Lin did, not as past medical leaders and bishops did - take responsibility for the situation, apologize, and make amends when possible.

        (For the initial article about "Prep School Predators" see here. For the article about my teacher Tek Young Lin, see here. For yesterday's article about alumni reaction to how the school is handling the situation, see here.)