MANAGED CARE June 1996. ©1996 Stezzi Communications
If managed care is to fulfill its goal of promoting wellness rather than simply treating disease, physicians must learn to counsel patients effectively about food and cooking, argues a doctor who is also a cook.
Playing a dual role is familiar to Managed Care "Ethics" columnist John La Puma, M.D., a Chicago-based practicing internist who regularly doubles as a writer and speaker on ethical issues in health care. (This month, his column appears on page 53;  La Puma is also the co-author, with David Schiedermayer, M.D., of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics, McGraw-Hill, New York, 1996.) But readers may not know that every week La Puma dons a chef's hat for a third professional identity, working as a cook in a Chicago restaurant. His triple credentials enable him to offer compelling testimony to the managed care community — and helpful tips for your patients, too.
"Let food be your medicine and medicine be your food." — Hippocrates
You might wonder why a physician-ethicist went to cooking school. About 10 years ago, I noticed that many of the hospital patients I saw as an ethics consultant had been recently seen in the office for hypertension, hyperlipidemia, diabetes, heart problems or cancer. The hospital choices to be made were about life-sustaining treatment and "do not resuscitate" orders. Neither prescribed diet nor medication nor surgery had worked well for these ethics patients. Prescribed diets in particular seldom seemed to work for my own patients, especially those who were obese. I wondered if there wasn't a way to help such patients control their own health by prescribing the right diet and making it taste great. So, I decided to go to cooking school.
That was more than four years ago. In the time since, I myself have lost 30 pounds — and kept it off. More important, I've made it a habit to talk with patients about eating and obesity. I focus on two things: flavor (see below) and measurable risk factors (lipids, blood pressure, glycohemoglobin and sleep apnea). I continue to practice medicine and teach, and also work one day weekly at a regional authentic Mexican restaurant in downtown Chicago called Frontera Grill/Topolobampo with Chef Rick Bayless, making soups and sauces in the afternoon and appetizers at night.
The S.A.D. truth
Americans who shop, cook and take the kids out for dinner are pressed for time, short on money and hungry for real food facts. Many Americans now equate quantity — especially large quantities of fast food — with quality.
Yet limited time and money need not doom genuine quality, any more than improved outcomes in managed care are inconsistent with reduced costs. In fact, if armed with useful information, physicians can improve patients' food choices and help them find flavorful ways to eat right. I believe that eating and cooking for health is a logical next frontier for managed care.
The S.A.D. (Standard American Diet) truth is that many of the serious medical problems physicians see arise in part from too much food. The average adult weighed eight pounds more in 1991 than he or she did in 1980. Cardiovascular disease, diabetes mellitus and cancers of the colon, breast and prostate are diet-related, and specifically obesity-related. So are gout, cholelithiasis and osteoarthritis of the weight-bearing joints.
Obesity is probably the most prevalent chronic disease: 33 percent of the nation is 20 percent or more over ideal body weight. Unfortunately, many people, physicians included, still view obesity as a problem of willpower. It is not. Obesity is a chronic disease that deserves diagnosis and treatment, including medication and surgery. Pharmacotherapy is coming into its own, and amphetamine relatives such as phentermine, fenfluramine and dexfenfluramine are now in demand. Coupled with major lifestyle changes in uncomplicated cases, these agents are useful medications, although they do require lifetime use.
Chronic disease needs counseling as much as or more than medication, however, and physicians need to know how to talk to patients about food and cooking. Sadly, most physicians are not authorities on diet, and fewer than 40 percent of primary care physicians counsel their patients about diet or activity. Only a few medical schools require courses in nutrition. Research by University of Chicago gastroenterologist Robert Kushner has shown that physicians find that they have too little time, too little knowledge and too few good materials for counseling. Many patients do not adhere to diets and cannot or will not follow physicians' advice simply to "lose weight and exercise more."
Hungry for information
Because patients haven't been getting much advice about food from doctors, they are going elsewhere. Aromatherapists, chromium picolinate sellers and media-savvy healers who specialize in herbal mixtures are preying on obese patients like serpents swallowing dinner.
Physicians should talk to patients about food and cooking, not just about micronutrients. No one eats 50 milligrams of Vitamin E as a meal; we eat nuts and seeds and oils. Encouraging people to cook whole foods at home instead of grabbing prepared fast food is one way to help patients regain a little control over their diets.
People need accurate, solid, clear information and advice from their doctors about what they should eat. Accompanying this article you'll find a helpful trio of fives: five sources of office handouts you can use to educate patients (page 50), five good high-flavor, low-fat cookbooks to recommend (page 51) and answers to five of the questions patients most often ask about food and fat (see below). There's also a trio of delicious recipes (starting on page 49), one for each of the upcoming summer months, which should help make for an easy, tasty season of plenty for your patients — and perhaps for you, too.
What blocks good intentions
Many patients already know what they should avoid eating, but other factors stand in their way. Like the expectation of blandness and the disappointment of hunger after a "healthy" dinner. Patients are pessimistic about the chances of finding flavor in meals that are good for them, and about finding any familiar food items on their plates when they've committed themselves to a healthy diet.
Seven 'no-cook' flavor hints
How to overcome these factors? Offer ideas as well as admonitions. Many people have not had delicious meals that happen to be very low in fat or high in fiber. Few are familiar with preparing low-fat foods that taste good enough to be acceptably satisfying, especially to families with children. But the ideas are out there. Here, for instance, are seven "no-cook" ways to intensify the flavors of low-fat foods without resorting to sugar or salt:
Acidification. Good wine vinegars and fruit vinegars add a tangy flavor without a drop of fat. Citrus fruits — from lemons and limes to oranges and tangerines — are all acidic, and many are delicious when squeezed into or over soups, salads, main dishes and desserts. My favorite acids are high quality, long-aged balsamic and sherry vinegars. Try them in cooking liquids for grains, tomato sauces for pasta, sprinkled on top of a vegetable sauté, or on fresh berries and fruits. "Strawberries Marinated in Balsamic Vinegar" sparkles like Modena, balsamic vinegar's centuries-old northern Italian home.
Smell. Smell is 80 percent of taste. Allergic rhinitis is the most common reason for an impaired sense of smell, and is easy to treat. Diagnose and treat allergic rhinitis, and patients trying to find the flavors in low-fat, high-fiber eating will thank you.
Spices and herbs. Herbs are leaves; spices are everything else — stems, buds, blossoms, roots. One teaspoon of dried herb is three times as powerful as a teaspoon of fresh herb. Dried herbs are usually added at the beginning or middle of cooking; fresh herbs are most fragrant and aromatic at the very end. Most herbs are easy to grow, and can survive droughts, neglect and window boxes. Some, like rosemary, even thrive in dry soil. Growing fresh basil, oregano and cilantro in a planter box can be a year-round joy in the kitchen.
Infusion. To flavor oils and vinegars, just fill their bottles with fresh herbs, dried spices, citrus zest or crushed aromatics. Try garlic, oregano and bay olive oil; habañero-cilantro canola oil, and parsley, sage, rosemary and thyme white wine vinegar. Warming both oils and vinegars with the flavoring adds just a little more tang. Do not simmer or bubble — just bathe for a few moments. Pour the mixture through cheesecloth into a scrupulously clean, dry bottle, and set aside for a week or two in a cool, dark place.
Stacking. Stacking means using different forms of the same food together. Adding sun-dried tomatoes to a fresh tomato sauce and combining coriander seed with fresh cilantro in a "Caribbean Black Bean Soup" are examples of stacking. Stacking builds extra, complementary and complex flavor in almost any dish.
Tubes. Concentrates are convenient, economical space-savers. Anchovy, garlic, harissa, olive, onion, sun-dried tomato, tomato and wasabi are all available in toothpaste-like tubes with screw tops. Nearly undiluted concentrates, tubes add instant flavor to sauces, dressings or marinades, richness to cooking liquids for grains, and depth to a pizza base or cracker spread.
Color-matching. Foods of a color and class taste good together. Try two vegetables that are yellow, two fruits that are red or two herbs that are green. Tomatillos and serranos are naturals together; so are raspberries and strawberries; and so are fresh mint and fresh dill.
Quick tips for patients
Besides these flavor enhancers, simple tips for shopping, cooking and snacking can help, too. Here are six of them:
- Fruit makes an easy fast food snack. Fill bowls in every room in which you eat. Stash a few pieces in your luggage if you travel, or in your purse or briefcase for the ride home from work. I take apples, pears or bananas when I travel, even for a day.
- Turn off the television. Savvy marketers are not yet pushing the virtues of flavorful fresh fruits and vegetables.
- Eat and cook with someone else, especially kids. Many kids eat what they have helped, in any way, to create. Pressing the button on a microwave or stirring a sauce, particularly for beginners, counts as cooking.
- Shop for what's fresh, what's in season, and when possible, what's organically grown. Farmers' markets, whole-food and health-food stores have the best selections of great-tasting organic produce, and improving prices. Supermarkets have felt the competition, and are rapidly improving their quality and choices. Choose fruits and vegetables that are deep in color and heavy for their size.
- Cook for the week when you can. Make dishes that taste even better the second and third day than they do the first. I routinely double or triple recipe quantities, leave three or four meals in the fridge and freeze the rest. That way, there's always something good to choose.
- Take home half your entrée. Portion sizes in U.S. restaurants are enormous. Meals that overlap placemats are still a marker of quality in the minds of many customers. Even restaurant plates have increased in size by 4 inches over the past 40 years. Draw a line down the middle of the plate and ask to take home half. That way, the waiter can make you lunch for tomorrow.
Fat and feelings
Obesity is defined as a body mass index — that is, weight in kilograms per height in meters squared — of over 27. Morbid obesity is defined as a body mass index of 40. Genetics play a part, but in 1980, only 25 percent of adults were obese; now, the prevalence is 33 percent nationwide, 47 percent in Mexican-American women, and 49 percent in non-Hispanic black women. The gene pool hasn't changed that much in 16 years.
It's too simplistic to say, "Each day, keep your fat gram intake at about 35, eat at least five fruits and vegetables, and exercise 30 minutes." But it's a good start.
Tips for treating the obese
Psychologist and obesity expert John Foreyt, Ph.D., at Baylor College of Medicine lists six suggestions gleaned from the peer-reviewed literature for helping patients lose weight and keep it off. They are:
- Focus on health rather than appearance. Taking off and leaving off five or 10 pounds often reduces total cholesterol levels and blood pressure, and improves energy level and self-esteem. Positive reinforcement goes a long way in turning that five into 10, and 10 into 20.
- Set realistic goals. Encourage thinking in terms of symptom improvement rather than number of pounds lost. One pound per week, give or take half, is just where most patients should be.
- Emphasize exercise. To maintain weight loss, and accelerate its rate, a few minutes daily makes a difference. Patients should pick any activity they like. They should not buy treadmills or riding machines or anything else they don't already know how to use and love using.
- Ensure social support. Peer support groups can be invaluable. It is still politically acceptable, if not correct, to make fun of and blame obese patients. It is also wrong and painfully myopic. Blaming the affected person in any disease is ineffective therapy.
- Focus on self-esteem. A physician's empathy with obese patients is one of his or her important tools. Weigh patients privately, keep unnecessary comments to yourself, and use extra large cuffs to measure blood pressure.
- Normalize eating patterns. If your patients skip breakfast and lunch, and then eat continuously until bedtime, it may help to have them try to eat at least 25 percent of their calories at each meal. Binge eating may be a sign that further psychological exploration is required.
Just as other medical problems do — even in the age of the gatekeeper — obesity and diet difficulties may require referrals and consultations. How about some American Dietetic Association (ADA) pamphlets and a registered dietitian?
The dietitian's role
Dietitians have more time available than primary care physicians to review diet diaries, assess patient motivation and talk about appropriate food substitutions. Dietitians also teach patients how to add calcium to deficient diets (three glasses of skim milk give 1200 milligrams), when and what to drink when exercising strenuously (up to a quart of plain water, hourly) and how to read food labels and the U.S. Department of Agriculture food pyramid (there's a lot left out and between the lines).
Many dietitians are also eager to learn techniques for making low-fat food taste really good. Last year, in partnership with cooking authority Carl Jerome, I offered a half-day ADA "Flavor-Intense Low-Fat Cooking" class, which was sold out just two days after registration was opened. Its popularity, I believe, was a reflection of the hearty potential appetite for some of the flavor-intense techniques reflected in "Three Recipes for a Tasty Summer," beginning below.
Managed care's palate
Disease prevention and health promotion are the foundation of managed medical care. To be fair to generations ahead, we need to establish different eating habits that are more sustainable than the ones most patients have today. Yet few patients will eat any of the 16 pounds of grain needed to produce a pound of beef if the grain isn't delicious, satisfying and affordable.
In the current managed care environment the time physicians have for counseling patients is squeezed as never before. But isn't it better business, as well as better medicine, to offer succinct, sympathetic and realistic advice today if it can prevent some of the costs of obesity-related illnesses tomorrow?
By talking about food and eating in the office, and by encouraging home cooking, physicians can help to improve the health of many patients. Giving patients some of the tips I've provided here is a start. You may want to try them yourself, too. The flavors alone are worth it!
Five questions patients ask about food and fat
Here are five queries to be ready for when you counsel patients on healthy shopping, cooking and eating:
Do "fat-free" foods really contain no fat at all? And why do I gain weight eating them?
If it has less than half a gram of fat per serving, it can still be called "fat-free." Some fat-free foods are loaded with simple sugars or salt, making them unhealthful. In commercial baked goods especially, sugar replaces fat, and its calories. Neither "fat-free" nor "low-fat" foods are necessarily low in calories.
Don't "fat-free" foods have lots of chemical additives?
Many packaged and bulk foods do, but many fresh foods don't. Remember, not all chemical additives are bad; vitamin C keeps many foods from browning, and some foods are helpfully supplemented with iron and folic acid.
I eat "97 percent fat-free" lunch meat. Isn't that good?
"Ninety-seven percent fat-free" means that the food is three percent fat by weight or volume, not by calories. The real nutritional questions are: How many grams of fat per serving does it have? And how big is the serving?
Two-percent milk is low-fat — right?
Not at all. Whole milk is 3.3 percent fat by weight, so milk that is 2 percent fat by weight is only a little bit better. Two-percent milk is 98 percent fat-free, but actually provides 38 percent of its calories as fat. One glass of 2-percent milk has as much saturated fat as three strips of bacon!
How much fat do "light," "monounsaturated," and "polyunsaturated" cooking oils have?
When it comes to fat, all cooking oils are created equal. They all have the same amount of fat — 14 grams and 125 calories per tablespoon — regardless of whether they're "light" or dark, mono or poly, olive or corn.
Recipes For A Tasty Summer
On the next three pages, author John La Puma, M.D., presents healthy recipes you can offer your patients — and try yourself. They're full of fresh, delicious seasonal flavors that take advantage of farm markets and no-fuss cooking. It's almost a coincidence that they're vegetarian, full of complex carbohydrates and fiber and have no saturated fat.
Big Baked Potatoes With Hot and Ripe Mango Salsa (8 servings)
Most ripe mangoes have a little yellow or orange blush — the more blush, the riper the fruit. Like bananas and tomatoes, mangoes ripen faster when two of them are placed together in a paper bag. The fruits give off a natural ethylene gas, which has just this effect.
- 8 large baking (russet) potatoes, pierced with a fork
- 1/2 medium white onion, diced very small (about 1/2 cup)
- 1 carrot, diced very small (about 1/2 cup)
- 8 ripe mangos, peeled, seeded and coarsely chopped (about 8 cups)
- 2 serrano chilies, seeded and minced
- 1/4 bunch cilantro, coarse stems removed, minced (about 1/2 cup)
- juice of 1 lime
- zest of 1 lime, minced
- Place potatoes on a rack in the middle of a 450-degree oven and bake until their skins are crispy — about 45 minutes. Remove the potatoes, let cool slightly, and split lengthwise.
- Combine remaining ingredients except lime zest in a nonreactive bowl and allow flavors to mingle for a few minutes before spooning into the steaming potatoes.
- Sprinkle with zest and serve.
Flavor Tip: To get the most out of the lime, roll it gently beneath your palm to break up the seedlets inside. Use a sharp paring knife to peel away just the thin green skin, leaving behind the bitter pith underneath. Finally, cut the lime in half and squeeze.
Nutrition Tip: The rib of a chili attaches the seeds to its wall, and gram for gram, packs the most capsaicin — the natural chemical that makes chilies hot and lips numb. It also can improve your sense of smell if your nose is stuffy. Smell the flowers!
Substitutions: Try half of a stemmed, seeded, minced fresh orange habañero pepper instead of the serranos: It has a wonderful tropical flavor, and blends in beautifully with the mangoes.
Pasta Shells With Diced Tomato, Basil and Arugula (6 cups)
This one-bowl recipe depends on the ripest, most aromatic tomatoes you can find. You'll love how well a search for quality repays you — especially if you wind up in your own backyard garden.
- 2 large cloves garlic, minced
- 2 ripe medium tomatoes, diced fine
- 8 sprigs basil, coarse stems removed, slivered
(about 1/2 cup)
- 8 leaves arugula, coarse stems removed, slivered
(about 1/2 cup)
- 1 tablespoon balsamic vinegar
- 2 tablespoons bean stock (see below)
- 1/2 pound pasta shells, dry
- Mix all ingredients in a deep mixing bowl except the pasta.
- Boil four quarts of water, add pasta, and remove when barely al dente (about seven minutes)
- Drain in a colander, and pour the still-hot pasta into the tomato mixture.
- Toss together, taste and season with salt and fresh ground black pepper. Serve immediately.
Flavor Tip: Undercook the pasta, just slightly: It will absorb all the flavors in the bowl as you toss.
Nutrition Tip: Bean stock substitutes beautifully for oil here, adding body and volume, but not one of the 14 grams of fat per tablespoon in all oil. See September's recipe for more.
Substitutions: If arugula is unavailable, substitute flat-leaf parsley and a generous half-teaspoon of red pepper flakes. If bean stock is unavailable, use vegetable or chicken stock. Other pastas, like farfalle (bow ties) and orecchiette (little ears) work well too.
Gingered Yellow Pepper, Fresh Corn and Chick Pea Soup (8 bowls)
This smooth soup is vibrantly yellow, and a great way to use the bounty of summer farmer markets. Add "Pasta Shells with Diced Tomato, Basil and Arugula," a hearty loaf of bread and a glass of soft, fruity red wine, like a Beaujolais or a Merlot, for an elegant, easy supper.
- 10 large yellow peppers, cored, seeded and halved
- 1 large yellow onion, diced medium
- 6 garlic cloves, minced
- 2-inch chunk of ginger, peeled and sliced thin
- 6 cups vegetable or chicken stock
- 2 cups cooked chick peas, rinsed
- 2 ears of corn, niblets cut away and reserved
- 1/2 cup scallion greens or chives, minced
- Place the peppers in a large bowl, cover with a double layer of plastic wrap, and microwave on high for seven minutes.
- Combine the onion, garlic, ginger and stock in another bowl, cover with a double layer of plastic wrap, and microwave for seven minutes.
- Remove the peppers from their bowl, put half aside, and place half in a 44-ounce blender jar. Ladle half the stock-onion mixture into the blender too and blend very thoroughly. Repeat with the remaining peppers and liquid, and return to the bowls.
- Add the chick peas and corn, cover, and microwave for seven minutes more.
- Garnish with minced scallions or chives and serve.
Flavor Tip: To intensify the flavor further, pour the soup into a sauce pan, simmer until the volume is reduced by a quarter, and stir a teaspoon of sherry vinegar into each bowl before serving.
Nutrition Tip: Sweet yellow peppers have almost one- and-one-half times as much vitamin C as sweet green peppers, and eleven times as much beta carotene.
Substitutions: Substitute canned, drained chick peas (also called garbanzo beans or ceci) for soaked and newly cooked ones. Save the bean stock for making a vinaigrette or for cooking grains.
Five phone numbers to call for patient handouts on food
To find more tips for your patients on healthy shopping, cooking and eating, try dialing these five telephone numbers — or surfing for the Web's comprehensive guide to nutrition resources at http://netspace.net.au/%7Ehelmant/nutid.htm .
(303) 678-8475: That's Health magazine in Boulder, Colo., which offers sturdy, handsome, single-topic information sheets.
(800) 4-CANCER: The National Cancer Institute in Bethesda, Md., makes available excellent pamphlets on fruits and vegetables.
(617) 621-3000: Here you'll find Oldways Preservation and Exchange Trust in Cambridge, Mass., which has information on healthy traditional cultural diets. Mediterranean and Asian versions have been completed; a Latin American version is expected soon.
(202) 686-2210: This is the Physicians' Committee for Responsible Medicine in Washington, D.C., whose vegetarian diet information is useful whether or not you agree with the committee on all issues.
(510) 642-8061: Here you'll reach the Berkeley-based University of California Wellness Letter, which provides a monthly summary of clinical data about diet and health.
Five good high-flavor, low-fat cookbooks
Want to arm your patients with recipes that will help them savor healthy eating, not just submit to it? Suggest these recent cookbooks. The recipes in them work best with what's ripe and in season.
Jerome, Carl. Cooking for a New Earth: A New Approach to Home Cooking that Promotes Wholesome Eating and Healthy Living. Henry Holt, New York, 1993, 343 p., $25 hardback, $14.95 paperback.
Johns, Pamela Sheldon and Hess, Mary Abbott. Healthy Gourmet Cookbook. Collins Publishers San Francisco, 1994, ISBN 0-00-255373-2, 225 p., $45 hardback.
Kirchner B., The Bold Vegetarian. Harper Collins, New York, 1995, ISBN 0060950560, 286 p., $16 paperback.
Raichlen, Steven. High-Flavor, Low-Fat Cooking. Penguin, New York, 1994, ISBN 0-1402.4123 X, 255 p., $18.95 paperback.
Raichlen, Steven. High-Flavor, Low-Fat Vegetarian Cooking. Viking, New York, 1995, ISBN 0-670-85782-3, 285 p., $24.95 hardback.