TBTAM’s NYC Restaurant Recommendations

Home cooking is what I do best. And yet, the most frequent e-mail request I get from readers, friends and family is – “Where should we eat when we come to New York?” Finally, after years of repeatedly wracking my brain for recommendations, I decided to create a restaurant recommendations page here on the blog. (You can access it as a drop down on the NYC Tab above)

The list is nowhere near complete, but it’s what I can up with off the top of my head this week, and I plan to update it over time. Restaurants are sorted by neighborhood, and I came up with my own little key up there so folks can get a sense of what kind of place I’m recommending.

Some restaurants I’ve reviewed here on the blog; most I have not (even though I have dozens of pics  and the best of intentions). But let me be clear – I am not a restaurant connoisseur. I’m just an ordinary New Yorker who knows what she likes. Your tastes could differ, so you might seek better advice from one of the sources in the sidebar. If you have a fave you’d like to recommend, tell us in the comments.

Should You Start Residency Eight Months Pregnant?

That’s the question being posed over at Mothers In Medicine, a wonderful group blog the tackles the tough issues faced by working mommy docs.  This time, it’s a 27 year old, fourth year medical student asking if she should apply to joint Family Practice-Ob residency, knowing that she will give birth one month into her internship year, or take a year off instead. (She got pregnant by surprise after failed infertility treatments. Aah, nature …)

Here’s the advice I gave her. Feel free to head on over and give yours.  It will be interesting to see what she does.

Congratulations! It’s always so interesting when our high-tech interventions fail and nature takes over.

Forget that this is residency – It’s a new job.  I don’t think anyone would consider starting a new job in their 36th week of pregnancy, especially one with such huge responsibility towards others, both those in your care and those who work alongside you in your program. It just doesn’t make sense for you, your employer or your fellow residents. (I like to think of myself as a feminist, but I’m also a realist.)

I wouldn’t take they year entirely off, however. Find a research mentor in ob-gyn at your home institution, and get started right now working on a research project in the field you love. Use your energy towards that instead of applications and interviews. If you start it now, you can take time off in the summer for maternity leave and get right back in after that.

You’re going to be a working mom forever, so I say get used to it before residency slams you. Taking a year entirely off is going to make it that much harder to make the transition to residency. You’ll have the upcoming year to work out child care and settle into your new role as a working mom. Trust me, you don’t want to be struggling to find the right babysitter or daycare during your first few months of internship. You need to be able to go to work and forget about home, knowing it’s all taken care of by someone you know well and trust implicitly to take care of your child.

Good luck and let us know how it all worked out!

Peggy

Unwanted Pregnancies, Not Abortion, Linked to Mental Health Issues in Women

I don’t know how many more studies need to be done to prove once and for all what those of us providing reproductive care to women have always known – that abortion does not cause mental illness.  But just in case, here’s yet another one, this time  “the most comprehensive and detailed review of the mental health outcomes of abortion to date worldwide” conducted by the UK National Collaborating Centre for Mental Health.

Data from 44 studies showed women with an unwanted pregnancy have a higher incidence of mental health problems in general. This is not affected by whether or not they have an abortion or give birth…Usually, a woman’s risk of suffering common disorders such as anxiety or depression would be around 11-12%. But the researchers said this rate was around three times higher in women with unwanted pregnancies.

How much better the British Health Services limited budget would have been spent in providing direct reproductive and mental health services to women.

Can we please just stop trying to prove the obvious to those who will never believe the data and spend our energies helping women and their partners prevent unplanned pregnancy?

Birth Control & Blood Clots – Visualizing The Risks

If you’ve been using the Patch, Yaz or Yasmin, you’ve got to be wondering in the wake of this week’s news whether or not you should reconsider your choice of contraceptive. After all, the FDA has pretty much confirmed that these methods have a higher risk of blood clots than older birth control pills. By now, your mom has probably called you and told you to get off that nasty pill, your roommate may already have hidden next week’s patch from you, and you’re holding your breath waiting for a call back from your doctor, who’s probably fielding about a hundred calls today alone from worried pill and patch users

All you really want to know, though, is this –

What’s My Risk? 

It’s an important question that deserves an answer and a conversation with  your doctor. Let’s see if I can help inform that discussion. But first, you need to know a a bit about the subject at hand – blood clots.

What are Blood Clots?

Blood clots are blockages in the vein or artery that occurs when the blood coagulates in the blood vessels.

  • A DVT (deep veinous thrombosis) occurs when blood coagulates in the veins of the leg or arm, where it causes pain, swelling and inflammation.
  • A PE (pulmonary embolus) occurs when a clot forms in the lungs or breaks off from a DVT in the leg and gets lodged in the lung. PE’s causes shortness of breath and chest pain, and if large enough, lack of oxygen and even death.

DVTs and PEs are treated with blood thinners, which almost always work to dissolve the clot, although long term sequelae of the clot can occur.

  • Clots to the heart and brain are exceedingly rare in young women. In birth control pill users, that risk is confined to women over 35 who smoke (and should not use estrogen containing hormonal birth control) and women who suffer from ischemic migraine with aura or underlying medical problems such as heart arrythmias that predispose them to stoke. (Women over 35 with regular migraine may also be at increased risk).

For the otherwise normal, healthy young woman on pills or the Patch, the risk for heart attack and stroke is just too rare to even begin to compare between users and non-users of these methods. And in fact, these risks have not been reliably shown to differ between currently marketed methods. So in this discussion we’re going to confine ourselves to talking about the risk from DVT, where the data appear to be a bit clearer.

How does Birth Control cause blood clots?  

Birth control methods that contain estrogen increase the risks of blood clots by altering the delicate balance of clotting factors produced in the liver. In spite of this, however, most women taking estrogen don’t get clots. So, other factors must also be at play for a clot to form.  Here are those other factors that we know and understand –

  • Long plane flights and car rides. Prolonged immobilization can cause the blood to pool in the legs and clot. In my two decades of practice, almost every clot I’ve seen in my patients using estrogen containing birth control occurred after a long plane flight or car ride. That’s why it’s so important to get out of your seat and walk around on a long plane flight and make frequent stops on long car rides.  And, unless they’re rising in business or first class with a seat that allows them to elevate their legs, I also advise all my patients taking estrogen to wear knee high travel compression socks, since studies have shown that these can lower clot risks due to plane travel.
  • Genetic mutations / Family History. Some people are predisposed to clotting because they carry a mutation in their clotting factors, the most common of which is Factor V Leyden mutation, found in about 5% of the population. Women with such mutations should avoid estrogen. Some day we’ll have an inexpensive blood test to identify these women, but right now the best clue to a genetic mutation is a family history of blood clots. In families with such histories, genetic screening can be done in the affected individuals to identify the mutation and then screening of other family members to find out who is at risk.
  • Obesity and smoking also increase the risks of clotting, in the arteries as well as the veins. Women over 35 who smoke should not use estrogen containing birth control.
  • Surgery and hospitalization. Prolonged immobilization is the reason. Hospitals use compression stocking, pneumatic air pumping leg wraps and even low doses of blood thinners to prevent clots due to hospitalization. (God forbid they get the patients up and walking, but that takes nursing staff, and we’d rather spend the dollars on devices and drugs, don’t get me started…)
  • Varicose veins. Birth control pills don’t cause varicose veins, but women who have varicosities (not superficial tiny spider veins, but large deep veins in the leg) have a higher risk of clotting due to pooling of the blood in the veins of the extremities.
  • Advancing Age. The biggest factor associated with blood clot risks is age, with the elderly being at particularly high risk compared to younger individuals. However, pills are generally still safe to use in healthy women up to the age of menopause.
  • Pregnancy. Perhaps the highest risk women take for blood clots is during pregnany, a time when your risk for clotting increases up to 5 times the rate in non-pregnant women.  Here, the hormone of pregnancy, fluid shifts and edema in the legs are culprits. Researchers often compare the risks of hormonal birth control to the risk of pregnancy, although a better comparison is to compare it to the risk from using another method, combined with the risk of getting pregnant from that method if it is less effective.

The progestin component of pills

Scientists believe one of the factors affecting clot risk in one method vs another may be the progestin component.

  • Northindrone (1st generation progestin)
  • Levonogestrel (2nd generation progestin)
  • Norgestimate, desogestrel, gestodene (3rd generation progestins)
  • Dropeserinone (the progestin in Yaz)

Why? It’s not so clear, and some experts maintain that it makes no biologic sense that, estrogen dose being equal, progestins should impact clot risk at all. Despite this, research is mounting that lower clot risks seem to exist for first and second generation pills. Norgestimate pills may have a similarly low risk, perhaps because they are metabolized in the body to levonorgestrel. The progestin in the Patch is metabolized to norgestimate, but the higher estrgoen dose in the patch probably contributes to that method’s higher clot risk compared to norgestimate pills.

Now that you’re an expert on blood clots, let’s visualize the risks of your birth control

Because the risk of PE is so low, most studies either combined DVT and PE risk, or report on DVT risks alone, which is what I’m going to do.  In general using the patch or  yaz will increase your odds of a DVT by about 50% – that’s called relative risk of 1.5. Translating that to absolute risks is difficult, because the actual numbers of clots occurring in a given study depends on so many things, not the least of which is how they define that a clot has occurred. Each study the FDA examined used a slightly different methodology – some used pharmacy database prescriptions for blood thinners, some used claims-based diagnoses and others added confirmatory chart reviews. Each method has it’s biases, and none is perfect.

Absoute Risk DVT- Background

The background rate of clots among healthy women of reproductive age that I have seen most often quoted in the literature is about 4 per 10,000.  This is your risk if you do not take hormonal birth control.The dots represent 10,000 women over a year’s time, with brown dots unaffected women and red dots those who have a DVT.

DVT Risk – Levonorgestrel and norgestimate pills

The risk in users of second generation pills containing levonorgestrel, or 3rd generation norgestimate pills is about 6 per 10,000. This is the risk that Ortho Evra and Yaz were compared to by the FDA. Here’s what that looks like –

DVT Risk – Ortho Evra Patch

Use of the patch increases that risk to 9 per 10,000.  Here’s what that looks like –

In case you’re having trouble visualizing it, I’ll put it side-by-side.

So you can see, as reported to the FDA,there is an excess of about 3 cases of clots per 10,000 women using the patch compared with those using an older pill. If you’re on the patch, clot risk does not appear to diminish over time. So your excess risk remains about 3 per 10,000 as long as you use the patch.

DVT Risk – Yaz

The risk from using Yaz and Yasmin comes in pretty close to that of the patch, at around 10 per 10,0000. The risk for clots with Yaz decreases the longer you use it. So if you’ve been on it for over a year with no clot, your risk drops significantly for getting a clot in the future, to about 5 per 10,000.

DVT Risk -Pregnancy

Finally, what about the clot risk from pregnancy? Actually, that’s the highest risk of all – about 20 per 10,000 or 2 per 1,000.

What about the Ring? And pills containing desogestrel?

Excellent question. The FDA hasn’t addressed the clot risk with the Ring specifically outside of the FDA approval process. We do know that the ring imparts a significantly lower estrogen exposure than the patch and a 35 ug pill, but it’s unclear if that translates to a lower clot risk. The ring, after all, contains etononorgestrel,  the active metabolite of desogestrel.

Pills containing desogestrel have come in at a risk of about double that of levonorgestrel pills, so I’m going to assume in the absence of data to prove otherwise that the  risk of the ring would be about 8 per 10,000.

Why does it take so long for us to learn about these risks for methods that are already on the market?

Almost all newer contraceptives will have an undefined clot risk, since clinical trials are just too small to detect a statistically significant increase in clots, which as you know now are relatively uncommon events. It’s only when a method makes it out into the general population of millions of women that an increased clot risk becomes evident. (Of course, if the manufacturer does not report all the clots that occur in a trial, that’s a different story, and the subject of recent lawsuits related to Yaz.)

Bottom Line

Your chance of dying from a blood clot related to your contraceptive is about one in a million. The chance you’ll get a blood clot is well below one percent no matter what method of birth control you use.  In that very low risk range, your chance of a blood clot, in order of increasing risk, is –

       Method

Risk per 10,000*

Percent risk*
Non-hormonal. Not pregnant.

4 per 10,000

0.04 %
Levonorgestrel pills Noregstimate pills

6 per 10,000

0.06 %
Desogestrel Pills

8 per 10,000

0.08%
Nuvaring

? 8 per 10,000

0.08%
OrthoEvra Patch

9 per 10,000

0.09 %
Drosperinone pills

10 per 10,000

0.1%
Pregnancy

20 per 10,000

0.2%
* These numbers are estimates based on my best good faith interpretation of the literature and data presented to the FDA on 12/8-9/11. Better numbers may be forthcoming from the FDA or other sources in the future, but for now I need something for my patients and myself to work with. Margaret Polaneczky, MD

Bottom Line

Even if you take the pill or the patch, the odds are overwhelming that you’ll make it through your reproductive years without ever having a blood clot. 

The risk of actually dying from a blood clot due to your hormonal birth control is about one in a million.

If you want to avoid the clot risk associated with estrogen containing contraceptives, you can use something else for birth control. Depo provera, the progestin only pill, Implanon, the IUD and barriers such as condoms and diaphragm are all reasonable choices.Each of these methods come with their own risks and benefit, and none is perfect.

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Additional Reading from TBTAM

FDA Allows the Patch to Stay, But with Better Labeling Supporting an Informed Contraceptive Choice

After cautiously clearing Yaz for continued use yesterday, an FDA Advisory Panel today addressed post-marketing data showing similarly increased blood clot risks among users of the contraceptive patch.  The committee, after having been clearly quite  extensively briefed,  heard testimony from Ortho Evra’s  manufacturer and experts in epidemiology, gynecology and hematology. They also heard moving testimony about  a young woman who died from a massive pulmonary embolism while using the Nuvaring,whose parents argued that not only the Patch, but most of the newer methods carry an increased clot risk that no woman should be allowed to take without being adequately informed.

The committee ruled that despite limitations of the data, the patch most likely carried a 1.5 times relative risk of blood clots compared to 2nd generation levonogestrel pills, but not necessarily higher than that of newer pills containing 3rd and 4th generation progestins and drosperinone.  With a few dissenters, the committee voted to allow the Patch to stay on the market, but asked for new product labeling outlining the increased clot risks.

The Power of a Good Graphic

The Committee seemed to be particularly moved in their deliberations by a visual presentation from  the manufacturer showing that the relative risks of Ortho Evra, while elevated compared to older second generation oral contraceptives, were comparable to that of other newer contraceptives – all of which have remained on the market. A summary slide presented by Anita Nelson, MD, showing absolute risks clustering in a similar range between the patch and other new progestin-containing pills, appeared to be equally compelling in this regard.

In perhaps a reaction to the power of a good graphic, the committee also very astutely recognized that current package labeling is ineffective in conveying comparative risks between methods for both clinicians and their patients, and asked for visual representation of risk in package labeling. They also spent sometime brainstorming how to best communicate risks to patients in general, recognizing that leaving it to the manufacturers may not be the best way to accomplish this important goal.

The Patch – A Unique Method for a Niche Market

The group’s decision on the patch appears to have been impacted in large part by the opinion that the method has a unique place among contraceptive methods due to its transdermal delivery system., even if it is that very system which may be imparting the increased risk.  Although dissenters pointed out that research has not shown the patch to have improved efficacy or compliance over pills,  anecdotal reports from members of the committee and gynecologist Dr Anita Nelson stressed that for some of their patients, the patch was simply the only method they were willing and able to use.  This testimony from practicing physicians appeared to have influenced most of the  panel members, even those who argued initially that the method’s risks did not outweigh the benefit, that there was a niche group of women for women the method might still be appropriate.

As one member of the panel pointed out today, that niche has already been carved by adverse media reporting and the pull back of the manufacturer from DTC advertising and detailing of the method. As a result, the patch was now used by only about 2% of hormonal contraceptive users in 2010. It is this 2% that the Committee appeared to be considering in their decision top allow the patch to remain on the market. It’s a decision with which I have to agree.

Who are the patch users?

They’re sometimes women who have breakthrough bleeding on every pill they try. Women using anti-seizure drugs that cause hormone levels in lower dose pills to drop below the range of efficacy. Women with estrogen withdrawal headaches on pills, who want the efficacy of a hormone but need the steady levels a patch provides (and aren’t willing to use the ring).  And women who have gotten pregnant on pills, don’t want an IUD or Depo, and whose partners won’t wear condoms.

Now the FDA is making sure that they’re woman who’ve been informed that the price they pay for the benefits the patch provides is a slightly higher risk of blood clots. Hopefully, as a result of the FDA Panel’s deliberations today, the Patch’s (and other hormonal contraceptive method) package labeling will evolve from a medical legal document into a tool to truly inform and support an educated contraceptive choice.

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More on Today’s Ruling

Politics & The Morning After Pill


Kathleen Sibelius, head of HSS, has overruled the FDA and blocked its recommended approval of the emergency contraceptive Plan B for over the counter access. The move runs counter to Sibelius’  pro-choice record, and to President Obama’s stated commitment to uphold science over politics.

Her argument? She is protecting 11 year old girls, who she states do not have the cognitive maturity to use the medication correctly.

Apparently, though, 11 year olds have the maturity to use Tylenol, a drug that have been shown to cause serious side effects, and even death, if taken at too high a dose.  (Some studies suggest that even taking it at recommended doses for as little as 4 days can cause liver abnormalities.) In fact, if they want to, any 11 year old can purchase up to 100 Tylenol pills for less than a week’s allowance.

The morning after pill, on the other hand, has no serious side effects, even if taken improperly. At a cost of almost $50 for one pill, it is likely never to be purchased by anyone, adult or teen, in a dose large enough to do anything other than what it’s intended to do, which is to prevent an unplanned pregnancy.

This is a travesty.

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More on the Morning after Pill

Mushroom Lasagna

The leaves disappear from the trees;
The time of the singing of the birds is done;
And the sizzling of sauteed mushrooms can be heard across the land.

There’s a sadness that comes to me in late autumn, as the days shorten and nature’s color palette moves from brilliant yellow, orange and red into the muted browns. But then I think of the mushroom, and my spirits begin to lift. Add in pasta, Parmesan cheese and a bechamel sauce, and let’s just say I’m ready to stop the season’s clock right here and now and live in November forever.

No, I did not make this week’s NY Times recipe for Gooey Wild-Mushroom lasagna – Although it looks delicious, there’s too much cheese in that dish for both my taste and my waistline.  I wanted a simpler recipe that would let the mushroom’s flavors dominate and fit a bit better into a healthy lifestyle. The recipe I ended up using began with Ina Garten (How much do I love her?…), got tweaked a bit at the Smitten Kitchen (Check out those pics…) and then of course, I had to tweak it some more myself to make it less calories and add a few more flavors.  What resulted was honestly one of the best things I have ever made or eaten. We served it for Sunday dinner with broccoli on the side, then the next night as a side with broiled steak (OMG…) , and again tonite as a smaller side along with roast cauliflower and a steak salad. Each time I ate a little less, and enjoyed it a little more. (Meaning it reheats well.)

I’d like to experiment a bit more with this recipe – adding in some shallots, using a bit less flour, perhaps upping the proportion of broth to milk in the bechamel, or replacing it altogether with this olive oil bechamel from Martha Rose Shulman. Turns out Martha Rose has already made a mushroom lasagna with olive oil bechamel. (Great minds think alike.) It looks incredible.  I think I’ll make that one next time. I’ll let you know how it turns out.

Mushroom Lasagna

For the pasta
3/4 pound dried lasagna noodles
1 tbsp olive oil
1 tsp salt

For the bechamel
3 3/4 cups skim milk
1/4 cup mushroom broth (from the cooking mushrooms or made with dried mushrooms – instructions below)
1 stick butter
1/2 cup all-purpose flour
1 tsp kosher salt
1 teaspoon freshly ground black pepper
1/2 teaspoon ground nutmeg

For the mushrooms
2 tbsp olive oil
2tbsp butter
1 1/2 pounds cremini mushrooms
1/2 tsp salt
Fresh pepper
1 clove minced garlic
3 small stems of fresh thyme leaves

For the lasagna
1 cup freshly grated parmesan cheese
Paprika (for the top)

1. Preheat your oven to 375°F. Lightly grease a 9×13 inch lasagna pan with olive oil or butter. (I use a le Crueset pan and highly recommend it.) Bring a large pot of water to boil with salt and a oil. Add the lasagna noodles and cook for 10 minutes. Drain and set aside.

2. Slice mushrooms 1/4-inch thick. Heat 2 tablespoons olive oil and 2 tablespoons butter over medium in the bottom of the large skillet or saute pan. Cook the mushrooms with a 1/2 tsp of salt, pepper to taste and the thyme for about 5 minutes, or until they are tender and release some of their juices. (You may need to do this in two batches if you don’t have a really large saute pan). Now here’s what I did that I think is kinda’ clever – you know how the mushrooms give off so darned much liquid, and then by the time you’ve cooked it off you’ve got a small dry mushroom? Well, I got tired waiting for it to cook off and wanted my mushrooms plump, so I drained off about a 1/4 cup of that rich brown broth and added it to my bechamel.  If you don’t want to do that, you can soak some dried mushrooms in boiling water and make a little mushroom broth instead and add that to the bechamel. In the last few minutes, add the garlic so it does not burn.

3. Heat the milk in the microwave or on the stove and set aside. Melt 1 stick butter in a large saucepan. Add the flour, then cook over a moderate heat constantly stirring until it turns a rich nutty brown (about 4 minutes – don’t leave it and keep stirring). Pour in the hot milk, a little at a time at first and then the rest quickly, whisking to combine. Add the broth, still stirring. Stir in salt, pepper and nutmeg and continue cooking over medium-low heat, whisking frequently, until it is thick (about 5 minutes). Set aside.

4. Spread some of the sauce in the bottom of a lasagna pan (8×12 or  9 x 13 baking dish). Arrange a layer of noodles on top, then more sauce (about 1/4 of what remains), 1/3 of the mushrooms and 1/4 cup grated parmesan. Repeat two more times then top with a final layer of noodles, your remaning sauce and last 1/4 cup of parmesan. Sprinkle with a bit of paprika. Bake for 45 minutes, or until top is browned and the sauce is bubbly. Let sit at room temperature for 15 minutes before serving.

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More mushroom recipes from TBTAM

What to Eat on NYC Marathon Day – Tri-color Pasta with Creamy Mushroom Sauce

Keeping with my recent theme of Autumnal-colored meals, I chose a tricolor pasta to use with this luscious creamy mushroom sauce from one of my fave cookbooks, Regional Italian Cuisine. The dish hails from Tuscany, where more genuine folk would serve the sauce with a mixture of homemade egg and spinach tagliatelle, and call it Paglia e Fieno (“Straw and Hay”). It was a great way to use up the last of the basil from my garden before the cold weather gets it.

It was also a great dinner to wind up a brisk autumn day during which I walked the city for over 3 hours – which is what happens when you decide to meet a friend for a walk in Central Park followed by brunch on the day of the NYC Marathon, and find yourself detoured for blocks by the race at practically every turn.  I didn’t mind the extra-long walk a bit – the weather was glorious, the city shining and beautiful, and the people ebullient – this is one of New York City’s finest moments.

On my way to the park, I caught the wheelchair front-runners as they came off the Queensboro Bridge into Manhattan.

And happened to be along the Park Drive as the female front runner hit mile 24.

The reservoir, as always, was glorious. And for a Sunday morning, gloriously empty.

We ate brunch on the Upper West Side at French Roast, sitting outside in the sun – how we scored a table without a wait is a small miracle in itself.  On the sidewalk, a bookseller was plying his wares – in this case, a tabletop filled with books on philosophy and psychoanalysis. If I didn’t know better, I would have thought Woody Allen was having a stoop sale.

As I headed down Broadway after brunch, marathoners in their orange capes clogged the sidewalks. A half hour later, back near home on First Avenue, runners were still coming off the bridge into Manhattan in droves.  Amazing, really. The sheer number of runners, cheered on by their friends, family and fellow New Yorkers, filling the streets of New York’s boroughs, and Manhattan from the east to the west side.

Detours and police barricades notwithstanding, Marathon Day is hands down my favorite day in this amazing city I am privileged to call home. Congrats to all the runners in today’s race, from the front-runners to the last stragglers. I hope your day was as wonderful as mine.

Tri-Color Pasta with Creamy Mushroom Sauce

This is not exactly a dieter’s dish, although a limited portion served with a large salad could be a meal well within a calorie-counter’s daily budget. To be more genuine use 1/2 lb spinach fettucine and 1/2 pound regular fettucine instead of the tricolor pasta.  To be truly genuine, make your own egg and spinach tagliatelle, as outlined in the original recipe.

1 lb tricolor pasta
3 1/2 ounces mild raw prosciutto
11 ounces fresh mushrooms (I used crimini)
Juice of 1/2 lemon (plus another tbsp or so for the sauce at the end)
1/2 bunch fresh basil leaves, torn
1/2 bunch fresh parsley, minced
1 cup heavy cream
1/2 cup plus 1 tbsp beef stock
1 garlic clove, crushed
1 1/2 tbsp butter
Salt and freshly ground pepper to taste
Parmesan cheese for serving

  • Start your pasta water heating.
  • Cut the ham into thin strips and set aside. Clean the mushrooms, slice thin and drizzle with the lemon juice.
  • In a saucepan, melt 1/2 tbsp butter and add the crushed garlic. Simmer over low-med heat until the garlic is soft. Pour in the cream and beef stock and allow to cook down until smooth and dense.
  • Meanwhile, in a small frying pan, melt 1 tbsp butter. Add the mushrooms and saute until limp. Add the parsley and ham and saute a bit more until the liquid of the mushrooms has evaporated and the ham begins to crisp a bit at the edges.
  • By now, your pasta water should be ready. Start your pasta cooking. When it is done, drain it well and place in a warmed bowl.
  • Season the cream sauce with pepper, salt if needed, and a little more lemon juice, and pour over the hot noodles. Toss with the mushroom-ham mixture and the basil leaves. Serve with grated parmesan cheese.

Autumn Red Quinoa Salad with Edamame, Roasted Sweet Potato & Cauliflower

Here’s a nice healthy lunch for autumnal days. I love the colors – the bright green edamame, the orange sweet potato, red pepper, and yellow cauliflower against the red grain reminds me of an autumn hillside. Packs easily to take to work and keeps for several days in the fridge. Serve it with a dollop of my new fave food, sheep’s milk yogurt.

Autumn Red Quinoa Salad

I used what I had on hand for this salad – ergo the roast peppers Mr TBAM had just made and the basil and parsely from the garden. The olive oil from the veggies and the peppers was enough for me, but you might want to add a bit more olive oil. We didn’t have any red onion or scallions – if we had I would have used either one.  

For the Quinoa
1 cup red quinoa (I used Quinoa Harvest  Inca Red Quinoa)
2 cups water
1/4 tsp salt

Roasted veggies
3 tbsp olive oil
1 large sweet potato, peeled and cut into 2 inch dice
1 small head cauliflower, trimmed and slices lengthwise into 1/2  ince slices
Kosher salt and pepper to taste

Other salad additions
16 blanched, frozen edamame pods (I used Whole Foods 365 organic edamame)
6 strips roasted red peppers in garlic & olive oil, cut into 1 inch pieces. (We had homemade on hand, you can use jarred)
1 stick celery, cut into small dice
2 heaping tbsps capers (optional – probably not needed if you have scallions or red onion)
1/3 cup chopped fresh parsley (+ a few sprigs for garnish)
6 basil leaves, chopped
Juice of 1 large lemon

  1. Preheat oven to 425 degrees fahrenheit
  2. In a medium saucepan, mix 1 cup red quinoa and 2 cups water with 1/4 tsp salt. Bring to a boil, then cover and simmer on very low heat for 15 minutes without stirring. Remove lid, fluff and cool.
  3. While quinoa is cooking, toss diced potato and cauliflower slices in olive oil, spread out on cookie sheets and sprinkle with kosher salt and generous pepper. Roast 15-30 mins till done, turning halfway through. Let cool.
  4. Steam and slightly cool the edamame. Pop open and collect the seeds in a small bowl. Salt lightly.
  5. In a large bowl, layer the quinoa with the roast veggies, celery, peppers, capers, edamame (all but a few seeds for garnish), basil and parsley. Squeeze juice of a large lemon atop it all and toss lightly. Garnish with a few saved edamame seeds and a bit of parsley. Serve.

The Mississippi Personhood Amendment – An Open Letter to Dr Freda Bush

On November 8, Mississippians will be voting on ballot amendment 26 , the so called “Personhood Amendment” that if passed, would declare a fertilized egg a person.

The question at hand is, would the Personhood Amendment be used to outlaw contraception?

Dr Freda Bush, an Ob-Gyn and spokesperson for the Personhood amendment in Mississippi, is misleading voters that it will not. In a press conference in support of the amendment in September, she stated this –

The personhood amendment will not ban the use of hormonal contraceptives.

The video of this press conference is being used to reassure voters about the intent of amendment 26. And yet the information Dr Bush presents about contraception and the amendment stands in complete contrast to that which the personhood movement itself has presented. Here is the standard “talking point” on contraception from personhood sites at states across the country seeking to pass similar amendments –

Won’t a Personhood Law Outlaw Contraceptives?

No, recognizing personhood has no effect on contraceptives because true “contra-ception” only prevents conception (fertilization). However, personhood would prohibit any chemical abortion that kills the youngest boys and girls before or after they implant in their mother’s womb. When the abortion industry says that personhood would outlaw contraceptives, it’s lying. These people have spent decades telling women that such chemicals did not kill a living embryo. Women should know whether or not a chemical would kill their children. A personhood law will end the lies.

It has been a long standing tenet of the anti-abortion movement that birth control pills are considered to be “chemical abortifacents”. They will most surely attempt to use this amendment, if passed, to outlaw hormonal contraception.

Still not convinced? Check out the Colorado Personhood website, where they adress what they call the “scare tactics” of those who oppose the amendment. Here, they try to convince voters that the amendment would not ban contraceptives, and yet in the end only barrier methods come out unscathed.

Contraception comes from the words “contra” and “conception”. Properly understood it means something that prevents conception. In 1965 the American College of Obstetricians and Gynecologists issued a medical bulletin which “officially” changed the definition of conception from the union of a sperm and an egg to implantation of the young human being in the wall of the uterus. The reason they did this was to make chemical abortifacients seem more palatable to the American people who would now be tricked into believing that the human being did not begin until implantation. While the AMA and pro-abortion bioethicists have tried to obfuscate the meaning of conception, embryology is very clear about the beginning of life: the beginning of life (under normal sexual reproduction) takes place when the sperm touches the ovum. Barrier methods of contraception that prevent the union of the sperm and the egg will not be outlawed, since neither a sperm nor an egg by itself is a human being.

Dr Bush, you and I both know that to our patients, the word “Contraception” means more than just condoms. You yourself have stated that you prescribe birth control pills in your practice. Can you honestly tell me that the “talking points” of this campaign do not encompass the intention of making such prescribing activities illegal?

You have admitted publicly since your press conference that

“I’m not the authority on what would and would not be banned”.

I think that is correct. And yet you have portrayed yourself as that authority. As a result, your press conference is being used to spread misinformation that directly contradicts what appears clearly to be the true intent of the law, which is to outlaw both abortion and any birth control method other than diaphragms and condoms.

Dr Bush, you must by now realize the full intentions of those who are using you. They are taking full advantage not only of your pro-life politics, but of your gender and your race to sway voters to vote against their own self-interest, for a bill that would limit their access to the contraceptives they have relied upon, and that you have prescribed, for years.

Fortunately, it’s not too late. You still have time to hold another press conference. To tell the public, and your patients, the truth about Amendment 26. Don’t tell them that their birth control is safe if you are not sure it is. Tell them the truth.

Your patients have trusted you for years. They deserve no less.

__________________________________________
Required reading – The Next Front in the Abortion Wars – Birth Control.

Photo credit – Phil Bryant, AP Photo. Licensed for editorial use.

The Meaningful Use Song (with Apologies to Gilbert & Sullivan)

As billing compliance leader in my department, I’ve been charged with getting my colleagues on board with Electronic Medical Record Meaningful Use. (What does meaningful use have to do with billing? It’s complicated, but the codes up until now have been reported along with billing codes, so it sort of fell into my lap. Lucky me…)

Generally, meaningful use refers to using the EMR in a way that harnesses its immense power to store and retrieve data in a way that makes sense and potentially improves clincal outcomes- by checking for drug interactions in real time, for example, or to track blood sugars, blood pressure or other data, or to allow for electronic prescriptions and shared data between clinicians using common language.

Specifically, when we say “meaningful use” these days, we are referrring to the list of meaningful use standards developed by CMS – a very specific list of 25 objectives, along with defined quality measures (like percent of women getting mammograms) that will be used to report and track health outcomes in practices using EMRs.

CMS is offering financial incentives to medical practices to use their EMR in a meaningful manner this year. We will be reporting data starting in October 1 to CMS, and must meet 20 of the 25 meaningful use objectives and report outcomes on chosen quality measures to qualify for the incentive payment. In addition, we are reporting separately to the government on the use of electronic prescribing, and face possible penalties for docs who are still stuck on paper. In time, our outcomes on the quality measures will be reported to the public on the CMS website.

Does Meaningful Use Improve Clinical Outcomes?

That’s the 20 billion dollar (the amount 2009 Hi-Tech Act allocated to the meaningful use incentive program) question. We really don’t know as yet whether or not EMR use itself favorably impacts patient care.  Some studies say EMR use does not improve health outcomes, but more recent studies of diabetes care and in low resource areas have suggested that EMR use may be beneficial.

We also have no idea if docs who attain meaningful use are better docs than those who don’t. Despite this, the CMS website will have clear implications as to the outcomes of doctor’s practices in terms of standard quality measures. It’s a bit worrisome to me, especially since so many of the outcomes are driven by patient compliance (a word I know a lot of my readers don’t like, but there it is…) Not to mention the thorny issue of using mammogram screening in women over 40 as an outcome measure when we just decided that it is no longer recommended to routinely perform it in everyone. (Don’t get me started on that issue again…)

Overall, I think meaningful use is a step in the right direction

I do see meaningful use as an attempt to rein in the wild, wild west of EMR development to try to create some standardized functionality and communication. It’s also a way to begin to corral the freestyle and autonomous EMR use that has evolved among early EMR users, who did what they needed to do to get their work done during the evolution of the EMR around them, but who now need to step back and reassess how well (or not) they are using this powerful tool that has been foisted upon them.

But my god, this whole process has been painful.

And so damned complicated, I needed a song to keep it straight. Ergo that parody up there, which actually covers all 25 meaningful use requirements as defined by CMS. (or at least as I see them…)

Of course, I could have just learned the Meaningful Yoose Rap. But please… me singing rap?

Emergency Contraception is NOT an Abortifacent

When patients ask me how emergency contraception prevents pregnancy, I tell them that it’s primary mechanism is to delay ovulation (release of an unfertilized egg from the ovary).  There is no evidence that the EC aborts or prevents implantation of an already fertilized egg.

The efficacy of EC depends on where you are in your menstrual cycle when you have unprotected sex –

  • If you are destined to ovulate in the next 1-5 days, EC will delay the release of the egg from the ovary until the sperm have lost their viability in the reproductive tract. This is how it works.
  • If you’ve already ovulated and the egg is still in your reproductive tract, you’re possibly already pregnant by the time you take EC. If so, it’s not going to work.
  • If you’re not due to ovulate for >5 days or are 5 days or more past ovulation, then you’re unlikely to have gotten pregnant anyway, and the EC hasn’t done much. (But take it anyway, please, since not every ovulation is predictable)

Now a nicely done study reinforces yet again that delay of ovulation is indeed the mechanism by which this important contraceptive works to prevent pregnancy.

Researchers enrolled 450 women presenting for emergency contraception at a clinic in Chile,where they assessed where in their cycle these women were at the time of unprotected intercourse by using hormone assays and ultrasounds throughout the rest of that menstrual cycle to see if they ovulated, menstruated or became pregnant.  (Previous studies relied on menstrual history alone to pinpoint ovulation, a much less reliable methodology.) The EC used in this study was levonorgestrel.

Altogether, 103 women who took EC did so just prior to ovulating – Although 16 pregnancies would be expected in this group based on normative data, none of theses women became pregnant. In contrast, 45 women took EC on the day of ovulation – 8.7 pregnancies would be expected to occur in this group , and in fact, 8 pregnancies did occur.

The efficacy when used before ovulation was 100%. On the contrary, when used after ovulation has occurred, the number of observed and expected pregnancies is not statistically different, indicating that no reproductive process subsequent to ovulation is interfered with by LNG-EC. This finding is incompatible with the inhibition of implantation by LNG-EC and is consistent with the mechanism of action of EC reported in a recent review.

Other research has shown that EC does not alter the proteins in the endometrium necessary for the implantation of  the fertilized egg.

Although overall, EC has not had a major impact on unplanned pregnancy rates in the United States, it remains an important method of contraception for women. It’s important to counteract misinformation about its mechanism of action for women considering it’s use.

_____________________________________________________________________

More info on EC from The Emergency Contraception Website

Prenatal Tay Sachs Screening – Not a Perfect Test

This week’s NY Times has a most powerful and beautiful essay written by Emily Rapp, entitled “Notes From a Dragon Mom”, in which she describes what it is like to parent a child who is destined to die. Rapp’s 18 month old son Ronan has Tay Sachs disease, a progressive and incurable neurologic disorder that will result in his death within a few short years of life.

How do you parent without a net, without a future, knowing that you will lose your child, bit by torturous bit?

Depressing? Sure. But not without wisdom, not without a profound understanding of the human experience or without hard-won lessons, forged through grief and helplessness and deeply committed love about how to be not just a mother or a father but how to be human.

Rapp’s essay is a foray into the true connection between parent and child, and, in a way, a celebration of how that relationship is all the more special because it is devoid of the pressures of perfect parenting for the perfect future.

Ronan has given us a terrible freedom from expectations, a magical world where there are no goals, no prizes to win, no outcomes to monitor, discuss, compare. But the day-to-day is often peaceful, even blissful.

As a mother, I want to thank Rapp for her wisdom as she shows us all how to be better parents, and wish her continued strength and joy as Ronan’s mom.

As a doctor, I’d like to address the section of the essay where Rapp talks about Tay Sachs gene mutation screening.  It’s a short paragraph with just enough information to answer the question the reader probably has, which is – “How did this happen, when we have prenatal testing for Tay Sachs?”. Unfortunately, it is also just enough information to confuse and even frighten women who have had or are considering having prenatal screening for Tay Sachs.

The prenatal test I took for Tay-Sachs was negative; our genetic counselor didn’t think I needed the test, since I’m not Jewish and Tay-Sachs is thought to be a greater risk among Ashkenazi Jews. Being somewhat obsessive about such matters, I had it done anyway, twice.  Both times the results were negative.

Oy. Let’s see what I can do here…

A TAY SACHS SCREENING PRIMER

What is Tay Sachs?

Tay Sachs is a genetic disorder caused a recessive mutation in the gene for hexosaminidase-A, an enzyme that catalyzes the breakdown of fatty acids in the brain. In the presence of defective Hex-A, fatty acids accumulate in the brain, causing permanent damage and progressive neurologic decline and eventually, death.

Babies born with Tay Sachs carry two copies of the defective gene, one from each parent. Parents who are carriers of recessive genes can be detected though prenatal genetic screening. This screening has been concentrated to date in high risk groups, which in the US are primarily Ashkenazi Jews, who have a carrier incidence of 1 in 30.

Who Should be Screened for Tay Sachs?

At this point in time, prenatal Tay Sachs screening is recommended to be offered to individuals from groups with increased mutation carrier incidence  – Ashkenazi Jews, French Canadians, Louisiana Cajuns and Pennsylvania Dutch. Rapp is of Irish descent,  a group with a mutation carrier incidence somewhere between 1/50 and around 1/200.

Of course, a major reason why couples screen for Tay Sachs, and for other genetic disorders, is because they want the option to terminate an affected pregnancy. An indeed, with the advent of prenatal diagnosis, the incidence of Tay Sachs among children born in the Ashkenazi Jewish population has plummeted.

In addition to using screening prenatally, some Jewish communities screen much earlier, and actually maintain online databases of Tay Sachs carrier information, so that couples can log on and screen out one another before embarking on a courtship, in an attempt to reduce marriages between two carriers. In Montreal, voluntary high-school based Tay Sachs screening programs have led to a 90% decline in the incidence of Tay Sachs in high risk communities.

Tay Sachs – Not Just a Jewish Disease 

Rapp has also written an essay on Salon entitled ” Tay Sachs is not a Jewish disease“, in which she argues that the panel of Tay Sachs genes tested should be expanded beyond the most common mutations found in the Ashkenazi Jewish populations.

…we need to consider more carefully who should get tested for what, and why. As it turns out, there are about a hundred mutations of the Tay-Sachs gene. Unfortunately the common, standard prenatal screening only detects the nine most commonly detected mutations – commonly detected among those of Ashkenazi Jewish descent , like my husband.

…Until gaps like this are rectified, until the testing catches up with the facts, and until insurance companies are willing to redefine the “standard” array of tests, more families will suffer this kind of horrific loss and the great potential of prenatal screening will never be achieved.

In Rapp’s case, she and her husband indeed would have qualified for screening, and I am assuming from the fact that she was tested twice that they knew in advance that her husband was a mutation carrier.

Tay Sachs Carrier Screening

There are two ways to determine if a parent is a carrier for a Tay Sachs gene mutation – DNA testing (carrier screening) and Hexosamindase -A activity levels.

DNA Carrier Testing

Among Ashkenazi Jews, DNA carrier testing will detect up to 99% of carriers. In the case of a couple where only one is Ashkenazi, initially carrier screening the Jewish member of the couple is thus a good way to go, since the DNA screening tests perform so much better in that population.  Then, if that individual screens positive, the next step is to screen the non-Jewish member of the couple. And that’s where the DNA test falls short –  in non-Ashkenazi individuals, it detects at most 60% of affected individuals. In Rapp’s case, the gene she carried was a rare one indeed, having” last surfaced in 1997, among people of Moroccan descent”.  Thus, it is not surprising that Rapp, despite being a mutation carrier, would have had a negative carrier test result using the available DNA testing.

There are to date over 100 known mtutations in the Hex-A gene that can lead to Tay Sachs disease, and we just do not as yet, nor are we likely soon, to have commercially available screening test for every mutation known to date. In the case of a non-Jewish individual married to a Jewish carrier, non-DNA screening for Hexosaminidase-A activity provides a better alternative to DNA testing.

Hexosaminidase-A Activity Testing

Individuals who carry Hex-A gene mutations, while phenotypically normal, have lower than normal levels of Hex-A serum activity on a simple blood test. This test actually formed the basis of the first screening for Tay Sachs, before we had DNA testing, which is thought to me more specific.

In some ways, though, DNA testing is too specific – it’s like searching for 1 of 100 needles in a haystack. And when you only know how to find 9 of those 100 needles, maybe you’re better off using a magnet – Hex-A Activity testing. It may not tell you which gene you have, but at least it tells you whose haystack has the needles. At that point, you would proceed to testing the baby.

Some might even use Hex-A testing as first line testing in an Ashkenazi individual, or combine it with DNA testing to get as close to 100% certainty as possible even in that population. And, as populations diversify through intermarrriage, Hex-A activity levels are being suggested as a better screen that DNA testing.

Of course, even hex-A activity testing isn’t perfect . But it’s pretty darned good.

Testing the Baby

Remember, that even if both members of the couple are carriers, there is only a 25% chance that the child will be affected. So if both members of the couple are Tay Sachs carriers, or if one is a carrier and the other uncertain, then testing the baby is done using CVS or amniocentesis to test for Hex-A activity, DNA or both. CVS and Amnio are both invasive tests with a small but real risk for miscarriage. Preimplantation genetic testing is also available for couples undergoing IVF who wish to screen for Tay Sachs.

But even these test are not perfect. Which, in the end, was the whole point of my writing this post. So let me say it again –

NO PRENATAL DIAGNOSTIC TEST IS PERFECT

We can talk about how to make Tay Sachs screening more effective. We can expand the number of genes we test for, and the number of individuals who are offered screening, in order to come closer to realizing, as Rapp puts it “the great potential of prenatal screening.”

But we cannot, and must not, set up the expectation among women and families that the technology exists and is available that will guarantee them a perfect child. We cannot set up the expectation that technology exists to detect every child with Tay Sachs, or any other genetic disorder, prenatally.

Or, as the National Tay-Sachs and Allied Disease Organization so eloquently puts it –

We are all carriers of recessive genetic diseases but standard healthcare practice does not screen everyone for all diseases because the technology does yet exist to accurately and cost effectively screen everyone.

Which, in the end, brings me back to Rapp’s most excellent essay, which teaches us to love our children for who they our for as long as we have them – whether that is three months, three years, or a lifetime.

___________________________________________________________

For more information on Tay Sachs Screening

I Hate Fluorescent Overhead Kitchen Lighting

Adam Roberts, the Amateur Gourmet, abhors the cold flourescent lighting in his otherwise totally awesome retro LA apartment kitchen. He solved the problem by getting some mist table lamps from CB2 and placing them around his kitchen. Nice fix, Adam!

I had a similar issue here in my NYC rental apartment, which I have solved when my brother in law, who built our dining room wall unit, left behind a task light. I simply clamped the task light to my spice cabinet, bouncing the light off my white ceiling. Viola! Warmth and light. Even with the overhead flourescent light on as well, the room has a warm feeling. Maybe not as cool looking as Adam’s but I love the feel. See the difference –

Fluorescent light on – Food looks unappetizing and I feel depressed.

Task light/fluorescent combo – Aaaah….Happy food, happy cook.

Steel Cut Oats with Cinnamon, Dates and Sheep’s Milk Yogurt

It’s healthy, it’s delicious, and with the littlest bit of planning, it can be made conveniently enough for the busiest lifestyle. I know, because I live that lifestyle. And until now, breakfast was a coffee and a muffin from the truck on the way to work. No longer.

Once or twice a week, here’s what I do – while we’re cleaning up the dinner dishes, I start the oatmeal cooking. When it’s done, I take the pot off the stove and put it in the fridge. In the morning I will take out a quarter of the original batch, put it in a glass jar and heat it in the microwave. (I’m avoiding plastic when I can.) I then take the jar and put in in a bag with a small container of yogurt, a bowl and a spoon. On the way to work, I stop for coffee at the truck, and by the time I reach my desk, the oatmeal is still warm (I only love 5 blocks from work). I spoon the oatmeal into the bowl with the yogurt, and sink into my morning heaven. If I’ve gotten to bed early, I’ve also gotten up early, and beaten my first patient to the office by at least a half hour, so I can take my time and really enjoy it. If not, I just start in on office hours, nursing my oatmeal between patients throughout the morning. Either way, I’m happy.

My long term goal it to get up really early and exercise, and to eat before I get to work, but for now, this is working for me. And its a heck of a lot healthier than a muffin.

Sheep’s milk Yogurt?… Really?

OMG once you’ve tasted it, you’ll never go back to the cow. It’s got a tangy freshness that is just so special.

From a health perspective, sheep milk has a higher calcium and  nutritional content than cows milk, and while it also has more fat, 25% of that fat is medium chain triglycerides, which may benefit weight loss. Plus I find it that much more satisfying than low fat yogurt, so I only need a few ounces to feel satisfied. With Old Chatham brand, the one I’m using now, you can skim the cream off the top for a lighter fat version.

Sheep’s milk is also rich in omega-3 fatty acids and linoleic acid, and may have favorable effects on cholesterol and heart disease risk. In one study, switching from cow to sheep’s milk lowered total cholesterol among folks who ate a dairy-rich diet.  In another, sheep’s milk cheese consumption led to favorable changes in inflammatory and atherogenic markers.

The best tasting brand I’ve eaten so far is from Bellwether Farms in California (maybe because it was my first…), but the yogurt from Three Corner Field Farm is a very close second. Old Chatham makes a sheep yogurt that is more akin to the greek yogurt, and has wonderful flavors like maple and ginger.

Oatmeal with dates, Cinnamon & Sheep’s Milk Yogurt

This batch will make 4 servings. Bob’s Red Mill oats, which I am using now, calls for 3 cups of water to 1 cup of oats and a 20 minute cook time, but I’m happier with 3 1/2 cups water and a longer cooking time. You should experiment with the brand you use to find the amount of liquid and the cook that works best for you. I also like Whole Foods 365 and Trader Joes Brands. Dates have the wonderful quality of melting into the oatmeal as it cooks, dispersing their sweetness throughout, obviating the need for maple syrup or brown sugar, and, along with the cinnamon, giving it a wonderfully nutty brown color.

  • 1 cup Steel Cut Oats
  • 3 1/2 cups water
  • 1/4 tsp kosher salt
  • 1 cinnamon stick
  • 12 dates (Medjool if you can find them) pitted and cut into small pieces
  • 2- 6 oz containers of sheep’s milk yogurt (you’ll eat 3 oz each day)

Combine water, salt, oatmeal, cinnamon stick and chopped dates in a medium saucepan. Bring to a boil over medium heat. Lower heat as far as possible, cover and cook 30 minutes, stirring several times to keep it from sticking, and removing the lid for the last 10 minutes if it seems too liquidy.  Remove from heat, remove cinnamon stick, cool and store in fridge. To serve, remove 1/4 of the oatmeal, reheat for 1-2 mins in microwave. Serve with a side of sheep’s milk yogurt. Enjoy!

Nutritional info (calculated at Caloriecount.com)

More Make-Ahead Steel-Cut Oats Recipes from Around the Web

  • Pinch My Salt uses McCann’s, makes 8 servings at a time and refrigerates each serving separately in small containers
  • Mark Bittman cuts morning cooking time to 7-10 mins by making Overnight Steel Cut Oats (and tops w/ almonds and dried cranberries)
  • The Novice Chef tries her hand at overnight oats
  • Two Peas and  a Pod top their oatmeal with brown sugar and then torch it, creme brulee style. Definitely a weekend recipe.
  • Ohsheglows makes hers ahead, and has 5 different recipes on her blog, some using almond milk
  • Side of Sneakers makes her overnight in a crock pot and also uses almond milk
  • Apartment therapy uses little jars like mine.

Do you have a favorite steel cut oats recipe?

Tips for steel cut make-ahead success? A favorite brand of sheeps milk yogurt? Feel free to post it in the comments section below.