The Twinkie Diet

Mark Haub, professor of human nutrition at Kansas State University, has astounded America by losing 27 lbs while eating mostly junk food. He also lowered his cholesterol and body fat.

Haub’s methodology was simple – he  limited himself to 1800 calories a day. Here’s a typical day on the Twinkie Diet, courtesy of CNN –

Haub’s sample day

  • Espresso, Double: 6 calories; 0 grams of fat
  • Hostess Twinkies Golden Sponge Cake: 150 calories; 5 grams of fat
  • Centrum Advanced Formula From A To Zinc: 0 calories; 0 grams of fat
  • Little Debbie Star Crunch: 150 calories; 6 grams of fat
  • Hostess Twinkies Golden Sponge Cake: 150 calories; 5 grams of fat
  • Diet Mountain Dew: 0 calories; 0 grams of fat
  • Doritos Cool Ranch: 75 calories; 4 grams of fat
  • Kellogg’s Corn Pops: 220 calories; 0 grams of fat
  • whole milk: 150 calories; 8 grams of fat
  • baby carrots: 18 calories; 0 grams of fat
  • Duncan Hines Family Style Brownie Chewy Fudge: 270 calories; 14 grams of fat
  • Little Debbie Zebra Cake: 160 calories; 8 grams of fat
  • Muscle Milk Protein Shake: 240 calories; 9 grams of fat
  • Totals: 1,589 calories and 59 grams of fat

You may be surprised, but I’m not.

I did pretty much the same thing earlier this year when I lost 33 pounds in 11 weeks eating the “American Diet” as part of a randomized diet trial being conducted here at Cornell Medical College.

The pounds literally dropped off and my cholesterol inched towards normal as I struggled to force down lunches of pizza and oreos and potato chips, breakfasts of bacon and eggs and toast, and dinners of macaroni and cheese and hot dogs, all lovingly prepared and delivered to me by the research kitchen staff and totaling just 1200 calories a day. It was hands down the easiest diet I’ve ever been on, and though I begged Charlie the study director to let me stay on it so I could get the rest of this weight off, he would not  extend the study just for me.

Of course, there’s something incredibly satiating about having food prepared just for you. (Mommy…) And I don’t think that I would have had the will power to limit my portion size myself. I recall watching the staff painstakingly weigh and measure every single item for me, trimming the bagel to exactly the right amount of grams, counting out the potato chips or measuring out the chocolate pudding to exactly 1/2 cup. There’s no way I’d do that for myself without grabbing a few extra bites. No way at all. I don’t know how Haub did it.

Should you try the Twinkie diet?

I don’t know. As a lifelong dieter forever looking for the ultimate weight loss tool, a new diet is always appealing. I can see distinct advantages in a weight loss program that incudes previously forbidden foods and which is successful, at least in the short term.

But let’s face it – the Twinkie diet is not going to help you make the habit changes we need to make to keep the weight off in the long term. Before long, I would expect Haub will gain his weight back, as most folks do after almost every diet. That’s what’s starting to happen to me, though it’s taken about 6 months for me to inch back up about 10 pounds past the end weight from my own Twinkie diet.

Since Charlie won’t let me back into his study, I’m on my own again. So, this week I’ve embarked upon the South Beach Diet, which has performed well for me in the past.  I’m pleased to say that I’m down almost 5 pounds in just 3 days.

Wish me luck. I still have a long way to go.

Playing the Insurance Coverage Game

A patient called today – her Nuvaring fell out sometime yesterday (she’s not sure where) and she is only two weeks into her cycle. She went to the pharmacy to get a new ring, but her insurer denied the refill because it is too soon.

Now, I could spend the next half hour on hold with her insurer to get the Ring refill approved, and they may not approve it anyway.

So here’s what I did – I prescribed her a pack of birth control pills to take, starting today. She will finish that pack but refill her ring in two weeks, and now she will be two weeks ahead on her ring refills.

I hate the game, but I’m good at it….

Hormonal Contraception Thickens Cervical Mucus – an Under-Appreciated Effect

Ask any third year medical student how hormonal contraception prevents pregnancy, and they’ll probably tell you it prevents ovulation.  What they won’t tell you is that this effect is variable and dose-dependent, and if we depended on it alone, hormonal contraception would be much less effective.

That’s because of the very important, and in my opinion, much under-appreciated effect of hormonal contraception on cervical mucus.

A Cervical Mucus Primer

Fertile cervical mucus – which forms under the influence of rising estrogen levels in the first half of the menstrual cycle and is maximal around ovulation – is thin, watery, clear and easy for sperm to traverse.

Non-fertile mucus – which forms after ovulation and also in pregnancy under the influence of progesterone – is the exact opposite – thick,tacky, non-distensible and impossible for sperm to penetrate. (It’s not called the mucus plug for nothing…)

A Progestin Effect

Cervical mucus during hormonal contraceptive use mimics that of the second half of the menstrual cycle – scant, thick and impenetrable.

The responsible party here is progestin – molecules with names like levonorgestrel, medroxyprogesterone, norethindrone, norgestimate and desogestrel – which mimic the natural effect of progesterone on cervical mucus.  Even in birth control pills that contain estrogen, this progestin effect dominates at the cervix.

This effect on cervical mucus explains why the progestin-only pill, Norplant and Implanon work so well to prevent pregnancy, even though ovulation can still occur during use of these methods.

Mirena IUD thickens cervical mucus

Now, a new study shows that the Mirena IUD also thickens cervical mucus and prevents sperm penetration.

This is not surprising, since Mirena contains the progestin levonorgestrel. But it is important information about how this method works to prevent pregnancy – in addition to impairing ovulation and fertilization, Mirena also prevents sperm from getting into the fallopian tube in the first place. One could argue that in fact, if sperm and egg never meet, the other contraceptive mechanisms of this IUD become unimportant, making the Mirena really mostly a local delivery system for progestin.

This effect on cervical mucus also may explain why users of the Mirena IUD have low rates of pelvic infection, a side effect that doomed the Dalkon Shield. (Of course, the Dalkon Shield also had a multifilament string that allowed bacteria to enter the uterus. Modern IUDs have monofilament strings.)

Could we thicken mucus without hormones?

I think a lot about this contraceptive effect of progestins, wondering if we could find a way to thicken cervical mucus locally without systemic hormonal exposure. The Mirena comes as close to a local effect as we have to date, although its progestin is still systemically absorbed and has body-wide effects.

But if we could develop a locally applied non-hormonal product that does the same thing, wouldn’t that be a great contraceptive option?

Atoms for Peace Galaxy

Atoms for Peace Galaxy. Image from ESO.

This galaxy, located in the constellation Aquarius, bears a striking resemblance to a cartoon atom. It is named for Preseident Dwight D Eisenhower’s “Atoms for Peace” speech, in which he called for worldwide efforts to discover peaceful uses for atomic energy. It’s a speech well worth reading in its entirety, but here is a salient excerpt –

…for me to say that the defense capabilities of the United States are such that they could inflict terrible losses upon an aggressor–for me to say that the retaliation capabilities of the United States are so great that such an aggressor’s land would be laid waste–all this, while fact, is not the true expression of the purpose and the hope of the United States.

To pause there would be to confirm the hopeless finality of a belief that two atomic colossi are doomed malevolently to eye each other indefinitely across a trembling world. To stop there would be to accept helplessly the probability of civilization destroyed–the annihilation of the irreplaceable heritage of mankind handed down to us generation from generation–and the condemnation of mankind to begin all over again the age-old struggle upward from savagery toward decency, and right, and justice.

Surely no sane member of the human race could discover victory in such desolation. Could anyone wish his name to be coupled by history with such human degradation and destruction…

…My country wants to be constructive, not destructive. It wants agreement, not wars, among nations. It wants itself to live in freedom, and in the confidence that the people of every other nation enjoy equally the right of choosing their own way of life.

So my country’s purpose is to help us move out of the dark chamber of horrors into the light, to find a way by which the minds of men, the hopes of men, the souls of men every where, can move forward toward peace and happiness and well being.

This remarkable image comes from the European Southern Observatory and appeared this week on NASA’s Astronomy Picture of the Day, a website where every day, a different image from our universe is featured.  Peruse the archives for some amazing stuff.

You can also download a free program that will make each day’s Astronomy photo your desktop image. (Windows only, sorry…) I downloaded it today on my desktop at work,  and can’t wait to see what new image awaits me there tomorrow morning.

Susan on China

My friend Susan has a way of cutting through to the core of any issue. She just returned from a business trip to Beijing with these observations –

On public transportation – “As a New Yorker still waiting for the 2nd Ave subway, you’ll appreciate this – The Chinese completed 3 new subway lines in the last 5 years in Beijing alone! If there was ever any doubt in your mind that the Chinese would surpass us, let this set that to rest.”

On the auto industry – “The number of Chinese who own cars has risen exponentially in the past 5 years. They’re all so proud of this, and I’m thinking  – Wait a minute. This means that the majority of the drivers in China who are currently on the road have been driving for less than 5 years? That’s like having an entire country of teenage drivers!”

On the language – “Our kids need to learn Mandarin so they can talk to their Chinese bosses when they are cleaning their houses.”

On women in the workplace – “Four out of the five high level Chinese execs at the meeting were women, while I was the only women among the five American execs at the meeting – which is typical of the American firms we work with. I think something different is going on in China as far as women in the workplace, and I suspect it is one of the reasons they are doing so well.”
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Photo credit – By en:user:CobbleCC in English Wikipedia (English wikipedia) [CC-BY-SA-3.0 (www.creativecommons.org/licenses/by-sa/3.0) or GFDL (www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Pasta Puttanesca ala San Marzano

I”ve been making Puttanesca sauce for some years now, since first discovering it in Mark Bittman’s minimalist column in 2008. Puttanseca is a fast and easy pasta that makes a perfect weeknight dinner for hard working folk, as the prostitutes who are said to have originated the recipe well know.

But I have never before tasted a Puttanseca as good as this one, made a few weeks back after a Saturday afternoon raking leaves at the cottage. You might say it was the fall air, or the well water, or the bittersweet taste of season’s end that lent it such fabulous flavor.  I think it was all that, but mostly it was the San Marzano tomatoes, which I used for the very first time in this sauce. All I can say is Oh – My – God. How did I not know about these tomatoes before?

San Marzano are officially the best sauce tomato in Italy, grown in the Campagna region and certified authentic with the EU D.O.P. emblem, Denominazione d’Origine Protetta. However, the seeds of the San Mareno tomato have found their way across borders and the brand we used was actually grown domestically in the United States. While it lacks the DOP stamp, I can tell you these tomatoes are fabulous!

There are numerous imported brands of San Marzanos, available pretty much at any supermarket here in New York. (We got ours at Gourmet Garage). If you can’t get San Marzano’s where you live, you can order them online. I can’t wait to try this sauce again using an imported brand, though I can’t imagine it could taste any better than this.

Pasta Puttanesca

I’ve started with Bittman’s recipe, adjusting the amounts of various ingredients to my taste. You should do the same.

3 tbsp olive oil
4 garlic cloves, minced
6 anchovies, straight from the can
1/2 cup black olives, pitted and cut in half
1 tsp dried red pepper flakes
3 tbsp capers, drained
black pepper and salt to taste (you won’t need much salt, if at all)
1 (28 oz) cans an Marzano plum tomatoes
chopped fresh basil leaves for garnish
1 lb linguine
Grated Pecorino or Parmesan-Reggiano cheese

1. Boil the pasta water. Bring pot of water to boil and salt it.

2. Make the sauce. Heat 2 tablespoons oil with garlic and anchovies in skillet over medium-low heat. Cook, stirring occasionally, until garlic is lightly golden.  Add tomatoes to the skillet, with salt and pepper to taste. Raise heat to medium-high and cook, stirring occasionally, until mixture becomes saucy, about 10 minutes. Stir in olives, capers and red pepper flakes, and continue to simmer.

3. Cook the pasta and toss with sauce. Cook the pasta until it is tender but not mushy. Drain quickly and toss with sauce and remaining tablespoon of oil. Taste and adjust seasonings, garnish with herbs if you like, and serve. Pass the Parmesan.

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More on Puttanesca and San Marzano Tomatoes

  • Mark Bittman makes Puttanesca in this NY Times video
  • Jamie Oliver makes a big ole Puttanesca, using dried oregano and lots of anchovies (complete with German overdubbing….)
  • Chef Lyon has a video lesson –  onions, balsamic and oven-roasted tomatoes give his Puttanesca a California feel
  • San Marzano Tomatoes – Everything you ever wanted to know
  • Natashya makes Tyler Florence’s Puttanesca and serves it with strip steak
  • Bitchin Camero makes hers with parpadelle
  • Budget Bytes calculates her Puttanseca costs at 84cents a serving, but if you use San Marzano tomatoes it’ll be a bit more (and worth every penny)

Win Free NYC Taxi Rides for a Year

UPDATE- The Nissan VN200 has won the competition!

At the risk of enlarging the contestant pool and lowering my own odds of winning, I”m telling you all about this great new contest sponsored by the NYC Taxi and Limousine Commission to help pick the winner of the Taxi of Tomorrow.

In 2007, City officials convened a group of stakeholders, including representatives of taxi drivers, owner and passengers, to create a set of goals for the next New York City taxi cab, a project called the Taxi of Tomorrow. In December 2009, the TLC issued a “request for proposals,” inviting auto manufacturers and designers to submit their best ideas for a purpose-built vehicle to serve as a New York City taxicab. Whichever of these designs that the City selects, if any, will be the next New York City taxicab (subject to constant improvements and enhancements) for the next ten years.

Complete a survey rating your top choice among the three finalists, tell the TLC about your taxi riding habits and opinions, and you’ll be entered into a sweepstakes to win free taxi rides (up to $5,000) for an entire year!

I personally liked the Karsan. Be eliminating the passenger front seat and adding a 4th rear facing seat to the back, all passengers can enter and exit the cab with ease, eliminating the “you go first” dance and the old back seat scoot.

From the survey, it also appears that the TLC is considering having an additional taxi light that warns that a passenger is about to be discharged. As a biker, I am ever fearful of car doors opening, so I love that idea.

I also took the opportunity in my survey to recommend that the TLC do a better job of staggering cab start times, with hopes of eliminating the 3:3o -5pm “witching hour” as I call it, when all the cab drivers are heading home to Queens and it’s almost impossible to get a cab.

So head on over and cast your vote, and may the best cab (and the luckiest New Yorker) win.

HRT Worries – This Time, It’s Ovarian Cancer Again….

HRT once again takes the media center stage, this time with new research linking post-menopausal estrogen use to ovarian cancer.

The data comes from a large European study  – the European Prospective Investigation into Cancer and Nutrition – and was presented as a poster (abstract B101 in the linked pdf) at the American Association for Cancer Research Meeting in Philadelphia.

In this study of over 160,000 women with 9 years of follow-up, use of post-menopausal estrogen-only therapy for more than five years was associated with a small but significantly increased of ovarian cancer. The increased risk occurred across all types of estrogens (sorry, Suzanne….) and all routes of administration, and increased with duration of estrogen use.

No increase in ovarian cancer risk was found for women taking estrogen plus progestin therapy.

This is not the first study to suggest that postmenopausal estrogen use may increase the risk of ovarian cancer.

  • The Breast Cancer Detection Demonstration project reported an increased ovarian cancer risk among users of estrogen-only (E) therapy. Similarly, that study found no increase in risk among users of estrogen plus progestin therapy.
  • The Womens’ Health Initiative reported an increase in ovarian cancers among users of combination hormone therapy (E+P) , but that risk was not statistically significant, since the data was based on only 32 cancers. To my knowledge, they have not yet reported ovarian cancer data from the estrogen-only arm of that study.
  • A Swedish study also reported ovarian cancer risks with estrogen only therapy, as well as with sequential estrogen + progestin, but not with combination daily E+P. In that study, a small increase in risk was also seen for low dose vaginal but not oral estrogen, and women who had had a hysterectomy did not have an increased risk of ovarian cancer with any regimen.

Just how big a risk are we talking about?

Unfortunately, I don’t have much to go on here, other than the research abstract (don’t get me started again on the publicity surrounding poster presentations instead of waiting for the peer-reviewed published papers), but let’s see what I can do….

There were 424 cases of ovarian cancer among 162,920 study participants during nine years of follow up, for an overall annual incidence about 3.7 per 10,000.  That number is remarkably similar to the risk for ovarian cancer among WHI participants – 3.4 per 10,000. Both seem a bit high given that the population incidence of ovarian cancer here in the US is 1.3 per 10,000 annually, and may be related to the age of the women in these studies. But lets go on….

Users of estrogen-only therapy had a relative risk for ovarian cancer of 1.65, meaning that their risk was 65% higher than that in women not using hormone therapy. Unfortunately, the abstract does not give us the risk in hormone non-users. But for argument’s sake, let’s suppose it is the same as the US background risk of 1.3 per 10,000.* Then the risk among users of estrogen-only HT would be 2.1 per 10,000, or an additional .02% per year.

What does this mean for you?

Let’s assume the association is real. Let’s also assume you are miserable with hot flashes or some other menopausal symptom and want to take hormone therapy.

What are your risks?

Well, that depends what regimen you take – estrogen alone or estrogen + progestin. And that, in turn, depends on if you have a uterus. Your risk for ovarian cancer will be further affected by whether or not you actually still have your ovaries.  Combining this data with that from the WHI (statistically, this is not permissible, but I have to practice medicine in real life, so I’m gonna’ do it.), let’s graph it out –

 

Notice that the risk for breast cancer among users of estrogen alone, at least in the WHI, was actually lowered. I put a question mark there because it remains a bit of a puzzle how that data came about, and no one is convinced yet, but there it is. (Update – I think I am beginning to understand how this might be possible. See this post for a possible explanation of these findings)

You can also see that no matter how you look at it, for an individual woman, these are small numbers. What makes them big is when millions of women use HRT – now we are increasing disease rates across a population.

What also becomes obvious is that the best cancer hand, so to speak, is dealt to the woman who has had a hysterectomy with removal of the ovaries. Of course, that woman has also had a major operation, which carries its own risks, so consider that before you go asking for a hysterectomy so you can take your hormones without any increased cancer risks.

Bottom Line

If you choose to take hormone replacement, you should consider both its risks as well as its benefits in making your decision.

Use of estrogen for less than 5 years did not increase ovarian cancer risks in this reported study, and in the WHI, the breast cancer risks did not kick in for the first 3-4 years of use. This suggests that short term use of HRT around menopause carries little risk, and goes along with recommendations that women use the lowest dose for the shortest period of time and reassess the need for continued use on an annual basis.

If you are one of those women who choose to take hormone therapy for prolonged periods of time, your risks, though real, are not large.

Remember too, that there are non-hormonal options for treating many of the symptoms of menopause.
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* I am not a statistician, just a doc trying to figure out how to make this stuff make sense to my patients and inform my own medical practice. If any of my readers having more expertise in this arena wish to jump in to correct me or suggest better numbers, I’m all ears.

Photo credit – Picasso’s Portrait of Dora Maar. From Musee national Picasso, Paris

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12/29/10 UPDATE – I’ve begun rethinking the breast cancer data on estrogen alone, based on something called the Gap Time Theory, which states that it is only because the women in the WHI were 10 years post menopausal that breast cancer risks were lower in the estrogen only arm. If this theory were true, it would remove that potential benefit in women starting estrogen only treatment at menopause. Until we have better studies, all of this is hypothetical, unfortunately.

Herbed White Bean & Sausage Stew

Melissa Clark published a wonderful recipe for white bean stew in last week’s NY Times, marveling that she was able to make it without having to pre-soak her beans. Inspired by her recipe, Mr TBTAM and I decided to shorten the making of this stew even further by using canned beans. The result – a fabulously rich and flavorful autumn dinner in just over an hour.

Herbed White Bean and Sausage Stew

This recipe is a great use for those herbs that remain green in the garden through fall and early winter – rosemary and thyme. In addition to using canned beans, we replaced water with chicken broth, added some diced tomatoes, spiced things up with additional onion and garlic and a few red pepper flakes, and served it with freshly made jumbo croutons. You can lighten this recipe up by using chicken or turkey meatballs instead of sausage.

2 tablespoons extra virgin olive oil, more for serving
1 pound sweet Italian sausage, sliced 3/4-inch thick
2 tablespoon tomato paste
1/2 teaspoon ground cumin
2 medium carrots, finely diced
2 celery stalks, finely diced
1 large or two medium onions, chopped
4 garlic cloves, finely chopped
2 teaspoons kosher salt, or to taste
2 thyme sprigs
1 large rosemary sprig
1 bay leaf
2 14 oz cans chicken broth plus 1 can water
2 – 15.5 oz can Great Northern beans, rinsed and drained
1 – 14.5 oz can diced tomatoes
2 teaspoons balsamic vinegar, more for serving
1/4 tsp red pepper flakes
1/2 teaspoon ground black pepper, more to taste
Jumbo Croutons for garnish (recipe below)

1. Heat the oil in a large stockpot over medium-high heat. Add the sausage and brown until cooked through. Remove sausage from pan and hold.

2. Add the tomato paste and cumin to the pot. Cook, stirring, about 2 minutes. Add the carrots, celery, onion and garlic. Cook, stirring, until the vegetables have softened, about 5 minutes, adding in the rest of the spices about halfway through. Stir in the beans, chicken broth and tomatoes. Turn the heat up to high and bring to a boil, then reduce heat to low and simmer gently about 1 hour, till the broth thickens. Add the sausage back in during the last 10 minutes.

3. Stir in the vinegar and pepper. Taste and adjust seasoning. Ladle into bowls and serve drizzled with additional vinegar and olive oil. Pass around the croutons.

Yield: 6 to 8 servings.

Jumbo Croutons

Half a Baguette (we had half of one in the freezer)
2-3 tbsp Olive oil
Salt and papper to taste

Thaw the bread if need be, then using a bread knife, cut into 2 inch cubes.Toss with the olive oil, then sprinkle with salt and pepper. spread onto baking sheet and bake at 400 degrees fahrenheit fo about 5-10 minutes, turning a few times during cooking and watching closely so they don’t burn. Serve.

The Journal In-Box

Occasionally, I find the time to sift through medical journals piling up  on my windowsill, or scan the table of contents of the journals that I get delivered via email. Here are a few tidbits I found interesting during my latest foray into the pile –

Diet, Exercise, Pregnancy and PCOS. A 6 week structured diet and exercise regimen significantly enhanced clomid-induced ovulation in infertile women with PCOS previously resistant to ovulation induction. Given that weight reduction will also decrease the risk for diabetes, hypertension and heart disease, that’s one very effective intervention!

DHA in Pregnancy – Is it doing a anything? DHA, despite being recommended as a supplement during pregnancy, did not improve offspring intellectual function or decrease maternal depressive symptoms. So why exactly are we recommending it?

Depo Provera and Fractures – Use of this injectable contraceptive in the UK was associated with a slightly higher rate of fractures in users of all ages, with risk highest after 2-3 years of use. This is not surprising given what we know about DMPA’s effects on bone mass. The risk is not high, and for women who cannot use other methods effectively, Depo remains an important contraceptive option. But for long term DMPA users, the risk for fracture is s a consideration that should be added into the benefit risk equation for use of this contraceptive. (This study was published in August  and I just got around to reading it now…)

Perinatal Mortality in midwife vs Obstetrician-assisted births in the Netherlands. Midwife assisted low risk pregnancies have higher perinatal mortality than high risk, physician assisted pregnancies. This unexpected finding puts the entire Dutch triage system of obstetric care into question. However, as most Ob’s will tell you, much of what can go wrong at delivery is unexpected. Being ready for anything is the safest way to go as far as I’m concerned.

Genital Warts Incidence Trends Downwards after HPV Vaccine Program Initiated in Australia. A 59% decline was seen in women in the age group eligible for the vaccine. Declines were also seen in heterosexual men (who are not vaccinated) suggesting that “herd immunity” may be accumulating. A more important public health outcome will be what happens to cervical cancer rates over time. But this data are encouraging.

NYC Woodpecker

This noisy little guy was going to town on the apple tree on our roof a few weeks back. Haven’t seen him since.

Ginger Stout Cake

Autumn brings thoughts of ginger – ginger snaps, ginger bread, and our new family favorite – Ginger Cake. I’m not sure what makes ginger a cold weather spice in our society. Maybe it’s because in cooler climates like ours, the rhizomes are harvested in autumn. No matter – I love ginger all year round, and keep crystallized ginger in the freezer to use in recipes or munch on whenever I want a tangy bite.

This particular recipe uses both ground and fresh ginger root  – an entire 4 oz of fresh ginger, to be exact. This looks like a lot while you are chopping it,  but don’t worry. It tastes just fine and the small pieces are undetectable in the final product except as flavor. The cake itself is moist, flavorful and really very special.

Making this cake is almost as fun as eating it. Remember that erupting volcano you made for your 4th grade science fair? You get to relive that experience when you add the baking soda to the boiling beer/molasses mixture. Bring the kids in to watch – it really erupts! (Science buffs can tell us why in the comments.)  Make sure you use a large pot, or you’ll have a real mess on your hands.

STOUT GINGER CAKE

This recipe comes from the Gramercy Tavern, was originally published in Gourmet and is now available on Epicurious. The original recipe calls for Guinness Stout, but here I used a double chocolate Stout that gave it an exceptionally fine flavor. I’ve also added a garnish of sliced candied ginger and serve it with a dollop of  whipped cream. I like my whipped cream with a tad of sugar, but you can make yours unsweetened if you prefer. Thanks to Irene for introducing us to this wonderful cake and talking me through the baking of it.

1 cup stout beer (Guinness or other – I used Young’s Double Chocolate Stout, available at Food Emporium here in NYC)
1 cup molasses (not blackstrap)
½ tbsp. baking soda
4 oz. piece of fresh ginger, peeled and finely chopped by hand (make it as fine as you can)
3 large eggs
1 tsp. vanilla extract
½ cup granulated sugar
½ cup firmly packed brown sugar
¾ cup canola oil (you can use vegetable or peanut oil if that’s what you have on hand)
2 cups all-purpose flour
1 ½ tsps. ground ginger
1 ½ tsps. baking powder
1 tsp. ground cinnamon
½ tsp. ground cloves
¼ tsp. freshly grated nutmeg
1/8 tsp. ground cardamom
½ tsp. freshly ground black pepper
Sweetened whipped cream and and thinly sliced crystallized ginger for topping and garnish

1. Preheat oven to 350 degrees. Butter and flour an 8 or 9 inch tube pan.
2. In a very large saucepan over high heat, combine the stout and molasses and bring to a boil. Turn off the heat and add the baking soda. Allow to sit until the foam dissipates. Stir in the chopped fresh ginger and let it steep while the mixture cools to room temp.
3. Meanwhile, in a bowl, whisk together the eggs and both sugars. Whisk in the vanilla and oil.
4. In a separate bowl, whisk together the flour, ground ginger, baking powder, cinnamon, cloves, nutmeg, cardamom and black pepper.
5. Combine the stout mixture with the egg mixture, then whisk this liquid into the flour mixture, half at a time.
6. Pour the batter into the pan and bake for 1 hour, or until the top springs when gently pressed.  (Mine took exactly an hour, Irene advised you to check yours at 50 minutes) Do not open the oven until the cake is almost done, or the cake may fall slightly. Transfer to a wire rack to cool. Make sure to cool completely and loosen the edges well before inverting onto plate – it should come away intact.

Serve with crystallized ginger slices and whipped cream.

Sweetened Whipped Cream

1 cup cold whipping cream
3 tbsp confectioner sugar
a drop of vanilla

Combine ingredients in a large bowl and whip at high speed using an electric mixer till it forms soft peaks. Refrigerate till use.

HRT and Breast Cancer Deaths – Just in Case You Weren’t Listening the First Time…

A new analysis of long term data from the Women’s Health Initiative confirms what we already knew the first time around – Use of combination hormone replacement (HRT*) is associated with a small, but real, risk of breast cancer. This new 11- year follow up data carries that knowledge out to its not unexpected conclusion – namely, that some (although not most) breast cancers can be fatal, and therefore the the use of HRT can increase breast cancer mortality.

While it may seem a bit of a “Duh”, this study was, in fact, necessary to quell the WHI critics who continued to argue that the breast cancers caused by HRT were somehow less aggressive than those occurring off HRT. (They are not.) It was also a wake up call for many women who were continuing to use HRT and thinking that somehow its risks did not apply to them. A fair number of these women appear to be coming off of HRT, at least in my practice. Others are staying the course and accepting the risks as they have been defined. Either of which is fine with me.

The spin going on around this study – both for and against HRT use – is tremendous and ultimately confusing to women.  The pro-HRT crowd (some of whom have relationships to Pharma) is using language like “The increased risk from using HRT for 5 years is the same as if your menopause occurred 5 years later”, which is technically true but so what?  The bioidentical hormone crowd (usually also selling the same) are using the study to further hype how their regimens are safer than the evil Big Pharma products – based on no data. Which leaves the rest of us to try to find ways to help our patients understand the risks, place them into perspective for themselves and make a decision about how and if to treat their menopausal symptoms.

While the breast cancer risks associated with HRT use appear to be quite real, for a individual woman, they are not that large. Here’s how I explain the risks to my patients –

There will be 7 extra cases of breast cancer and 1.3 additional breast cancer deaths for every 10,000 women per year who use HRT. Said another way, if you use HRT for 20 years, your risk of getting breast cancer will be increased by 1.4 % and your chance of dying from breast cancer will be increased by about a quarter of a percent. If you use HRT for less than 20 years, we can cut those numbers down accordingly.**

If you don’t already know it, I do have my own set of rules for prescribing HRT. This new data has not changed them.

_______________________________________________________________

* HRT means estrogen and progesterone taken together, as opposed to ERT, or estrogen alone. In the WHI, ERT use was actually associated with a lower rate of breast cancer, a finding unique to this study that begs for replication before we can bless ERT as breast-safe.

** The formula I used for cumulative risk is CR = 1 – e-IR*t ,where CR = cumulative risk, IR is the annual incidence and t is the number of years (in this case 20). If any statistician types reading this can confirm my methodology or numbers I’d appreciate it.

Graph above from JAMA. 2010;304(15):1684-1692.

Roast Pork Tenderloin with Braised Cabbage and Port Wine Sauce

The coincidental timing of my husband’s birthday near Columbus Day and peak foliage has turned this once minor family celebration into one of my favorite annual events – a weekend getaway to our cottage in the Endless Mountains with Mr TBTAM’s parents. Add in bro Joe with Rachel and clan in a rented RV, bring eldest daughter in from college, make the weather glorious and warm, go for Sunday brunch at Berry Fields Farm and put the Phillies in the playoffs (with a no-hitter reminiscent of the one that occurred on the day Mr TBTAM was born, which is why his middle name is Donald), and this year’s birthday weekend was very special indeed.

My only disappointment was that Joe’s family had already hiked Ricketts Glen before we arrived, and the meager apple harvest this year meant no apple stand or applesauce makers at the Forksville Fall Festival.

Joe, Rachel and my mother-in-law Irene are all fabulous cooks, so the weekend was one long Iron Chef event that started earlier in the week as we planned and coordinated via phone what we’d make and who would bring what. Since we had brought two separate pairs of tenderloin, we even had a brine-off. Irene had started her tenderloin brining Friday night, but Mr TBTAM and I could not start ours till we arrived to the cottage Saturday late morning, in brine that Joe (who had arrive the night before) had made and set cooling at around 7. It was clear by their rich color that Irene’s tenderloin were the superior brine, but by the time the dish was done no one knew or cared which was which.

We all crammed into the kitchen to cook the birthday dinner together, with Irene and Joe sharing Chef de Cuisine while Rachel and I played Sous Chef. Everyone got along famously, and the dinner was incredible. We served the tenderloin with a side of green beans, homemade applesauce and roasted herb potatoes. The birthday cake was a dense ginger cake with whipped cream (recipe coming soon…).

I don’t have space or time to detail the rest of the food we made that weekend, except to say that the pork leftovers went great with Frugal Fig Flatbread and salad for Sunday dinner, and leftover salad and fig flatbread were delicious additions to omelets and sausage for Monday morning brunch.

But better than the food that weekend were the moments with one another.  Joe and Em jamming on guitar, Joe and Marvin kibbutzing on the porch, me hanging with Rachel under the stars while the kids and the boys watched the game at The Barn, Luke drawing, Mr TBTAM blowing out his candles, laughing with Grace and Nats in the middle of the night, Irene and Rachel cooking breakfast, going on the world’s longest wild goose chase for those elusive fall apples, worrying we’d get tossed out on our ear by the Lake association for parking an RV in the driveway, hiking the lake and just sitting around the fire together talking.

Thanks Irene and Marvin, for joining us again, and thanks Joe, Rachel, Luke and Grace for making the long trip up north. And thank you, Mr TBTAM, for being born on the best weekend of the year.

Roast Pork Tenderloin with Braised Cabbage and Port Wine Sauce

This recipe is based on one from Chef Mark Peel (which can be found in the Gourmet Cookbook) with Irene’s modifications. It’s a lot of work and worth every second. The recipe below will serve 6. We doubled the meat (but not the cabbage) to serve 10 with leftovers.

Peel’s original recipe uses pork loin and brines for 2-3 days. We used tenderloin and brined for 6-8 hours. We also substituted chicken for veal stock in the port wine sauce. We saw no need to blanch the cabbage before sauteing, as Peel does in his original recipe. Finally, doubling the cabbage and using red onions and more garlic adapted it further to our tastes.

Brine
2 quarts water
1/3 cup Kosher salt
3 tablespoons granulated sugar
4 cloves garlic
2 tablespoons cracked black peppercorns
A few red pepper flakes
1 tablespoons dried thyme
4 whole cloves
4 whole allspice, cracked
1 bay leaf

Pork
2 pork tenderloins, 3/4 to 1 lb each
1 head (2 pound) red cabbage, cored, split and cut into thin slices (The thinnest you can get without using a food processor or mandoline)
Freshly cracked black pepper
2 large red onions, peeled and cut into 1/2-inch-thick round slices
1 tablespoon olive oil
2 large garlic cloves, peeled and chopped (2 teaspoon)
1/4 cup balsamic vinegar
8 fresh sage leaves, chopped fine  (optional – we left them out)
1 tablespoon drained capers

Port Wine Sauce
1 tablespoon (1/2 ounce) unsalted butter
2 large shallots, trimmed, peeled, and chopped (2 tablespoons)
1/4 cup balsamic vinegar
1 cup ruby port or sweet marsala wine
1 cup canned beef or chicken broth
1 tbsp butter (to add at the end)

  • Brine the pork. Combine 2 quarts of water, 1/3 cup kosher salt, sugar, garlic cloves, peppercorns, red pepper flakes, thyme, cloves, allspice, and bay leaf in a large stockpot and bring to a boil. Reduce the heat to low and simmer for 15 minutes. Remove the stockpot from the heat, transfer the brine to a large mixing bowl, allow to cool to room temperature, then refrigerate until cold, at least 2 hours. When the brine is thoroughly chilled, add the tenderloin, ensuring that it is completely immersed, and refrigerate, covered, for 6-8 hours. When ready to roast, remove the meat from the brine, and dry with kitchen towels.
  • Cook the pork and onions. Preheat the oven to 400 degrees. Season the pork lightly with black pepper. (It should not need salt.) In a large cast-iron skillet, over medium-high heat, brown the pork loin on all sides, then remove the pork to a platter and reserve. Distribute the onion slices on the bottom of the cast-iron skillet and place the browned pork loin on top. Transfer to the oven and roast until the internal temperature of the pork is 150 degrees, about 15- 20 mins. (15 mins if you like it pink, 20 mins if you like it more well done.)
  • Prepare the Port Wine Sauce. While the pork is roasting, prepare the Port Wine Sauce. In a small saucepan, over medium-high heat, melt the butter. Sauté the shallots until wilted, about 5 minutes. Pour in 1/4 cup balsamic vinegar and cook until completely absorbed, about 2 to 3 minutes. Add the port wine and cook until 1/2 cup remains, about 5 to 10 minutes. Add the stock and cook until the sauce begins to thicken, about 5 to 10 minutes. Strain the sauce through a fine-mesh, stainless-steel strainer into a small pot and keep warm. Add the butter just before serving.
  • Caramelize the onions. Remove the cast-iron skillet from the oven, transfer the pork loin from the skillet to a platter and let it rest in a warm spot. Using a stainless-steel spatula, scrape the bottom of the skillet to loosen any browned particles. Remove an of the onions that are burned. Sauté the remaining onions over medium heat until caramelized, about 10 minutes, remove from the pan and reserve.
  • Saute the cabbage. Add a little olive oil if needed to the pan and heat. Add the garlic and cabbage. Sauté until the cabbage is thoroughly heated through, and crisp-tender, about 4 to 5 minutes. Add the 1/4 cup balsamic vinegar and the caramelized onions, stir briefly, add the sage and capers, and season with kosher salt and black pepper to taste. Remove from the heat and keep warm till the sauce is reduced and ready.
  • Serve. To serve, cut the pork loin into 1/2-inch-to-2-inch-thick slices. Place the cooked cabbage on a large warm platter. Arrange the slices of pork on the cabbage, ladle the sauce over, and serve immediately.

Doc Gurley in Haiti

She’s tweeting her medical mission in Haiti.  So tragic are the unmet medical needs of these people.

docgurley Doc Gurley

Saw an alone 9-month-pregnant 19 yr old. No birth kit, no string for the cord, no plan for who would be with her.

Gave supplies+discussed how to ask helper to wash hands. Nothing sharp&clean for cord so gave scalpel. Acted out birth, w/handwashing #hai

Also saw woman with overwhelming postpartum uterus infection. Someone used hands at delivery to pull out pieces of placenta (see next tweet)

Saw 14yrold girl w/months of excruciating pain, mass in her lower belly, wasting. Ruptured appy? Tumor? Left her w/ narcotics, antibiotics.

Also, women do not have menstrual protection supplies

I’ve been asked, if there are no pads, what do women use? In the cases I saw, one used a page of a magazine & another a dinner-napkin.#haiti

God bless you, Doc Gurley, and the members of your team for all you are doing. What can we do to help?