Cuba on My Mind

There is no simple way to describe Cuba to you. Every image, every encounter, every experience evokes a rush of conflicting emotions, because it is a country of such incredible contradiction.

It amazes me to think I actually visited a country whose government suppresses free speech and restricts the freedom of its citizens, and while I enjoyed unlimited internet access (when the router was functioning), Cuban citizens do not.

What amazes me more is that this same government affords these same citizens universal, free medical care, with an infant mortality rate and life expectancy equivalent to ours, a literacy rate of 100%, and an education system so excellent that they are exporting doctors and scientists across South America.

We exit the airpot to see anti-American billboards,

and yet everywhere we go we are welcomed by the people of Cuba with open arms, music, warm hearts (and a Mojito…). 
Cuba’s cities are an ecelectic mix of mid-century and centuries old architecture in colors that brighten the soul,  
and yet many of these same buildings are literally crumbling before your eyes, bringing forth a great sadness. 

It is a place where one cannot get something as simple as an Excedrin, where bathroom attendants dole out small rations of toilet paper like precious jewels and flush the toilets with buckets of water because the plumbing system is unreliable. But the food system is working, and Cuba is now one of the world leaders in successful urban gardening and sustainable agriculture.

We were forced to change our Havana concert venue twice because air conditioning broke down, and the union hall we ultimately performed in, never designed for musical performance but graciously offered for our purposes, had both an out of tune piano and poor acoustics. And yet, in that hall, I heard a flute solo I shall never forget and some of the most beautiful voices I think I will ever hear.

I was told that Cuba was an anachronism, a country trapped in the mid-century, epitomized by the many antique cars we saw on the streets. And while it is true that there are pockets of the past, they exist mostly in the architecture and the automobiles. The people I met were very much citizens of the 21st Century, in many ways poor by our standards, but in some ways rich. Those I met were doing important work in medicine, science, agriculture and the arts, despite what for us might be a crippling lack of resources. And while I remain confounded and disturbed by the harsh realities of their political system, and frustrated by their crying needs for so many of the things we take for granted here, it is the strength, warmth and talent of the Cuban people that I will recall most when I think of my visit there.
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Up next – Cuban Food. 

(Note – I initially wrote maternal mortality up there and meant to say infant mortality. Cuba’s maternal mortality rate is higher than the US’s, but they are aggressively working towards lowering it)

Endometrial Thickness in Post Menopausal Bleeding – Is 3 mm a Better Cutoff?

An abnormally thickened post-menopausal endometrium

A new meta-analysis suggests that the commonly used 5 mm cut-off for endometrial thickness on transvaginal ultrasound may be a bit too optimistic at predicting the absence of endometrial cancer in women with post menopausal bleeding. European Researchers now suggest that 3 mm is a better cut off point, below which there is a 98% reduction in the chance of having cancer of the endometrium.  A thickness of 4 mm gives a 95%, and 5mm a 90% reduction in odds of cancer.

That means if you have post menopausal bleeding (which has a 10% chance of being a cancer among all comers), an endometrial thickness below 3mm on transvaginal sonogram  reduces your chance of cancer from 10% to  0.6%, while the old  5 mm cutoff would have reduced you odds to 1%.

From what I understand, the researchers created receiver operator curves (ROCs) for each study, and them combined then, as opposed to a single ROC from the combined data, which was what had been done in the past to generate the 5 mm cutoff.  Having a pretty rudimentary knowledge of statistics, I have no idea which methodology is better, and will await commentary and guidance from those who know these things better than I.

I do know, however, that in the past few months I diagnosed two patients with endometrial cancer whose endometrial thickness was below 5 mm.  Given that no cut off value is 100% predictive, this of course was bound to happen sooner or later given how long I have been practicing, but it was nonetheless disconcerting. Interestingly, both women had endometrial thickness which would have put them above the 3mm cut off recommended in this new study.

Ultrasound as a Tool for Evaluating Post-menopausal Bleeding

I, for one, have long appreciated transvaginal sonogram as a non-invasive tool for evaluating post menopausal bleeding.

In years past, a single drop of blood more than a year after menopause meant an automatic trip to the OR for a D&C – that’s  a “dilation and curettage”, also known as a “dust and clean” to my mom’s generation. This would include women who bled from vaginal dryness, infection, blood thinners or even the occasional errant menstrual cycle, most of whom do not have endometrial cancer. That’s a lot of D&C’s.

With the advent of office endometrial biopsy, or EMB as we call it,  most women were saved the trip to the OR, trading it for a quick, but rather painful office procedure.  (If you’ve ever had an EMB, you might not consider it such a good trade off..)

Then along came vaginal ultrasound, and we were able to stop even those endometrial biopsies in all but the few whose sonograms did not make the 5 mm cutoff. The OR is now reserved for those women unable to have an office biopsy or who have obvious endometrial polyps on sonogram (which require removal to rule out malignancy, just as colon polyps require removal.)

There’s nothing more satisfying than being able to reassure an anxious woman that her bleeding is a benign process and she does not need to have an invasive test. (Of course, one must interpret the sonogram results in light of the clinical scenario., and sometimes your clinical sense tells you to biopsy regardless of the sonogram results. If it does, trust it. You just may be right, as I was with those two patients I mentioned.)

Now what?

It’s too soon to say, but I’ll be watching this one closely. If we do move from a 5 mm to a 3mm cut off, I predict I’ll be doing more endometrial biopsies in my menopausal patients, something that will make neither my patients nor me very happy.  The question of course, is how many more biopsies, and at what cost (both financial and in terms of complications such as perforation or infection)? I could not glean that answer from the paper.

But if more biopsies is what we have to do, then we will do it. Because the downside is missing a diagnosis of cancer.

And that’s something none of us wants.
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Timmermans, A et al. Endometrial Thickness Measurement for Detecting Endometrial Cancer in Women With Postmenopausal Bleeding: A Systematic Review and Meta-Analysis. Obstetrics & Gynecology: July 2010 – Volume 116 – Issue 1 – pp 160-167.

TBTAM at Women’s Health.gov

I was privileged to be the featured interview this month at the Spotlight on Women’s Health series at Womenshealth.gov, the website of the Office of Women’s Health. Thanks to the editors for their thoughtful questions and  for the opportunity to speak to women about HPV, healthy living and, of course, cooking!

Women’s Health.gov is a fabulous website that  features fact sheets on over 100 various health topics,  drug and drug interaction information links , clinical trial information, health statistics and much, much more. It’s a great first stop for any information you’re seeking on Women’s Health, whether you are a patient or a health professional. It’s a real honor to be featured on the site, especially when I read the interviews with the wonderful women who preceded me in the series.

Embrace Life

Back home, promise Cuba posts coming. In the meantime, watch this gorgeous video from the UK promoting seatbelt use. And buckle up!

Hola de Habana!

I’m here in Cuba on a concert tour with the Yale Alumni Chorus. (No, I did not go to Yale, but when you sing, you meet some amazing folks who extend some amazing invitations…)

Internet access is too unpredictable in our hotel and our schedule is too jam-packed for more than an occasional brief post, but I promise I will tell all when I return next week. I will tell you that last night’s joint concert with the small but brilliant local Coro de Camara de Matanzas was an experience I will never forget.

In the meantime, a little taste of Cuba –

Oh yeah – Zippy’s Here

Zippy* managed to get through customs (maybe he has relatives here?) and is having a marvelous time. He does want Dr Rob to teach him to drive when he gets home.

He also says to tell you all that he loves the Cuban kids – they always have a smile!

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*For those of you who don’t know him, Zippy the Lobster is a crustacean on a mission to see the world and raise money for Children’s Brain Cancer Research, thanks to the efforts of his adoptive father, Dr Rob.  If you’re reading this post, why not donate a few pesos to Zippy’s cause? Maria and Zippy raised over $200 last week when Zippy visited her in New York City. Let’s see if we can top that!

Soft Shell Crabs on a Bed of Leeks with Warm Herbed Potato Salad

It amazes me to think I spent more than half of my life not knowing that soft shell crabs existed. Seriously, I didn’t taste my first soft shell, cooked to perfection by my future mother-in-law on her stovetop in Philadelphia, until I was almost 30 years old. Today, Irene’s simple method – sauteeing flour-dredged and salt and generously peppered soft shells in butter – remains my favorite way to enjoy these amazing delicacies. Actually, I don’t cook the soft shells – Mr TBTAM does. His mom taught him, after all.

Sauteed Soft Shell Crabs on a Bed of Leeks

Mr. TBTAM may cook the crabs, but I present them. And tonight, it was on a bed of leeks, with a side of warm herbed potato salad and some sliced tomatoes. We got our crabs from Fairway, where they were so fresh, they wriggled ever so slightly if you touched them. I think these may be the last of this season for us – the shells were just starting to head towards the hard side on the edges. This short season is what makes soft shells so special.

For the leeks
4 large leeks
1 tbsp olive oil (If you can handle the calories, add also a tad of butter..)
Salt and pepper to taste
White wine to deglaze (optional)

Trim off bulb and dark green parts of leeks, then slice longways. Wash thoroughly in a bowl of cold water, rinsing and refreshing several times until all the sand and grit are gone. Drain on paper towels and blot dry. Cut in half again across and then slice very thin. Heat 1 tbsp olive oil in a large saute pan till hot. Add leeks and saute over medium high heat until softened, about 10 -15 minutes, adding salt and pepper about halfway through.  Remove leeks from pan to a small bowl. If you want, you can deglaze the pan with 1 tbsp of wine and add to the leeks. Cover with foil to keep warm while sauteeing the crabs.

For the crabs
6 soft shell crabs
1/4 cup flour
salt and pepper
3-4 tbsp butter

In the same pan, melt 2 tbsp butter. Lightly dredge the crabs in flour and sprinkle one side with salt and freshly ground pepper. Add to the pan (salted side down) and saute about 2 minutes till brown. Sprinkle a little more more salt and pepper on top before turning, then add another 1-2 tbsp butter to the pan. Cook another 2 minutes or so till done. If you do it right, this is what your soft shells will look like –

To serve, divide the leeks among the plates and place a crab atop the bed of leeks. Serve with a side of potato salad and sliced tomatoes. Split the remaining two crabs for second helpings. Serves 4.

Warm Herbed Potato Salad

12 small red potatoes (Not the teeny-tiny ones)
1/4 cup mayonnaise (Try 1/8 cup first and that may be enough for you..)
2 tbsp rice wine vinegar
1/4 cup chopped fresh herbs (I used tarragon, parsley, chives and a tiny bit of mint)
salt and pepper to taste

Clean the potatoes but don’t peel them. Slice into quarters and place in a stock pot, cover with water, add a tsp salt and bring to a boil. turn down heat and simmer till just cooked, but not too soft (about 15 minutes). While they are boiling, chop your herbs and mix them in a small bowl with vinegar and mayo. Drain potatoes, place into serving bowl, pour on dressing and toss gently.  Serve warm.

A Virtual Choir

Composer/conductor Eric Whitacre has created a virtual choir. He videotaped himself conducting, then asked singers to record themselves singing their respective parts and send it on to him. He then merged their voices and videos electronically. The end result is the amazing recording above – 185 singers making exquisitely beautiful music together.

Adding such joy to the world. That’s not virtual – that’s real.
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You can be part of Whitacre’s next virtual choir performance – no auditions are necessary, according to info on his facebook page, where he states he wants to compose an original piece and assemble a choir of hundreds, even thousands.  Watch for the announcement, either on his facebook or youtube pages, then make and send in your recording. You can be sure I’ll be sending in mine!  

Forskalin for UTI? Maybe – If You’re a Rat

A patient came into the office the other day carrying a small clipping from a reputable Women’s Health newsletter touting new research on an herbal remedy for urinary tract infections. Having recurrent bladder infections, my patient naturally was wondering if this was something she should try.

The article was entitled “Herbal Remedy Effective for Urinary Tract Infections”, and began with this startling revelation –


The common herbal extract forskolin can greatly reduce urinary tract infections and could potentially help antibiotics kill the bacteria that cause most bladder infections. 


but advised that the “popular” remedy was not FDA approved for this indication, so she should “ask your doctor.”

Googling it, I quickly discovered the research study being touted in the article – a small pilot study from 2007, in which researchers instilled a solution containing the herb Forskolin (Who thought of that name? Sounds like Foreskin…) into the bladders of lab rats previously infected with e coli, then sacrificed the rats and compared their bladders to those instilled with saline solution. Their findings – less bacteria in the forskolin irrigated rat bladders.

Needless to say, once I simply explained the research findings to my patient, she had absolutely no desire to try this untested herbal remedy.

“I’m no rat and I’m no guinea pig” she said.

Smart woman.

OBS Housekeeper’s Pulled Barbecue Chicken – From Philly to NYC

A few Fridays ago, I decided to drive down to Philly for the evening – my grade school was closing, and how could I miss the final party?

But I was having my Musical Theater Class over for our cast dinner on Saturday evening. And I wanted visit my Mom before leaving Philly on Saturday morning. How could I get it all done?

Enter my wonderful sister, the OBS Housekeeper and her amazing Pulled Barbecue Chicken!

Not only did OBS put me up Friday night, but Saturday morning while I visited with Mom, she (along with sis Basket Mom) shopped, then cooked the chicken for me to take back home to New York City, packing it in a covered aluminum tray for safe transport.  I popped it into the fridge when I got home, then whipped up some red pepper crostini, lemonade and a cucumber salad. My guests brought more sides, beer, wine, appetizers and desserts. (Thanks Ronnye and Paul for coming early and helping!) The rain held off till after dinner was over, and we had a great time singing around the piano during dessert.

Thanks, OBS and Basket Mom for making my weekend. And my party. I couldn’t have done it without you!

OBS Housekeeper’s Amazing Pulled Barbecue Chicken 

Actually, the recipe comes from Rachel Ray , but OBS makes it better that Rachel does, I’m sure. It is absolutely delicious! Serves 6-8, but adjust accordingly for a crowd. You can make it in the morning the way OBS did for me, refrigerate till ready to serve, then reheat quickly on the stovetop and you’re ready to go! Goes great with cucumber salad. 

4 boneless, skinless chicken breasts
salt and pepper
Water to cover
1 medium onion, finely chopped
4 cloves garlic, finely chopped
1 1/3 cups barbecue sauce (You can use pre-made, or make Paul’s recipe)
1/2 cup apple cider vinegar
hot pepper sauce
6 ounces mild cheddar Cheese, shredded
8 rolls

Wash and dry chicken breasts. Season with salt and pepper and place in a heavy pot with the onion, garlic. Add just enough water to cover, then the barbecue sauce, vinegar and a few drops hot sauce (more or less to taste). Bring to a boil, then reduce the heat and simmer until the chicken is cooked through, about 15 minutes. Remove the chicken from the sauce and shred with two forks.

Boil the sauce, skimming occasionally, until reduced by half, about 15 minutes. Season with salt and pepper. Add the shredded chicken and heat through. Serve in a crock pot or casserole dish with the rolls and cheese on the side. Let guests assemble their own sandwiches. Enjoy!

DrugWatch.com = Ambulance Chasers

I don’t know about the rest of you medical bloggers, but I’ve been getting emails from folks who run a website called “DrugWatch.com”, asking for reciprocal links and promoting themselves as the go-to place for patients to get up to date info on medication safety.

Tucked into the website is this promise – “We will never accept advertising from the pharmaceutical industry”.

Right. Because the whole site is a front for a bunch of Orlando lawyers trying to sniff out potential clients for medication-related lawsuits against the pharmaceutical industry.

DrugWatch.com is sponsored by The Peterson Firm, LLC, which is licensed by The Florida Bar to practice law in the state of Florida. The Peterson Firm, LLC’s main office is located at 2317 North Wickham Road in Melbourne, Florida, 32935. If you indicate to your Patient Advocate your desire to speak with an attorney about your legal rights, he or she may recommend various law firms and recommendations may include law firms from around the country including The Peterson Firm, LLC. If you decide to retain The Peterson Firm, LLC for the handling of your legal claims, The Peterson Firm, LLC may utilize experienced co-counsel (at no additional cost) to assist in the prosecution of your claims. If a Patient Advocate-recommended law firm is retained, The Peterson Firm, LLC may co-counsel and assist with the prosecution of the claim at no additional cost to the client. The Peterson Firm, LLC handles cases on a contingency fee basis, and there are no costs or fees charged to the client unless a recovery is made.

Big Pharma has their disease awareness websites. Now the lawyers have their drug side effects awareneness websites.

And the game goes on….

Gorilla Opera

Flash Brindisi – Members of the Opera Company of Philadelphia break into song at the Reading Terminal Market in Philly.

Food and music together? It doesn’t get any better than that!

Spring Supper Salad – Scallops, Green Beans & Baby Reds on Lettuce with Miso Dressing

Perfect for a light meal after a warm Saturday afternoon biking the West Side Greenway Trail. Stop at Fairway on the way home for provisions, then eat al fresco with a cold beer. Ahh, spring!

Scallop, Green Bean and Baby Red Spring Salad with Miso Dressing

The dressing is modified from Museum Cafes & Arts, a little gem of a book of recipes from museum cafes illustrated with gorgeous prints of famous works of art.  The rest of the recipe we made up ourselves. Although I’ve listed the weights of the potatoes, scallops and beans we used, you should just buy what you think you need. The dressing will serve at least 6. 

1 lb small red potatoes
salt and pepper to taste (just a tiny bit – the dressing is salty)
3 tbsp canola oil
1 1/2 lbs large scallops
Fresh lettuce
1/2 lb green beans
Miso Dressing (recipe follows)

Wash and dry potatoes well. Don’t peel. Cut into half (or thirds, however you want, to uniform size) Toss with 1 tbsp canola oil and 1/4 tsp salt and pepper. Spread on a baking sheet and bake at 400 degrees, turning halfway, for about 30 minutes, or until browned and cooked. While the potatoes are cooking, make the dressing, wash and dry the lettuce. Steam the green beans over boiling water till warm, bright green and still a bit crisp. Drain and set aside. Remove cooked potatoes to a bowl and set aside while you cook the scallops.

Heat 2 tbsp olive oil in a skillet until very hot but not smoking. Add the scallops and sauté until nicely browned, about 3-4 mins. Turn to the other side and cook one more minute.

Arrange the greens on a platter. Arrange the scallops, browned side up, on the bed of greens. Scatter some green beans atop the greens and place the potatoes on the side. Drizzle dressing over the scallops, beans and greens and serve immediately. Serves 4.

Miso Dressing

I happen to love this dressing, but if it’s not for you, make my warm tarragon vinaigrette instead.

1 tsp sugar
1/4 cup white miso
2 tbsp rice vinegar
1 tsp wasabi paste
1 tsp fresh lemon juice
1/4 cup light soy sauce
1 teensy-weensy drop sesame oil (optional)
1 1/2 tbsp canola oil

In a small bowl, whisk together all ingredients except the canola oil. Gradually whisk in canola oil.

Autism and Infertility – More Questions Than Answers

In the latest media barrage on autism, infertility treatments have come into question as a possible cause for this increasingly common developmental disorder. The reason is two research abstracts presented at the International Meeting for Autism Research this week in Philadelphia. (If you’re interested, the abstracts are on pages 9 and 11 of the linked pdf file).

One study assessed the history of IVF among 574 children evaluated at a special center for autism in Israel. The researchers found that 10% of the group diagnosed as autistic had had IVF, compared to a background rate in the overall population which they quote as 3.5%. Not surprisingly, maternal age was higher in the IVF group and the rate of prematurity was higher in the autistic children.

The second study was a look into a pre-existing database – the Nurse’s Health Study – which collects data from a cohort of nurses over time. The researchers compared the reproductive history reported by women who also reported having a child with autism and compared it to that of women who did not report having an autistic child. Of those with autistic children, 48% reported infertility with 34% having used ovulation inducing drugs, compared with 33% and 24%, respectively, in women without autistic children, a difference that was statistically significant when controlled for maternal age and self-reported pregnancy complications.

A Time article getting a lot of media play calls the results of the second study “some of the strongest evidence to date” linking autism to fertility treatment.

Unfortunately, that’s just not true.

Studies such as the one being reported this week certainly raise questions, but in reality do nothing to answer them. They are nothing more than preliminary forays that are fraught with problems when one tries to use the results for anything other than to inform further, better designed research. The problem is not necessarily with the studies themselves, which are clearly preliminary – it is with how the media is reporting the results. Which gets into the whole problem of PR and media reporting of research meetings, which I think is getting out of control, but that’s another post for another day…

For now, let’s go through the more obvious limitations of the data being presented.

1. The Nurses Study Population – A 33% rate of infertility in the control group and close to 50% in the study group? The background rate of infertility in the US is about 10%. Is this study population representative? I doubt it.

2. Recall bias – This is when an individual who has experienced an adverse outcome does a better job of remembering exactly what drugs and treatments she took than someone who has not had the adverse outcome. It’s human nature, after all, to spend hours, even days looking back and asking “What did I do that caused this?” But it means you remember a lot more than folks with no reason to be so retrospective. The Nurses Study, being a prospective collection of data, does not have this bias, but the Israeli study may.

3. Controlling for the underlying problem – infertility. The Nurse’s Study found that women having more cycles of IVF or clomid had higher rates of autism. But if you need to undergo multiple cycles of infertility treatment, isn’t it just possible that there is something about your gametes – either egg or sperm – that are the problem, and not the drugs themselves? The fact that autism is a highly hereditable disorder supports that there may be an inherent association between the state of infertility and autism. Maybe infertility is nature’s way of controlling the gene pool, so to speak, and we’re messing with it by helping folks get pregnant who maybe weren’t supposed to. Don’t tell that, of course, to the millions of normal, healthy and intelligent individuals born as a result of IVF. But it might explain small increases in certain conditions among children born after fertility treatments compared to the general population, mightn’t it?

While the researchers did control for age, that’s just not good enough. We all know that while age is an excellent marker for IVF success, it is ultimately the quality of the oocyte and sperm that is the most important factor in determining success in fertility treatment.

4. Cause of infertility – One way to tease out the effect of the gametes from the fertility drugs is to focus only on those women with tubal infertility – their eggs are fine, it’s the passageway that’s the problem. If this group had higher autism rates with ovulation inducing drug use, then that’s a stronger association. Unfortunately, the data presented were not detailed enough to address this question.

5. Consequences of fertility treatments – Ovulation inducing agents all lead to higher rates of multiple pregnanies with their associated complications of prematurity and low birth weight, both factors associated with autism. How much of the reported associations were due to these factors and not the fertility treatments themselves? 

6. Diagnostic bias – Could it be that parents who persist through multiple fertility cycles against the ever increasing odds that they may not have a child might also be more persistent in getting their child diagnosed with autism? It’s possible, I believe.

To date, well done research into developmental outcomes of children born as a result of assisted reproductive technologies (ART) has not found significant risks, but most studies have been confined to infancy and early development, prior to when some children may be diagnosed with autism. Recent studies on longer term childhood outcomes among children born as a result of ICSI (intracytoplasmic sperm injection) have been quite reassuring in this regard. One small study did find a higher rate of autism in children born after ICSI, but not IVF, and the numbers were so small (3 children only had autism), that it’s difficult to make larger conclusions from the data. A recent review article found no reliable studies of autism and ART, and calls for more research.

I would agree.
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Photo from NBC.com

Tag Team Skillet Gnocchi Casserole

How do you get a deliciously healthy family supper together when you have a late meeting and your husband has to pick your younger daughter up from a study session at a friend’s house across town? Not to mention stay on your diet?

Sounds like a job for the Weeknight Warriors! But this time, you tag team it. Here’s how we did it  –

4:50 pm – Just before heading onto your late afternoon meeting, you find a great recipe on Eating Well.com site, which features 500 calorie dinners!

5:00 pm – Call Mr TBTAM to get his agreement on the meal choice, then email him a list so he can pick things up on his way home from work. Head to your meeting.

6:30 pm – Mr TBTAM, now home with gnocchi and spinach, heads into the kitchen to prep.

7:00 pm – Mr TBTAM sets the table, then leaves to pick up younger daughter. You leave the office and head home.

7:15 pm – You head straight from the front door to the kitchen, stopping only to don an apron, and start cooking. You feel like a TV chef with a staff of kitchen elves –  the onions and garlic are all chopped, the can of tomatoes and beans are opened, the salad greens and spinach washed and everything is out on the counter waiting for you!

7:45 pm – Everyone’s home, dinner is on the table. Go Team!

Tag Team Gnocchi Skillet Casserole

Modified from Eatingwell.com. The big short cut in this meal is using prepared gnocchi, but feel free to use homemade. This dish would be good with pasta as well, but the gnocchi are really special. Serve with a green leaf salad with a light dressing to make it to 500 calories total. We made the goat cheese tomato dressing suggested on the website, but it ended up a bit too watery to post the recipe.

I modified the Gnocchi recipe from EatingWell by boiling the gnocchi first, using a tad more olive oil so the gnocchi would not stick (I use a stainless steel and not a non-stock skillet), spinach instead of swiss chard, increasing the onion to large, substituting chicken broth for water and adding some fresh basil and hot pepper flakes. My calorie count is about 20 calories more per serving than the recipe on the website, or about 340 calories. Of course, that’s only if your serving size is 1/6 of the total. Unfortunately, I think I ate about 1/5 of it, so I actually had about 400 calories. It’s all about portion size, isn’t it?

Boiling lightly salted water
1 16-ounce package gnocchi (We used Emilia brand from Fairway, also at Trader Joe’s)
2 tablespoons olive oil
1 large onion, thinly sliced
4 cloves garlic, minced
1/2 cup fat free chicken broth
6 cups fresh spinach leaves, washed and drained
1 15-ounce can diced tomatoes
1 15-ounce can white beans, rinsed and drained
1/4 teaspoon freshly ground pepper
1/4 tsp red pepper flakes
2 tbsp chopped fresh basil (or a tsp pesto)
salt to taste
1/2 cup shredded part-skim mozzarella cheese
1/4 cup finely grated Parmesan cheese

Bring a pot of lightly salted water to a strong rolling boil. Add gnocchi and cook, usually for 2-3 minutes, removing them with a slotted spoon to a colander as they pop to the top of the water. Drain.

Heat 1 1/2 tablespoon oil in a large skillet over almost high heat. Add gnocchi and saute for about 5 minutes, turning them gently with a fork as they brown lightly. (Try not to eat any.) Transfer gently to a bowl. (Surprisingly, they don’t break apart.)

Add the remaining 1/2 tbsp oil and onion to the pan and cook, stirring, over medium heat, for 2 minutes. Add the garlic and cook another minute, then the chicken broth. Cover and cook until the onion is soft, 4 to 6 minutes. Add spinach and cook, stirring, until starting to wilt, 1 to 2 minutes. Stir in tomatoes, beans, basil, pepper and pepper flakes and bring to a simmer. Cook off any excess water that may have accompanied the tomatoes (next time I will drain the tomatoes).

Stir in the gnocchi and sprinkle with mozzarella and Parmesan. Cover and cook until the cheese is melted and the sauce is bubbling, about 3 minutes. Serve hot.

I Wanna’ Be Sedated

Dr Whoo and I seem to be in the same place at the same time. We both struggle with our weight because we are using food for other than sustenance. We use it to manage stress. Overeating is, after all,  a wonderful sedative. Soothes the savage beast and all that. And it really works. I’ve probably saved my marriage and my job and kept from killing my kids and my husband by sedating myself with food.

In Dr Whoo’s case, the sedative of choice is pasta. In my case anything edible and not growing mold, but preferably bread or pretzels with something fatty, either cheese or Nutella would do just fine, thank you. Mother’s little helper never tasted so good….

What am I sedating with food? Frustration, irritability and anger that results when conflicting priorities build and I have to make choices I don’t want to make. Sleep or get the work done. Help my kid with her homework even though its 10 o’clock and the first time I’ve sat down to relax all day. Ignore the email in-box while I finish patient charts. Or tackle the email while the charting builds up. (The two tasks can never both be completed in a single day, I am convinced.) Or once again finish seeing my patients for the day only to turn and face the ever growing pile of lab and radiology results and phone calls that came in while I was in office hours.

Bad internet connections also makes me overeat if I’m trying to get work done. By the time the damned site loads I can head to the kitchen and shove in a handful of something.

During the 11 weeks I spent losing 33 pounds in a controlled research diet, the option to sedate my frustration and anger with food did not exist. It was an interesting little experiment in dealing with life. I have to say I occasionally cheated during a particularly stressful evening with a little piece of pretzel dipped in nutella (hopefully Charlie, the study PI, is not reading this blog post…), but overall, I learned to cope without the food. It also happened to be a rather quiet time in terms of conflicting responsibilities.

Now, almost a month later, I find myself turning back to food. It may be that this has been a particularly stressful time – I’ve been working with a colleague to get a grant written while seeing a full load of patients and doing all my usual administrative work in my department. Not to mention trying to be a good mom, sister and wife, hosting a dinner party mid week and performing with my chorus. Thankfully last weekend was a quiet one, and I even got in a 12 mile bike ride on Saturday. Which did not stop me from hitting the pita chips and party leftovers that same night when I couldn’t find the ideal breast cancer knowledge tool anywhere in the literature ( a slow search because the library connection was slow) and needed to come up with something to write in the grant to explain how we were going to measure that variable. I headed to bed at 4 am feeling lousy.

Sunday I awoke at 10 and made the smart decision to head to the office, where the library’s internet connection was fast and there were no windows to remind me that it was a gorgeous spring day and I was working.  I also happened to be away from any kitchen and my daughter came with me to do her homework, so no guilt was involved. I actually got a huge amount of work done, and more importantly, I made it through the day without overeating. That meant that night, instead of feeling guilty, I felt elated. I had written several important parts of the grant (which my collaborator may trash, but that’s okay, she’s better at this stuff than I will ever be), caught up on chart work and even posted a quickie blog post. My daughter got caught up on her homework and started a big project.  Not to mention that while she and I were working, Mr TBTAM had done the spring garden cleanup on the roof! I felt literally high thinking about all that we had accomplished that day. The frustration of the grant writing was over, the garden looked wonderful, and to top it all off, I did not have that cloggy brain that I get when I over eat. I felt physically great.

And then I had one of those Aha! moments.

I realized that while stuffing myelf with carbs and fat quite effectively sedates the frustration, it also squashes the joy for some time thereafer. Joy, is after all, a feeling of euphoria. Or as it has been so beautifully said – the unbearable lightness of being.

It’s hard to get that feeling if you are stuffed to the gills, your tummy bloated out with post carb gas, your post prandial brain plugged with the glue of sugar and your anger at yourself mounting because now you’ve lost momentum and gained back the weight you worked so hard to lose. True, you are no longer anxious. But you’re not capable of happiness at that point either. You’re too busy feeling lousy. Or at least I am. And that lousy feeling can last a lot longer than the frustration would have lasted if I’d just lived through it.

Don’t ask me how it took this many years of living to realize this, but I have.

Now of course, the question is this – How do I remember it the next time I find myself reflexly heading to the kitchen while waiting for the internet to load? Or my daughter to finish the math problem before I review it? Or the feeling to pass when I look at my calendar and realize that I can’t do it all?

That my friends, is the question.