Notes from the Road: Buenos Aires WPATH

I am in beautiful Buenos Aires at my second World Professional Association for Transgender Health. My first was held in Amsterdam in 2016 when I was a fresh faced, just-finished first year medical student. Now, as a mid-fourth year student I am significantly more exhausted and disillusioned; I also have so much more doubt about choosing this field of medicine as my calling.

I like to tell the story that I returned to medical school to practice transgender health. Specifically, to be able to prescribe transitional hormones and participate in the insurance racket to reach more people. And that is part of the story. The root truth is I have been compelled to be a full scope physician for many reasons and transgender medicine gave me a focus because it was something I could not attain as the Naturopathic Doctor that I was before.

The last session I attended at the WPATH ARGENTINA conference was an incredible and inspired panel of Brazilian intellectuals speaking on depathologizing the transfeminine and deconstructing cisheteronormativity. Fran Demetrio, a transfeminine Brazilian professor was so passionate and eloquent in her discussion of injustice, oppression, systemic violence and the colonization of knowledge imported by biomedicine. She was being translated which made some of the discourse hard to fully comprehend and I wished WPATH had provided a professional translator for her because what she had to say was so profound and important and well thought out. She framed a paradigm that took the personal out of the conversation and raised it to a social construct and human justice level. In rough translation, she explained that not including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the [transgender] patients knowledge. Considering and understanding this is essential to depatholgize the trans experience.

Despite the  multiple disparities that this population faces world wide, there is a slowly increasing body of trans identified physicians and health leaders in the field. However, to date  many of the people making the decisions about gender medicine are not differently-gendered themselves. Surely, this is problematic. The numbers of trans identified health care leaders is increasing by the year, and with groups like the Transgender Professional Association for Transgender Health, they are seeking greater control around the discourse of gender medicine and claiming their place as necessary voices in the didactic.  

The tensions between cis and trans leadership has created a simmering anger within this medical community. A socialist friend of mine shared that in activism in general there is a current trend towards challenging aggressions towards advocacy leaders in many different fields with a similar theme of  – who has the power to speak and represent the cause?

I was personally attacked in this rising conflict this year when I created a transgender health elective as a third year medical student for global medical students to supplement core medical school curriculum. A variety of trans and nonbinary people on social media threatened to create a petition against the course as it does not have a transgender identified course leader and there were multiple flamings on Facebook. I personally received several vitriolic emails from different people about the course, its content, and my leadership. I was privileged to have a team of (cis and transgender) people who have been in the field for a long time holding leadership positions to assist me in creating online and email responses that were balanced, appealed to reason, and illustrated the many ways the course seeks to uphold and respect the “nothing about us without us” principle while promoting evidence based foundational medicine.

I brought up this conflict between cis and trans leadership in the didactic of transgender medicine again at one of the ethics seminars at WPATH, where leadership and authority privilege was being discussed. Unfortunately, I was emotional in my questioning of the ethics behind attacking ally’s and advocates, as I am still deeply shaken by this experience. The response from one of the panelists was that when working as a non trans person with the gender diverse community there is so much anger one must simply expect to be attacked and be ok with that.

I am a person who has been excavating emotional violence in my personal life and creating real boundaries to protect myself for the first time. I don’t think I can intentionally choose a career were the population I am exhausting myself to serve reserves the right to be emotionally violent towards me indiscriminately because of their experience of violence. That is like saying that my mother has the right to be violent towards me in any way she sees fit because of the abuse she and her mother suffered. No.

Again.

not  including the existential experience of trans voices in episystemic medical knowledge creates symbolic violence and perpetrates the colonialism of transgender relationships. This generates mental health violence and tramples the patients knowledge. Considering and understanding this is essential to  depatholgize the trans experience. “

Dr. Demetrio’s message ultimately lifted my perspective of the conflict to a healing systems approach. With this in mind, I am still recalibrating my commitment to trans health as a specialized field of medicine, while intentionally making room for the many trans identified health care leaders. As a nontrans woman and a white queer/lesbian, I devote the next phase of my medical education to the foundations of internal medicine as well as lesbian health, vaginal happiness, fertility, community health, and queer health issues like addiction and mental health. My view of women’s health includes trans and cis women, as does my passion for community wellness. I am confident that these past 11 years of studying transgender medicine and advocacy work will continue to inform the communities I serve, if in a less direct way.

I see now that when I claim my leadership vision within a paradigm that matches my own identity I can be stronger and more authentic.

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Embedding Resilience in Medicine

      Half an inch from the first four thoracic vertebrae lie the central nervous system transistors (stellate ganglion) for your fight and flight nervous system. Needless to say, my upper back is constantly aching. I am metabolizing the unique stress of being a brand new doctor/medical student in hospital life. It’s a different kind of stress than the first two academic years: those were crushing content & exams, but they were ivory tower academia. This is the very real medicine that is literally birth, life and death stuff. More visceral than literal, I find myself often crying,  sometimes gagging, and occasionally elated.

The purpose of third year clerkship aka #MS3 is to get a sampling of each major specialty to help us decide on a residency. Its a generic med school formula consisting of: Pediatrics, Surgery, OB/GYN, Internal Medicine Inpatient & Outpatient, Family Medicine, Psychiatry, Community Health. Inpatient, we legally cannot write patient notes. While we can actively participate in patient care,  everything we do needs to be seconded by a licensed doc; therefore, we are mostly shadows, errand runners, and absorbent sponges.

Unfortunately, some throwbacks to fraternal physician hazing rituals are still in place even for third year medical students. For example, my Internal Medicine inpatient rotation, which is already a 6am – 6pm shift 5 days a week (with a 1 hr drive on each side) also requires 6 -24 hour shifts in the 6 weeks. I asked a friend who is a year ahead of me and attended a different hospital clerkship if her rotation was scheduled as such, and she said she had to follow hospitalist hours for that same rotation – roughly 730am – 330pm. If the point is to learn each of the specialty’s roles, it makes sense to follow the professional hours. If the goal is to teach us that Internal Medicine requires an exhausting slog of hospital life, and how to forsake all other aspects of our personal and academic life for our career, then this approach in third year makes sense. Slate Magazine said it best: Third Year Kills Humanity of Medicine.

I haven’t done the above inpatient IM rotation yet and yes, I’m actively worried about my health, my marriage, and my coping skills during that onslaught. I did one 86 hour “sneak peek” week with our Family Medicine inpatient service last Fall.  I did enjoy the steep learning curve and patient contact; however,  I often felt lost and useless as my resident dictated her many notes and ran around the hospital following up on pages and other details. I did get some good studying done and learned some basic inpatient skills but there were hours, especially after the first 8,  that I wished I had something more productive I could be doing in.

In reality, the residents are much more forgiving than the administration and often let us leave early (6am – 10/11pm) saying “there is nothing we could learn at 2am that cant be learned at 2pm.” I am eternally grateful for this ray of grace. And I do understand that night shifts and on-call hours are foundational for many physician careers and practicing them could be relevant.  But why, when 55% of Internal Medicine and Family Doctors report burnout, are we being subjected to these mind numbing hours as third years? How will medicine ever change if the hazing continues to be perpetrated generation after generation?

I accept that being a doctor requires selflessness & sacrifice. I accept that long hours are often required and I like to work – for an income, for a team, and for a good reason. I’m a second career medical student, I study and practice clinical skills because this is what I love! I accept that as a resident I will bear the brunt of hours spent watchdogging and admitting in part because we are the cheap labor force of institutionalized medicine. But, I have 1.5 years of med school left, and 3-6 years of residency/fellowship ahead. What is the purpose of having me work 86 hour weeks now,  and how is it going to benefit my relationship towards medicine?

To embed resilience in doctors, we as a profession and as an academic incubator need to provide time & space for rest, relaxation, and quietude. Only in parasympathetics can we metabolize the soul-rattling experience that comes from facing death and sickness and the burden of chronic disease in North America. Not only are we facing grief/loss/mortality, we are taking on the enormous responsibility of decision maker. A backlog of unprocessed emotion leads to substance abuse, chronic pain, sleep disorders, lack of compassion, and who knows what other organic & chemical dysregulation. We need regular daily time to cook good food, sleep with our loves, be intimate and vulnerable, Netflick and chill, get to the gym or get outside. Only in that space can we emotionally integrate this transformation.

Our clerkship Dean Dr. Taylor sent out this  reaffirming blogpost last month in which an experienced physician Dr. Youngson writes to his younger self. He says:

     “As a medical student or junior doctor, it’s easy to feel powerless especially in a hierarchical medical system that too often teaches by humiliation, punishes those who question the status quo, and grinds people down through overwork and inhuman working conditions…”

Change medical education so that we as medical students (and residents and attendings and all doctors actually) are seen as people who are more than life-saving, problem fixing, chart dictating, disease curing machines. A more gentle, humane practice of time & space for medicine while living life alongside the role of physician has to start at the beginning of the clerkship year when we integrate it’s practice with our academic foundations, or it wont be ingrained as part of the way we approach medicine.

Once I started thinking about time, resilience and integration as the cure of medical burnout, I began seeing evidence everywhere. I heard a NEJM Interview from 01/03/18 with Dr. Armstrong from Massachusettes General Hospital’s new Pathways program where residents are given time and a scientific team to investigate complex patient-based cases. The 12/26/17 issue of JAMA has an article by Jack Coulehan, MD MPH from the Center for Medical Humanities, Compassionate Care and Bioethics on Negative Capability and the Art of Medicine that speaks to “sustaining the physician through the ‘humdrum routine’ of professional life… [Using]… the power to recognize the ‘true poetry of life'” and of medicine. This is a reflective practice. He says:

In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients – and with ourselves.”

The future of medical education is not only about competencies met and clinical acumen. The true scholars of the next generations of physicians will be those who can achieve their best in patient care and scientific fulfillment, while also living a satisfying, integrated and joyful life.

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Gender Affirming Health Care: Top Ten Tips

This article was written for the American Medical Student Association journal The New Physician October 2017. The original can be found at this link: http://mydigitalpublication.com/publication/?i=445109&utm_source=webtoc&utm_medium=referral&utm_campaign=O17#{“issue_id”:445109,”page”:1}. Volume 66, Number 5.

Picture this: it’s your second day of practice. You graduated medical school, made it into a residency, and now it’s time to be a doctor …. In walks your third patient of the day – medium height, medium build, medium length black hair, charming but shy face and awkward smile and – your quick-fire practiced analysis stops there – frozen, you can’t tell if this person is a girl or a boy. You glance at your paperwork. First Name: Robin. Last Name: Also Unhelpful. The person is talking in a midrange tone, and you aren’t listening because you are frantically scanning their body to figure out what lies underneath the black tee-shirt and dark Levis. You look up at the persons face and see it start to close as they observe you floundering to see past their gender.

Transgender Medicine is a newly emerging subspecialty, but every health care professional is already seeing transgender patients. Trans people have always been a part of every culture worldwide; in the last ten years there has been a public blossoming of gender expression in social media, television, and probably your personal family or friend circle as well. Transgender people have come out as part of our modern society, and as physicians we need to be culturally and medically competent enough to provide good medicine for this community.

As of 2017, there are several epicenters of transgender medicine, research and scholarship worldwide. The Dutch are famous for their longitudinal body of evidence on transgender health, as they have been collecting research and academic scholarship on transition medicine within their socialized health care system for over 30 years. As such, they have a tried and true so-called “Dutch protocol” for male to female (MTF) and female to male (FTM) transitions that has been used as a template for most international Standards of Care.

The US has several gender specialty clinics that conduct research and offer high quality trans health care. These clinics and hospitals are also key players in this rapidly evolving area of medicine, surgery and research. The best known of these include:

  • Fenway Health Center in Boston
  • The Center for Transgender Medicine and Surgery at Mount Sinai in NYC
  • The Mazzoni Center in Philadelphia (which puts on the free Philadelphia Trans Health Conference annually)
  • The Center of Excellence for Transgender Health at UC San Francisco

For future and current physicians interested in Transgender Medicine as a specialty, the key areas for concentrated trans care are Family Medicine, Endocrinology, Psychiatry, Surgery/Urology and Pediatric Endocrinology. There is not yet a fellowship available in Transgender Adult or Pediatric Endocrinology (Coming Soon!) but the first fellowship in Transgender Surgery has been piloted this year at Mount Sinai in New York City.

Whether you want to dive into the depths of the transgender community and learn the intricacy of this rich and diverse community or not, as it was said before every physician will see trans people in their career. Take the time now to become familiar with the basics of transgender health literacy, for your professional integrity and your patients.

TOP 10 TIPS FOR BEING A TRANS FRIENDLY PHYSICIAN

DON’T GET HUNG UP ON IDENTIFYING GENDER IN THE FIRST 3 MINUTES. Gender and Sexuality Identity begin to develop at 2-3 years of age. Your patient has probably been trying to figure out their gender for a whole lot of years before they showed up in your office, so chances are their gender is more complicated than your 10 second evaluation. Once you notice you can’t confirm male or female specifically (spoiler alert: you may be wrong in your assessment) MOVE on with your objective assessment and Listen to what the person is saying.

THEY IS THE NEW SINGULAR PRONOUN: For some people, She doesn’t feel comfortable, but neither does He. Some people live in the space between male and female, and those definitive English pronouns can feel extremely uncomfortable. Being mis-gendered by pronouns is also surprisingly hurtful to trans people. “They” is a neutral pronoun that just feels more comfortable for some people. Why not use it? (Ps. Please don’t use the “it’s just not good grammar” argument because chances are your grammar isn’t perfect otherwise; and, while it may commonly be an English plural pronoun, Latin-based languages have pleural pronouns that can also be used in the formal You/singular.) Again, the use of “They” is really helpful to some people for communication purposes, so embrace it, try it on every day, and get used to it. In fact, it really comes in handy when referring to someone whose gender you can’t figure out, as in saying to your attending “I’m not sure what’s wrong, but they look really terrible, would you come take a look?”)

ACCEPT THAT SOME PEOPLE LIVE OUTSIDE THE LINES: Technically, the term is “non-binary” for people that don’t neatly fit into the sex-gender binary of male / female. This is a complex spectrum of identities that can be any shape or form and have any meaning for an individual. The non-binary space can be intentional with hormone use, or how people are born or mature. For people who have always fit within the binary, it can be hard to remember that other people LIKE THE WAY THEY ARE. It isn’t our job as physicians to try and get them to fit within a specific box. For other people, the non-binary identity may be a stepping point, a transitional space, or something they struggle with. As always it is simply our job as health care providers to create a safe place where people can talk about their health care needs, and help them get these needs met.

STATISTICS DON’T LIE: Not a lot is known about trans health care seeking behavior from an evidence based perspective, but from my community I know that many of my gender minority friends avoid health care due to bad medical experiences being misgendered, disrespected, or worse assaulted/insulted or denied care. From the research that does exist, the statistics are alarming. Dr. Angela Carter, a transgender physician from Portland, Oregon writes “One in 5 transgender people have been turned away from healthcare because of their gender, and an estimated 30% have avoided seeking care due to fear of discrimination. Reports suggest that 50% of transgender people have had to teach their physician how to care for them; 24% of trans people have been verbally harassed while seeking care; and, 2% report an actual physical assault while trying to get care.Read more of her great Trans Health 101 article here: http://ndnr.com/endocrinology/transgender-healthcare/.

PAPERWORK: What is named, exists. If you have a box for Transgender or better yet Male to Female, Female to Male, and Gender Nonbinary on your intake form or embedded in your EMR next to Male and Female, you can have that helpful self-identifying information at the first encounter. At the same time, this improves the patients visit experience, offering a named identity and acceptance from the first encounter. Make sure your staff are educated in trans cultural competency as well. Include training elements like being compassionate and respectful with patients who may have gender incongruent birth names, insurance navigation, and associated pronoun use.

EMRs – UN/NECESSARY EVILS: It will take a long time and many years of advocacy work before most hospitals EMRs are updated to contain alternate gender identities; however, having staff who are trained in ways to communicate about gender differences can soften the experience for the person who is in an acutely ill and vulnerable state needing medical care. For example, triage personnel (and med students!) could say “”So, I know this may be a difficult question right now but what is your preferred pronoun and what is your is gender designation on your health insurance?” This non-judgemental approach leaves space for the person to give an answer without an explanation and conveys compassion in a business-like open-ended manner.

DON’T JUDGE A BOOK BY ITS COVER: Many trans people “pass” for their chosen gender completely. We need to be mentally and medically prepared for providing effective and competent health care to people who physically inhabit bodies that are hormonally and anatomically complex. Doing this work AND exploring your own personal, moral, or religious complexities of feelings about trans gender and identity needs to be done BEFORE that patient walks in your door needing your professional skills as a doctor, not your human opinions.

KNOW YOUR RESOURCES: The World Professional Health Association (wpath.org) has been the guiding force and academic collective of transgender scholarship for the past 30+ years. WPATH has been at the heart of the conservation and documentation of the protocols used for transitional medicine. There is a published a Standards of Care (version 7.0) that is available online and in print. University of San Francisco also has a superior online learning center with everything you need to know to start basic primary trans care including evidence based protocols. http://transhealth.ucsf.edu/trans?page=guidelines-home. Fenway Health is the east coast online epicenter for trans health resources and reading and has great free training webinars http://fenwayhealth.org/care/medical/transgender-health/. Take an afternoon and familiarize yourself with these sites, bookmark them, and pass them on.

KNOW MORE RESOURCES: No one should have to travel beyond state lines to get competent medical care. As with most kinds of medicine, having a grasp of your local resources is essential, especially for primary care docs who just can’t do everything (contrary to popular belief.) Know who is providing competent transgender primary care and endocrinology for adults and for children in your area, who has experience with transition hormone therapy, where to refer for respectful electrolysis and other cosmetic procedures, and who is offering the basic surgeries like mastectomy in your part of the world is a great way to provide your gender minority patients with access and resources. If there isn’t anyone offering these services, consider taking a WPATH certification course and becoming that person.

DON’T BE AN ASSH**E: The best thing to do when you make a mistake is apologize. I have over 10 years of professional experience with trans health and gender non-conformity has been part of my social circle for 20+ years and I still unfortunately misgender people, use the wrong pronouns, and say awkward things. And then I apologize and learn from my mistakes. Doctor-patient relationships are built on an exchange that requires integrity and some transparency. You don’t have to be the expert in trans medicine- your patient is the expert in what their body (mind spirit) needs. Your job is to help them maintain a safe and consensual medical space where they can address health concerns and work towards their optimal self-expression. This may include transitional hormones and gender affirming surgery for some, or it may be flu shots and cholesterol testing for others. Or oncology. Or labor and delivery. Or sickle cell anemia. Who knows what the person will need, trans people are people and you have one in your office right now. What will you do?

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Evolutionary Success vs Child Free Living

As you know, I have been struggling with my biological clock: my age and stress level tick louder than ever. Weighing the cost of motherhood against my career in medicine has never been an equal balance with scales always tipped in the favor of my seemingly insatiable appetite for knowledge. And yet – I’ve been studying fertility since 2004, seeing fertility docs since 2008, and  froze my eggs in 2013. I am always scheming to figure out “when is a good enough time”. Yes, I know there “is never a good time: but as a lesbian with a choice, isnt there a “better time”? And here I am, child free, finally happily coupled, and in my third year of medical school in 2017.

I just completed 6 weeks working with newborns and doing well-baby checks to mostly women under 30 in my first pediatric rotation. I I couldn’t help thinking about the definition of evolutionary success as progeny. Many moms I worked with had 4-8 other babies. Some were on opioids, many smoked pot and tobacco or even took buspirone and SSRIs throughout their pregnancy and had sick/addicted babies. Some were very very young. But evolutionarily, each of them had already surpassed me even with my 2.5 degrees, $500k of education,  and diverse, privileged, happy life. I realized I am currently an evolutionary failure.

I am an archetype of my Generation X.  I don’t have many excuses for child-free living left, having had a bacchanalian and free-spirited 20’s and 30’s. Is it time for me to “settledown”? Who am I if I choose NOT to have a child of my own?

My primary reasoning for not spawning includes RESPONSIBILITY – towards my career/education and more importantly, to the kid. Who brings a child into the world who is guaranteed a mom who is away from home 12-18 hours a day (unavoidable in medical school -residency)? Where is the evolutionary success in that? Generationally, I do not have the same programming my parents had to marry/reproduce, and as a lesbian it didn’t happen by accident. Also, as a kid myself who had a high ACE score, I don’t want to perpetrate even a privileged neglect into another generation. So, here I am: struggling with my generational expectation to break the glass ceiling, achieve my highest ambitions, follow my dreams … and shouldering the unspoken price of doing that.

Maybe I could redefine evolutionary success. Not “survival of the species” but survival of the…planet? Conscious eco-systeming? Or maybe even the more complicated redefining of family/familial success – what if evolutionary success was a life well-lived and well-loved, and a small carbon footprint; a kinship network of peers, lovers, and lifelong friends instead? Children no longer live to serve their elder parents, and even if I had a child, I would not be promised a safe and well-cared for death. Still, at the end of the day, even though I have many cousins with beautiful babies carrying on the family line in all directions, my personal lineage of Wright-Larson will not be carried on unless I have a kid. That feels sad. That does feel like failure.

I stand with my aching feet and my scrubs and pager, knowing raising my own babies is not likely going to be the life I get to live this time around.

I have always been an outlier. I chose Naturopathic medical school in the 90s, chose the urban underbelly in the 2000s, and chose osteopathic medical school in the 20-teens.  I’m 92% reconciled that I will enjoy my child-free life and travel to Tokyo, Vatican City, Barcelona, and live in expensive, romantic urban centers. Because I consistently choose career, love and adventure over a baby and domesticity I will be able to live a certain kind of lifestyle. But that doesn’t make it easier when I come home smelling like babies from a day at work, or when I see my cousins achingly beautiful creative charming kids. There is no consolation prize for evolutionary failure. Only the small faith that I am making the right choice for the kid I would create and maybe a for this planet, and hopefully for, myself and my love.

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Balancing with Ayruvedic Medicine – from Womens Power to Heal

510fafgjdbl-_sx336_bo1204203200_I am doing an Integrative Medicine Scholars program through the AMSA and we have to do a project to explore some aspect of Integrative Health. Ayurveda is a practice of medicine I don’t know much about, so I decided to do a personal practice incorporating lifestyle, nutrition and herbal medicine principles for the month of January. My friend Cathleen Miller helped me to figure out what my Dosha is (constitutional type) and lent me this amazing book, and …. here we go! Below is an outline taken directly from this text for (my) Pitta-Vata type.

Balancing Pitta-Vata Rhythms –

  • Rise with the sun and go to bed by 10 pm – maintain steady eating and sleeping routines
  • Ease yourself out of all stressful activities and maintain only those projects that create ease – allow adequate time to complete projects
  • Take ample rest
  • East wholesome, fresh, moderately warm, moist substantial and calming foods.
  • Avoid bitter, cold, raw, hot, spicy, oily, salty, fermented or stale foods and stimulants.
  • Shield against hot, wet, humid, cold, damp, or stressful environments.
  • Embrace serenity, love, warmth, healthy rituals and calmness.

Nutrition Principles

AVOID: caffeine, refined sweets, alcohol, saturated fats, excess salt, oily and spicy foods, and commercial dairy projects, as well as highly processed junk foods, meats, additives, frozen, canned, commercially grown, bioengineered, transgenic refined salts, sugars, flours and hydrogenated oils.

CHOOSE:

VEGETABLES Broccoli Brussel sprouts cabbage Cauliflower
Artichokes Asparagus Bamboo Bitter greens Black olives
Celery Cucumber Green beans Dark greens Parsnips
Peas Potatoes Sprouts Summer squash Sweet potato
Winter squash yams Watercress Bok choy Carrots
Daikon Beets Leeks

 

FRUITS Apples Apricots Coconuts Dates
Fresh figs Oranges Pears Pomegranate Tangerines
Mango Plums Raisins Quinces Limes
pineapple Avocado Banana Grapefruit Kiwi
Lemon Peaches Tamarind Rhubarb

 

LEGUMES Aduki beans Mung beans Kidney Lima
Lentil Navy Pinto Chickpeas Tofu
Black beans

 

NUTS Coconut Roasted sunflower seeds Roasted pumpkin seeds Poppy seeds
Water chestnuts Macadamia nuts Sesame seeds Pecans Walnuts
Pine nuts Pistachios

 

DAIRY Unsalted butter Cows milk Cottage cheese Sweetened yogurt
Buttermilk Whole cows milk cheese Cream Ghee Sour cream

 

OILS Sunflower Almond Olive Coconut
Dark sesame Light sesame

 

SWEETENERS Maple syrup Dates Sucanat

 

SPICES Coriander Cumin Cardamom Cilantro
Curry leaves Dill Fresh basil Fennel Turmeric
Saffron Peppermint Spearmint Ginger Anise
Mustard seeds Sage Nutmeg Thyme Ginger
Cloves Rosemary Tarragon Oregano parsely

 

Practices

  • New moon journalling with saraswati mantra – Aim Sarasvatyai Namaha
  • Ginger compress one week before the new moon (unless bleeding)

1 gallon water

1 handful grated fresh ginger

1 lg stainless steel pot with cover

2 stainless bowls

  Bring water to a boil, and add ginger secured in a ouch with a drawstring. Squeeze the  pouch to release the ginger juice and drop into the water. Simmer 30 minutes. Let sit 5 minutes before uncovering when taken off the heat. Create a compress towel and apply to lower back for 4-5 minutes or until lukewarm. For full instructions, see text p. 264.

  • Rose Oil Pichu – for headaches, hair loss, pain in the eyes, poor vision, mental fatigue and nose bleeds. Pichu: a powerful lubricating and loving therapy that helps maintain mental calm, emotional equanimity and helps balance the doshas. Best time: waxing moon phase. C/I bleeding. Best time: morning or early evening.

¼ cup dried roses

1 c sesame oil

Bring to boil over low heat and remove from heat, Add rose flower, cover and let steep 4-6 hours. Strain and use.

PICHU instructions: need pottery bowl, 12 “ clean cotton square and cotton hand towel.

  • Wash hair a few hours before
  • Release all stressful thoughts and details from the mind
  • Assemble the supplies on the floor close by
  • Soak the cloth in oil and lie down; place the cloth ear to ear. Press down on the cloth and wipe away excess oil
  • Rest quietly for 30 minutes and rise slowly, use hand towel to wipe away excess oil and maintain a peaceful attitude for the rest of the day.
  • Shakti Mudra – should be daily but 3 times per week seems doable – enhances sense of self, reinforces femininity, self esteem and restores vital energy to the womb.

Sit facing east

Bring palms together and separate slowly

Form the Shakti mudra hand position – see p. 192 text

Breathe deeply into pelvis and breathe out slowly, tracing the exhalation from the base 0f the perineum, circulating through the uterus and belly

Maintain for 15 minutes

Take a deep breath and make a commitment to a life of non-hurting

 

  • Yoni Mudra – 3 days before the new moon and full moon to revise Shakti prana.Not when bleeding.

Sit in meditative practice with palms facing up

Create the yoni mudra hand positions – see p. 155 text

Hold the hand gesture for 5 minutes

Allow breath to flow freely throughout the body, keeping the mind centered

HERBAL MEDICINE

Herbal Teas for PMS – Vata type predominant – take for 3 days of the new moon as well as the 5 days before menses

Helpful herbs: nutmeg, valerian, triphala, ashwaganda, shatavari, cinnamon, turmeric, fennel, dill and wild yam.

CINNAMON, CLOVE AND CARDAMOM DECOCTION (VATA) for PMS

2 c water

2 c organic milk

1 tbsp cloves

1 tsp cinnamon

1 tsp cardamom

½ tsp ginger

1 pinch saffron

 

LAVENDER FENNEL GINGER TEA DECOCTION (PITTA) for PMS

I c water

1 c organic cows milk

1 tso roasted fennel seeds

1 tbsp lavender petals

1 tbsp hops

½ tsp ginger powder

1 pinch saffron

bring water and milk to a boil. Toast the fennel seeds, then add all herbs and spices and simmer on medium for 15 minutes. Remove from heat, add saffron and stand 3-5 min before drinking.

 

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Heartbreak and Heart Failure

screen-shot-2016-11-06-at-2-48-11-pmSometimes life, work and study all seem  to dovetail and everything makes sense for just a few glorious moments. Cardiology was like that for me, in between the Frank Starling curves.

Last year we had a case study of a woman with congestive heart failure (CHF.)  Her husband had renal failure and needed dialysis, and she worked at a job she didnt love. She slowly developed worsening heart failure over the course of the case, with  shortness of breath, edema, high blood pressure, and poor circulation, eventually dying from it. I was impacted by the apathy she displayed in her efforts to recover – unwilling to eat more grains and greens, decrease salt,  get outside, exercise regularly, investigate psychotherapy, or better her personal life in any way. Instead, she just declined in health, adding a new prescription per year to mange her symptoms until she  – drowned. In her grief. Of heart disease.

This. Story. Happens. Every Day.

And not only in the US, or Canada or Europe. World-Wide.

The multitudes of meta-analysis risk factor evaluations like the Framingham, Whitehall and Rekjavic studeis have concretely illustrated important evidence about the facts of heart disease: atherosclerotic fatty streaks in arteries, high blood sugar, and  inflammation are the undeniable Holy Trinity of heart disease. What is not being avidly reported is the rate of divorce, or mood disorders in these same subjects. The sexual dissatisfaction. The childhood trauma. Socioeconomics and race are sometimes studied, and African Americans and Latinos have higher rates of heart disease. Nobody is surprised. Russia has the highest rate of ischemic heart disease in the world, along with some African nations and Indonesia. These countries also have horrible human rights records, with well documented transphobia, homophobia and police brutality.

screen-shot-2016-11-09-at-9-01-58-pmIf we are going to turn around heart disease, do we not need to acknowledge the humanity of the heart? The same  epidemiological study quoted deep within the content:

“Additional reports from this study have shown inverse associations between fair and respectful treatment at work and CHD [Congestive Heart Disease],and job control with future CHD risk.

Similarly, hypertension, which is the harbinger of heart disease through its effect on cardiac structure and function,  is hugely mediated by the stress response.

screen-shot-2016-11-09-at-9-11-31-pmI was talking to Dr. Stein, an internist specializing in HIV and also our OMS II course director, about this theory that heart failure is so rampant because we have no real medicine for soul-problems like dissatisfaction, grief, sorrow, envy, loneliness and such. He said the links between depression, elevated cortisol, hypertension and CHF are well documented and clearly evidenced.

He reiterated that it is known that People of Color have higher blood pressures because their lives are more stressful due to systemic and personally experienced racism aka “stress.” It is also well evidenced that African Americans with CHF respond better to different medications than other races – Hydralazine, a vasodilator that decreases resistance,  improves survival with  isosorbide dinitrate rather than the ACE inhibitors and Beta Blockers commonly used. Ha, decreasing [systemic institutionalized] resistance as a keystone in improving survival? I need to know more about the MOA of these drugs to understand why decreasing the catecholamines isnt enough for this population; maybe its because of the deleterious and constant push and pull the sympathetic blockers have on the heart receptors of someone living in the actual adrenergic rut of an unsafe society.

3f0a8388-0078-4c4f-88ef-36078365eae5Our cardiologist professor Dr. Glass stated that the average person with hypertension is on 3.4 medications to manage it. These are usually layers of diuretics to decrease the blood volume and drain edema (decreasing preload), and beta blockers to decrease cardiac work and improve cardiac output,  and/or other meds like diphydropyridines and nitrates. But guess what – it just came out recently that hypertensive medications may be CAUSING depression/ mood disorders while working to decrease blood pressure.  What a double whammy.  This was a big study from a database of a single hospital containing 525,046 patients over 5 years. This 2016 article stated:

Major depressive and bipolar disorders predispose to atherosclerosis, and there is accruing data from animal model, epidemiological, and genomic studies that commonly used antihypertensive drugs may have a role in the pathogenesis or course of mood disorders.”

  • Patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers had the lowest risk for mood disorder admissions
  • those on β-blockers (hazard ratio=2.11; [95% confidence interval, 1.12–3.98]; P=0.02) and calcium antagonists (2.28 [95% confidence interval, 1.13–4.58]; P=0.02) showed higher risk
  • those on no antihypertensives (1.63 [95% confidence interval, 0.94–2.82]; P=0.08) and thiazide diuretics (1.56 [95% confidence interval, 0.65–3.73]; P=0.32) showed no significant difference.

To summarize the findings,  calcium antagonists and β-blockers may be associated with increased risk, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be associated with a decreased risk of mood disorders. (Hypertension. 2016;68:1132-1138. DOI: 10.1161/HYPERTENSIONA HA.116.08188.)

It appears, the drugs that most directly affect the heart muscle itself are thus linked to more mood disorders, while those that work indirectly and decrease the work for the heart seem to have less impact on mood.

This is such a broad topic and there are so many layers to heart failure – blood pressure, kidney regulation of blood pressure, nutritional effects, blood lipids, blood volume, inflammatory mediators, free radicals and antioxidants, sleep quality and more – but I think that too often we lose sight of some of the most basic truths of happiness and heart health. And we also forget the deeply sensitive creatures that most of us are and fool ourselves that pharmacy could possibly be enough to cure a heart that is systemically broken, or the effects of a chronically hypervigilant nervous system.

imagesWIDJJQD2I am going to need to become proficient at cardiology as an Internal Medicine doc. But without a degree in psychiatry, or soul medicine, or archangel intervention, how can I possibly hope to help people recover their failing hearts when the intersections cut so deep? I am scared of all of those people that have no willingness, or ability, to look deep within and make the simple and profound choices towards life. This is the part of being a physician I most fear. The medical failures; the broken hearts.

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The Pitfall of Alcohol

I’ve been avoiding writing this post for at least a week, probably two. Mostly because it has personal meaning to me as alcoholism runs in my family on both sides – My mothers father was one of the “Mad Men” of the 50’s, worked in advertising and died of liver failure due to alcoholism. I guess he got pretty ugly in the end. My paternal grandparents didnt drink at all (which leads me to wonder if their parents were alcoholic) but all of their children have a penchant for the sauce.

Before I was a medical student, I thought the damaging effects of alcohol could be traced directly by measuring liver enzymes – and as long as those harbingers of hepatic cell death stayed within a reasonable limit, one was “getting away” with whatever one was doing. Enter: neurology. Boy was I wrong. Oh and Ps. Dead liver cells cant release ALT or AST, so good liver enzymes in the face of chronic alcoholism is actually a pretty bad sign.

The blood brain barrier is an effective barrier to most things except: nonpolar and lipid soluble molecules. Enter: CO2, O2, and ETOH (alcohol.) This means that as soon as alcohol is in your blood, it is seeping into your brain. And brain cells/ neurons are permanent cells – they don’t have the ability to divide, so they don’t replicate. You get what you started with – some axons can be regenerated, but once the cell body dies, your numbers start to decrease.

gait-ataxiaThe cerebellum is one of the parts of the brain most affected by alcohol cell death; this is why people become unsteady and clumsy anterior-vermiswhen drunk – inhibition of cerebellar function! There are multiple and complex inputs to this lower brain region from almost every aspect of the nervous system, so it can compensate for loss of neurons (when sober) for a long time. Up to 80% of cell death can happen before symptoms become noticeable! Unfortunately, once this is happening in the sober state, the cells are dead and there is no ability to recover balance or coordination.

I didn’t know that memory loss is also a component of chronic alcoholism. There are two halves to the cognitive decline that will happen eventually called Wernicke-Korsakoff syndrome, and these are from alcohol related destruction to two more areas of the brain.

confusionThe first set of symptoms is reversible, and is related to a deficiency of vitamin B1 aka thiamine. The mammillary bodies are wee nubs on the underside of the brain that are part of the social and emotional brain. They take information from the hypothalamus and hippocampus, and run it to the anterior nucleus of the thalamus. nrhpth08

 

 

 

 

This is a critical loop in emotional and social behavior integration at a cognitive level. I guess this is partially where the numbing effect of alcohol on the emotions could occur? With a deficiency of B1, the mammillary bodies hemorrhage and cause Wernickes encephalopathy, characterized by confusion and your eyes not tracking properly, as well as the unsteadiness from the damaged cerebellum. This is why in hospital treatments, alcoholics are first given thiamine/ B1 to see if it can reverse the symptoms. From a prevention standpoint, taking a good quality capsule (not tablet) daily multivitamin seems like a good idea for anyone drinking on a regular basis.

This condition can progress to irreversible memory loss for the past, with an inability to make new memories, plus psychotic symptoms. This is called Korsakoff psychosis. As people lose their ability to remember, they start making things up to fill in the blanks called confabulation. This can be really depressing for friends and family members as it becomes clearly evident that the damage is permanent.

and THEN, there is the metabolic damage that is occurring below the neck. (This next section is biochemical mumbo jumbo, but since this is my review exercise, I’m going to include it for my medical interest:)

screen-shot-2016-09-26-at-12-32-00-pmEthanol/ your drinks/ are 80% broken down by cells (cytosol) of the liver. 15% of alcohol is broken down by microsomes in the brain and liver, and this pathway is upregulated in chronic alcoholism. The remaining 5% are converted to fatty acids and phospholipids that are thought to play a role in tissue damage. Both primary pathways break down ethanol to acetaldehyde, which is metabolized  down to acetate…..Acetate, where have you heard that before? yes, NAIL POLISH REMOVER, flooding your liver and brain.

The major metabolic consequence is from the elevation of NADH that occurs in the cell and in the mitochondria in steps one and two with excessive and continual amounts of alcohol intake, because this NADH will inhibit the TCA cycle from running. No TCA = no glucose metabolism = no fuel for the cells. The brain will still need fuel, so the liver cleverly shifts the glucose from the alcohol (which can no longer be metabolized) to ketone production + free fatty acid synthesis (aka fat storage.) This explains, in painful detail, why alcohol makes you gain weight and affects blood sugar levels.

screen-shot-2016-09-26-at-12-36-56-pmFinally, I wanted to add this last slide for an important prevention note. This is the process of the 15% microsomal pathway that is upregulated with chronic high alcohol intake. Note the second step produces ROS – this is reactive oxygen species aka free radicals which are known to cause cell damage and cell death. Higher levels of ROS are bad in general and associated with greater inflammation and cellular damage across the board. This points to another potential place for prevention – with use of high dose antioxidants like CoQ10 200-300mg, resveratrol (500mg), alpha lipoic acid (200mg) and vitamins C (1000mg) and mixed tocopherol E (400IU).

screen-shot-2016-10-08-at-4-29-14-pmWhen alcohol intake gets high enough to start causing brain damage, obviously the primary treatment goal is to reduce the intake. Our first case study had a 37 yo male drinking 12-16 beers PER DAY. How many drinks, realistically speaking, are you having per day? How many does that add up to per week? Does that seem reasonable to you?

I don’t know enough about addiction to know how to address real chronic alcoholism. I imagine it is incredibly hard to quit, and even to reduce daily intake without a pure and strong internal directive to do so – no one can be told to do it,  the drive Must Come from Within. Treating underlying depression, anxiety, or life stressors are surely part of the picture, but what if you just drink to have fun? Sometimes, the party needs to stop, or gets out of control. I guess we all need to grow up sometime and learn to tolerate whatever it is we harbor inside our minds (before they get destroyed.)

Alcohol is a depressant, so withdrawal symptoms are the opposite – agitation, irritation, worse case scenario people can have seizures. Benzodiazapines, some sleep drugs and alcohol all work on the GABA-A receptor in the brain. Chronic alcohol use downregulates the expression the neurotransmitter GABA, one of the “off switches.” Once high levels of alcohol start to lower, it takes time for the brain to start making enough GABA again, resulting in foul moods, irritability and general unpleasantness.

There are medications like naltrexone and acamprosate that can help reduce the cravings for alcohol, and medications to treat the side effects of withdrawal, mostly aimed at these same parts of the brain. These are definitely worth exploring with a psychiatrist or addiction specialist to figure out what approach will work best for you. Complete abstinence does not need to be the goal. GABA as a supplement is not absorbed well, but is readily available and might be worth a try for someone who is just cutting down on daily intake, and has addictive enough a personality that switching to benzos instead of alcohol could exacerbate rather than relieve the problems. However, it is unlikely GABA alone would be enough to support sobriety. Making the very personal and often terrifying choice to look at one’s habits and face trauma/addiction is the place to begin. A comprehensive medical assessment with an empathetic and respectful health professional who has experience in addiction is next step. (if you are in Maine, I highly recommend Dr. Merideth Norris!)

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(Least)* Complicated

Walking the tightrope between being a current MSII medical student and a Naturopathic Doctor is a delicate balance sometimes. I never know whether my career as an expert in alternative medicine is going to be a blackball or a gold star because of the very mixed opinions people have about my former profession in the medical world. My plan, heading into the first day of medical school was not to tell anyone my (second) degree when I started (my third degree) at UNECOM, but it was announced in orientation so my cover was blown.

Being a ND in general is pretty complicated – working outside of insurance in most states is a financial challenge for patients as well as doctors, and public knowledge about the profession is highest on the west coast of the US and Canada, and in more affluent areas of the NorthEast. Many people get excited when I say I am a doctor, then look back blankly when I tell them what kind of medicine I practice(d). People who know the field have reactions that are pretty love: hate. Lots of lovers, quite a few haters, and an ever-growing population of quiet converts who realize that, as one anonymous Twitter medical student said in my recent Twitter Flaming on the topic: people who are interested in alternative medicine are usually trying to take care of their health and make themselves feel better.

IMG_6031I have recently been made aware of a woman who attended a west coast Naturopathic Medicine College who has turned against the profession “with an inside view” and who is engaging in aggressive muckraking. She is getting recognition and validation as an “insider” to Naturopathic Medicine as she did complete our 4-year postgraduate degree before she quit and moved to Germany. She has started a petition to defame the profession worldwide. The unfortunate thing is she lives outside the US and is not accountable for US or CDN slander laws. What she is doing is poignantly effective because she has inflamed the haters. One doctor in particular is a physician and educator with the influential Doctors in Training Boards Exam Review Series. He has a large Twitter following and has enthusiastically joined in the slander of the Naturopathic Profession. I worry about how his “expert” personal opinion will effect future generations of physicians who have not considered their professional opinions of Naturopathic Medicine due to lack of exposure.

Big media like Forbes has jumped on the “tin foil hat” bandwagon by supporting her claims that botanical medicine, nutrition, physical medicine, homeopathy, mind/body practices and stress management are invalid sciences without evidence. The American and Canadian federal Naturopathic associations have both started a counter-petition against these muckracking efforts.

All of this is personally upsetting for me. It stirs a complicated turmoil of emotions, injustice, pride, and frustration that mixes my own choices with a very clear working knowledge of the weight that “the big lie” technique can carry in the world of propaganda. All of this comes at a time when “Functional Medicine” and “Integrative Medicine” are the new darlings of allopathic medicine alongside epigenetics and the microbiome.

Newsflash: Functional Medicine and Integrative Medicine ARE evidence based Naturopathic Medicines, researched by and for NDs originally.

Naturopathic Doctors are systematically being defamed and slandered while our actual practice techniques are being picked up and renamed and celebrated for their effectiveness.

I feel helpless in the face of this complicated adversity. I made my personal choice to add an Osteopathic Degree to my knowledge base because there was more to medicine I wanted to know – pharmacology, emergency medicine, psychiatry, and other facets of transgender medicine I need additional training on. I know the great value of Naturopathic Medicine and so do a great number of North American consumers. I suppose I need to trust that the greater good will prevail in the end…. but that may not help me or my career path when I am placed in a hospital as an MSIII or resident with an attending like the Internist above who hates everything alternative and Naturopathic medicine stands for.

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Gluten Free Living

How to Eat Gluten Free

 Gluten Free is the new Vegetarian – almost every grocery store now has gluten free breads and products in their freezer sections, and crackers and baking mixes in the  aisles. Websites abound on not only celiac disease resources (a disease caused by severe gluten allergy) but also on gluten sensitivity, a mlder form of systemic immune response to the gluten molecules. It is easy to find gluten free recipes, resources, and restaurants in almost any geographical area.

So, what is all the hype? The bottom line is that gluten sensitivity begins with the immune system of the digestive tract becoming hypersensitive to gluten proteins like gliadin. The body creates antibodies to the sequence of amino acids, which enter the bloodstream and travel throughout the body. Whenever these antibodies see that same sequence (which is repeated as a small part of many tissues of the body exposed to blood i.e. thyroid, joints, brain, lungs, skin) they attack that tissue as if it was gluten. This creates “auto” or “self” antibodies, which are then produced in greater and greater numbers causing symptoms in a diverse set of body systems.

Therefore, gluten has been linked to autoimmune diseases such as lupus, rheumatoid arthritis, Hashimotos thyroid disease and multiple sclerosis. These are end stage conditions that develop years after smaller warning signals such as headaches, digestive disturbance, asthma, allergies, psoriasis, alopecia, insomnia and various “undiagnosible” ailments. Eliminating the offending foods or doing tests to assess your body’s immune response is the only way to assess if food is an underlying factor in your ill health.

Gluten is a protein that is found in the following Grains:

  • Wheat
  • Rye
  • Barley
  • Kamut
  • Spelt
  • Oats is technically gluten free but very often contaminated in manufacturing.

Therefore, people with a gluten sensitivity or allergy cannot eat any of these grains, or products that contain them such as soy sauce, gravy, doritos or other gluten based products. Oats are technically not a gluten containing grain, but should be avoided unless it states “gluten free” on the package.

Non Gluten Grains which are safe for gluten allergies & sensitivities include:

  • amaranth: highly nutritious, tiny seeds available whole or as a
  • rice: including brown and white rice, Arborio, basmati and rice flour
  • corn: including cornmeal, cornstarch and corn flour
  • millet: small seeds, eaten whole or combined with other gluten-free flours
  • quinoa: small seeds that can be eaten whole, as a hot cereal or ground into flour
  • buckwheat: used whole, cracked or ground into flour
  • oats: gluten free oats and oat bran
  • tapioca: made from cassava root, often combine with gluten-free flours
  • teff: very small black grain, contains symbiotic yeast
  • arrowroot: a starch used as a thickener, superior to cornstarch, blends well with gluten-free flours

Potatoes, sweet potatoes, squash, and other starchy vegetables can also be enjoyed by those who are gluten free.

For more information on gluten allergy, see http://www.thedr.com./store.html and order Unlocking The Mysteries of Wheat and Gluten Intolerance for yourself. Dr. Tom DC offers eloquent and thorough evidence based information on why it is worth at least trying gluten free living for one month and then reassess.

Many people have a wheat sensitivity or allergy, but can tolerate other gluten grains like spelt and kamut. Some people with a wheat, but not gluten sensitivity will later develop a gluten sensitivity. Corn, potato, dairy and/or soy sensitivities are also common in  people with gluten sensitivities. For this reason, it is best to start food eliminations by eliminating all of the above products, and slowly reintroducing each gluten grain as well as corn, potatoes, and soy separately to judge your individual reactions.

AVOID FOR GLUTEN -FREE SHOPPING:

  • look for labels that say – wheat (or whole wheat) flour, wheat germ, bran, farina, graham flour, semolina, gluten, modified food starch, wheat starch, vegetable starch, vegetable gum
  • Pastas – spaghetti, vermicelli, macaroni….. buy rice pasta, corn pasta, or some of the newer legume (bean) based pastas. Must say “gluten free”
  • Soups – commercially canned – read labels for “flour” or wheat
  • Desserts – most contain wheat – so read labels carefully
  • Cereals and breads – as with desserts – read labels carefully
  • It’s probably best to go to health food store in order to find alternatives. Most breads, bagels, wraps, pizza doughs, etc are kept in the freezer sections
  • For persons allergic to wheat, but not to gluten, you can use flour substitutes such as spelt or kamut (these are the most similar to wheat); rye, oats and barley can also be eaten.

TIPS FOR A GLUTEN-FREE DIET:

  • focus on protein, vegetables, fruits, and healthy fats like avocado 
  • Lots of delicious gluten free options abound: Tray various  pasta, breads, crackers, etc until you find what your taste buds prefer.
  • Avoid any food that contains wheat, barley, rye, oats – as well as spelt and kamut. Also, remember that gluten can be found in most processed foods, including soups, sauces, gravies, and of course in breads, cereals, and desserts.
  • 40% of people allergic to gluten are also allergic to soy and/or corn – which are often found in “gluten-free” breads, etc.
  • READ LABELS on everything the first few months to find hidden sources of gluten.

Eating Out and Travelling:

Most cream based soups and chowders are made with a gluten base. Boone’s in Portland has a gluten free chowder, bisque, crab cakes etc if you are craving those.

It is pretty easy being gluten free in restaurants once you get the hang of it. Focus on protein and vegetables, fancy salads and avoid gravies, pasta, gnocchi and sandwiches. If you are craving a burger, ordering it without the bun is pretty standard in today’s low carb world. Steak and arugula salad is always a good choice.

Sadly, fried treats are out the window like calamari, fried clams, fish and chips… once it gets battered it is almost always a wheat base. French fries are also often battered. Best to ask ahead of time instead of getting a delicious plate of inedible fries. Frontier restaurant in Brunswick has delicious GF fish and chips, and rice flour calamari.  Not cheap but delicious!

Fish options and mussels or raw oysters rarely have gluten unless they are fried or pan fried. Eating fish at home with rice and salad is a great nutritious option too.

Some places have gluten free sandwich bread but most places don’t. In a pinch on the road, subway will make a “chopped salad” which is basically a sub in lettuce/salad. Planning your food and having fruit, yogurts, nuts & seeds or trail mix, protein bars, and even leftovers or sandwiches on GF bread you make yourself before you leave become important while travelling.

What else? Gluten free breads and crackers abound.  I personally like Millet breads the best – available in Whole Foods GF freezer section. Rice breads tend to be very dense and gummy, but are easy to find. Mary’s Gone Crackers are a great GF crackers, followed by Nut Thins and Glutino brand. Glutino also makes a great pretzel. Rice cakes can have a bad reputation but are a quick tasty snack and great vehicle for dips, cheese, avocado and almond butter.

Sweets: Lots of gluten free cookies and treats are available! Any ice cream or candy without “cookie dough” or brownies or cones is usually GF. Many coffee places have at least one GF option. Flourless chocolate torte, chocolate mousse, crème brule or pannacotta are restaurant dessert options that are usually safe.

 

Namaste company also makes a “Perfect Flour” gluten free mix of flours that you can buy and use with any recipe. Makes cookies really easy!! They also have a great pancake mix if you love pancakes.

Tips for substituting wheat flour:

  • do not be concerned if batter appear thinner than wheat batters, this is common
  • add 1/2 tsp baking powder per cup of substitute flour; add just before cooking because it loses its potency when mixed with liquid and allowed to sit
  • refrigerating dough 1/2 hour helps improve texture
  • do not bake anything thicker than 4 inches
  • when baking, lower the temperature a little
  • baking time is usually longer, especially if egg or milk is eliminated from the recipe
  • experiment with your options – buy small quantities from a bulk food store and make half recipes first

For thickening, the following quantities equal 1tbsp of wheat flour:

*Arrowroot 1 tbsp = 2 tbsp wheat flour

*Corn starch 1 tbsp

*Potato flour/starch 1/2 tbsp

*Rice flour 1/2 tbsp

*Tapioca flour 1/2 tbsp – my favorite

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Vanquishing Fat Improves Weight Loss

12428062215_8a3fa42d45_zI dreampt I was lying on a comfortable table in a private office, with a machine sending warm Infra-Red rays into my abdomen, melting away my belly fat. I was dozing, and imagining the fat cells bursting and my body’s lymphatic system scooping them up and leaving me with a trimmer waistline as I  thought about my life for 45 minutes…. Oh Wait! That wasn’t a Dream! That is the Vanquish machine!

It must be the 21st century because medicine has finally found a way to literally melt off fat in targeted areas like the belly, hips and thighs. This revolutionary selective radiofrequency technology is non-invasive, safe and effective. Heat penetrates deeply into the body targeting adipose tissue (fat cells) while protecting other neighboring organs and skin layers with cooling air flow.

The Vanquish experience is relaxing, pain free and requires no medication or recovery time. It requires lying still for about 45 minutes. Best results are obtained when repeated twice per week for at least 3 weeks (six sessions). Clinical results are visible within 3-4 weeks after your last session – do not expect immediate results! Physiologically, your fat cells are melted and slowly die, spilling their contents into local tissue to be cleaned up by the lymphatic, immune and circulatory systems. This process takes a few weeks, which is why results are not immediate.

A little science on fat cell physiology. It is now recognized that a fat cell is not just a glob of fat. Adipose tissue is a metabolically active, highly functioning part of the endocrine (hormone) system.

When your energy in (food & alcohol) is greater than your energy out (activity, intellectual work and exercise) insulin directs the body to store fat. The capacity to store fat is seemingly endless,  as individual cells can grow quite large while chemically signalling neighboring undifferentiated cells to turn into new fat cells. Energy deficit (energy out greater than energy in) stimulates the adipose tissue to release free fatty acids and become smaller fat cells, or the cells can die through apoptosis.

Centrally located adipose tissue is used as a storage area for many fat soluble hormones and chemicals like estrogen, pesticides and THC. When fat cells spill their contents, these are also spilled. Adipose tissue also independently synthesizes chemicals like adipsin that activate the inflammatory cascade. (This is why heavier people can have more inflammatory disorders than thin people.) As the Vanquish machine melts away the fat cells, stimulating apoptosis (cell death) your body will have to clean up these excess chemicals and inflammatory mediators as well as the free fatty acids released. Fortunately, a healthy body is designed to effectively remove cellular debris like this through the lymphatic and circulatory systems.

Drinking extra water is essential during this process. We also recommend using herbal teas like the Traditional Medicinal Daily Detox Tea, nettle tea and organic green tea for free radical/antioxidant protection. Taking a good quality multivitamin provides minerals and B vitamins to support liver detoxification while daily exercise will also stimulate fat burning metabolism and support free fat elimination. Nutritionally, a meal plan focused on weight reduction principles will enhance the slimming effects of Vanquish. I suggest small amounts of whole fiber rich grains a few times a week, daily leafy greens and raw vegetables, low sugar fruits like apples and blueberries, lowered carbohydrate intake, no processed foods, and grass-fed meats, vegetarian proteins and fish.

Some individuals with compromised health or congested lympathic or liver systems may benefit from additional Integrative Medicine alongside Vanquish treatment plans to optimize results. Integrative Medicine combines the best of botanical medicine, clinical nutrition and evidence-based nutraceuticals with modern diagnostic, laboratory and pharmaceutical expertise. This style of medicine is patient-centered; no two patients will get exactly the same protocol with our highly individualized care. Targeted therapies could include reducing systemic inflammation, improving detoxification pathways, clearing lymphatic channels, or tailoring nutrition to promote fat elimination.

Dr. Wright will be offered a group metabolic detoxification program at Cosmetic Enhancement Center in January 2015 and again in March 2015. This 7 day detoxification program is the perfect complement to a Vanquish Fat treatment plan. Ask Dr. Wright or Dr. Atkins for more information about the Vanquish Fat treatment plan, Integrative Medicine, or our upcoming Metabolic Detoxification program.

References:

Integrative physiology of human adipose tissue. K N Frayn, F Karpe, B A Fielding I A Macdonald and S W CoppackInternational Journal of Obesity (2003) 27, 875–888.

Adipsin and an endogenous pathway of complement from adipose cells. Choy LN1, Rosen BS, Spiegelman BM.J Biol Chem. 1992 Jun 25;267(18):12736-41. http://www.jbc.org/content/267/18/12736.long  Accessed 24/10/2014

Adipose cell apoptosis: death in the energy depot. A Sorisky,  R Magun and AM Gagnon. Department of Medicine and Biochemistry, Microbiology and International Journal of Obesity (2000) 24, Suppl 4, S3±S7 http://www.nature.com/ijo/journal/v24/n4s/pdf/0801491a.pdf  Accessed 10/22/2014

 

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