Holiday Hiatus

Thanks for stopping by! After a hectic few weeks of moving out of Ann Arbor, celebrating Thanksgiving with family in sunny Southern California and settling into my new apartment, I am in the midst of another great internship rotation.

I am so fortunate to have been able to set up a "distance" rotation so that I can work in Seattle in the weeks between Thanksgiving and Christmas. After that I'll return to Ann Arbor to finish up my internship... I hear January tends to be cold in Michigan.

Until then I'm working with Rainier Valley Eats!, a project of Community Kitchens NW and Seattle Tilth. I was able to secure a position with a very generous local RD who specializes in community nutrition. When I'm not busy with my rotation, I am unpacking and reorganizing, cozying up with my fiance and a hot cup of tea, cooking, catching up with friends and participating in community events. Occasionally I make some wedding plans too.

It's a challenge to keep my hand on the nutrition pulse, but since I compulsively consume any and all articles I come across I will try to continue to reflect upon this important and dynamic field. While I'm gone, check out some of my sidebar links to satisfy your appetite for critical thinking.

Happy Holidays and Happy New Year!

Cooking by the Book

Just one cookbook. That's all I own. Until recently I had none, but as a close family member works at the Good Housekeeping Research Institute and is privy to such things as free cookbooks my first one, a vegan dessert cookbook, arrived in the mail last year. The design is sleek, the pictures are lovely but I cannot vouch for the recipes. I have yet to try one. I'm not used to cookbooks. Growing up the only recipes I used were on the sides of boxes. My mother owned a few cookbooks which came out on special occasions and had the expected food stains and crumbs on the frequently referenced pages but I never used them, had little attachment to them and never bothered to get any of my own. By the time I was interested in recipes there were plenty available (free!) online and cookbooks were beginning to seem unnecessary. And all that was before the iPad, the take it anywhere and everywhere, use it for everything better than a Kindle iPad. This week The New York Times asked the very question I've secretly wondered for years: are cookbooks obsolete?   While this extends far beyond cookbooks - the future of print books has certainly been in question for years - there has always been a certain weight given to cookbooks, precisely because they often bear the stains and the crumbs, the remembrance of meals past, with notes and scribbles added in the margins for slight tweaks, adjustments and personal preferences. I've kept quiet my disinterest in cookbooks because I do have an appreciation for what it means to save cookbooks, to pass them on from one generation to the next and to do what other foodies freely admit to doing - reading them in bed.  

Earlier this fall I spent time at the Jan Bluestein Longone Culinary Archive during which time I began to fully recognize the historic value of collecting cookbooks, how much they can tell us about popular notions on food and health and diet at a given time.  Just a quick glance at the covers of some cookbooks from the archive, which date from 1868-1950, gives a sense of the social and economic context in which they were published. 

1868

Reprinted with permission of the William L. Clements Library, University of Michigan

1909

Reprinted with permission of the William L. Clements Library, University of Michigan


1910

Reprinted with permission of the William L. Clements Library, University of Michigan

Reprinted with permission of the William L. Clements Library, University of Michigan

1950

Reprinted with permission of the William L. Clements Library, University of Michigan

I happened to read the NYTimes piece about iPads replacing cookbooks everywhere from home kitchens to culinary schools just as I finished reading Ruth Reichl's memoir Tender at the Bone, the first  book I've read for pleasure in recent memory. And a pleasure it was! The former editor-in-chief of Gourmet magazine can string together sentences with the same seeming ease with which she whips up gourmet meals and punctuates each vignette with a related recipe. I came across a comment from a woman who took the time to cook each recipe after she reading the corresponding chapter and found it added another layer of sensory stimulation to the experience. So is it a memoir? A cookbook? Reichl's food writing certainly blurs the lines between the two, and a good cookbook does the same. It not only offers recipes but insights into the writer's approach to the kitchen, views on food and taste and life. Many food blogs now follow suit - 101 Cookbooks is certainly one that comes to mind as does local Seattle favorite, Orangette.  Notably, these blogs were then published and went on to be award-winning books and bestsellers, underscoring the print book as the superior form, the measure of success. And despite the increase in iPad app users, the rise of food writing, interest in cooking and kitchen culture is not slowing. Or perhaps someone failed to mention the proposed moratorium on cookbooks to Seattle small business owner Lara Hamilton who left Microsoft to open Book Larder, a community cookbook store and culinary-events space which opened just last month. 

For those who are comfortable bringing iPads into the kitchen, subjecting them to the whims of flying flour, sticky fingers and dripping sauces, there is certainly great appeal to the consolidated convenience of culinary apps. But for those interested in more than just the recipes, the list of ingredients, measurements and cooking directions, looking for greater literary pleasure and kitchen wisdom, I have yet to find an app that offers the same satisfaction as a well-written, well-used, well-stained cookbook. 

Mommies and Me

I'm spending this last rotation before Thanksgiving at WIC, a federally mandated supplemental food program for women, infants and children who meet certain income guidelines determined by the number of household members living at 185% of the federal poverty guidelines. Housed in the county's public health department, there are certain perks to the job. Election day is one. Veteran's Day is another. Which is not to say that the best things about my job are the two days off this week, but after five months I'm feeling ready for vacation. I'd assume that many of the new moms I'm working with would say the same.

Working at WIC has forced me to face the obvious: I'm a women of childbearing age - perhaps closer at this point to the end of my childbearing years than to the beginning - and I know nothing about motherhood. Sure, I studied the nutritional needs of expecting and lactating moms and have memorized the stages of feeding for children but some parts of it are foreign simply because I have not experienced it myself. I keep having to check when it is that most kids start to roll over or crawl or speak or walk so I can reassure women that their children are early geniuses, very advanced, right on schedule or taking their time progressing from one stage of development to the next. As part of WIC's big push for exclusive breastfeeding (BF) I congratulate nursing moms. I also encourage moms to make sure their kids get more activity and less television time, though I understand little of the demands on their time and energy that inevitably lead them to fail in this regard. I see the looks of fear, concern and guilt on their faces when they learn that their child has jumped percentiles and is showing early signs of childhood obesity when they promise that their child eats well, no juice, no junk food, no television, has a healthy appetite and healthy level of activity. I sympathize with them, comfort them and mostly (at least during my first week) I just smile at them, wondering if they'll see right through my overeducated childless facade.  

Holding a friend's baby in Kerry Park

There's an unspoken divide between women who have children and women who do not. Greater, it seems to me, than the gulf between women who are single and those in relationships. I expect this is because having a child entails a combined physical, emotional and spiritual transformation that only those who have gone through it can understand. And while I expect that one day I will cross the threshold and enter this exclusive club, right now I can only guess what it really means. I face this reality every day working at WIC. 

Many of my friends are now parents and they too ask me questions about feeding their kids. While I've certainly read a lot about it I can only rely on my hypothetical bag of tricks, the ways I might sneak more vegetables into their meals, offer fruit as snacks, minimize their exposure to television commercials and give them flavored seltzer instead of soda. I might focus on fostering family meal time, teaching cooking skills and building a healthy relationship with food by listening to hunger cues rather than external stimuli. I might do all of that or I might be really really tired, stressed out and hanging on by my last nerve, in dire need of a vacation. I hope to one day find out. Right now, mom or not, I'm just grateful for the day off.

Of Kitsch and Kitchens

When I'm not busy with my internship I am planning a wedding. Until recently I'd put off certain low priority items. Like a gift registry.  I wondered what it was about getting married that suddenly necessitated additional appliances and dishes. Both of us have been living on our own for years and have acquired and accrued plenty of the basics in that time. We've cooked meals and entertained guests and lived lives like normal people and having lived without so many items until now, we felt no pressing need to get a lot more. Still, friends and family made the convincing argument that a registry at least provides a guide for guests who want to give a gift. This way you get gifts that you really need, or at the very lease might actually use. So I sucked it up, tried to maintain a healthy perspective and I registered for some essentials.

I was thinking about this today when I saw the kitchen exhibition at the Henry Ford. On display were four kitchens, dating from the 1700s to the 1930s. The first thing I noticed was how little I understood about how they might actually be used to prepare a meal. The second thing I noticed was how modest and simple they were. 

Kitchen from 1700s

Kitchen from 1830s

Middle class kitchen from 1890s

Middle class kitchen from 1930s

Finally, having spent some time working at a museum years ago, I couldn't help but wonder about the intention of the curator. I imagined the ways in which an educator might present these kitchens - asking visitors to compare them, to look at the details and what they tell us about the family who lived there, what that tells us about the economics of the time, the types of meals they prepared. But as a simple visitor I found the place lacking vision. Something I'm sure Henry Ford would not have appreciated.

The Henry Ford, as it's known, is a giant complex that boasts a museum, research center, factory, historic village, IMAX theater and high school. It's just one of a long list of Ford venues in the Great Lake state of Michigan. Both Henry and Gerald Ford have lent their names to Ford Field, Ford Lake, Ford Road, Ford library and Ford airport. I'd heard about it this summer and was waiting for the right time to visit.  On this sunny and warm autumn day, my daytime plans fell through and provided the perfect window of time to take a trip back in time.

After paying $22 admission, you can pay another $10 to ride the train 

Housed in an enormous building with poor lighting, the museum is divided into various sections that highlight inventions and imagination in the American experience. One section focused on agricultural innovations over time. Another had several dozen stoves. Still another showcased dollhouses from the past hundred years. One of the strangest sections focused on American pop culture beginning with the early 20th century and featured items from my own childhood, like Speak and Spell, Simon and the Mr. Professor calculator.  It all really seemed more like an elaborate private collection than a museum exhibition.

Many of these are Chanukah gifts I received as a child.
Now they are artifacts in a museum.

I was looking forward to an area called "With Liberty and Justice for All" which featured the women's suffrage and civil rights movements, among others. I sat on the Rosa Parks bus and listened to a recording of Ms. Parks telling her story. And I looked around for copies of Ford's notoriously antisemitic Dearborn Independent, which surely must feature into this section of the museum that displays KKK attire. Its absence was upsetting but also not surprising. It was just another example of how this museums offered lots of kitsch but no real content, commentary or substance.

Classic or kitsch?

I had a great day at the Henry Ford in spite of my inner critic.  After a day surveying American life - everything from nickelodeons to 8 tracks to planes, trains and automobiles and - while I'm not sure if this was the curator's intention - I was reminded how much of our history is told through objects. Objects we invented and used until they faded into obsolescence with the next great invention.   They tell of what we did or hoped to do. So I came home and realized that while I would like to stick with a wedding registry that sticks close to what I could really use, maybe not everything needs to be so essential.

(Factory) Farm to School

It's National Farm to School Month and last Friday I attended a fantastic Farm to School workshop through MSU's Extension Program. The workshop consisted of two very thorough presentations, a basic intro and then a more advanced nuts and bolts of getting farm to school programs off the ground in Michigan. Many school food service directors were in attendance but also a school nutrition consultant for the state's Department of Education, members of FoodCorps, reps from Detroit's Eastern Market, concerned parents and local food marketing strategists. The group had lively discussions and the four hours seemed to fly by with substantial ground covered.

Many schools have already initiated farm to school programs. The school district where I am currently working has a relationship with some local farms and occasionally gets produce from them. Introducing fresh produce in the school cafeteria on a regular basis is great. But at the end of the day most of the food served is not fruit and vegetables from local farms but from beef and poultry from factory farms.

I asked about this at the end of Friday's presentations. While I recognize the value of (and need for) increasing fruit and vegetable consumption among students, after observing cafeteria eating habits these past four weeks, I have seen that most students opt for meat and cheese-laden foods - these being important components of the reimbursable meals - and wondered if there were any efforts focusing on local farms for sourcing meat and dairy.

The answer was yes and no. Yes, there are certain dairy farms that are responding to the needs of school food service directors. For example, schools are required to serve fat free milk in a certain serving size and specific type of bottle that was hard to find on the market and a local Michigan dairy responded by making that product available. So clearly school food service directors can impact the supply chain. But no, there is no effort looking at the quality of that dairy or the types of practices used on those dairy farms or on any other farms for that matter. Why is this significant? Because in 2009-10, 31.6 million U.S. children participated in daily school lunch programs. That's a lot of buying power. I couldn't help but wonder how that could be harnessed to improve the food system even further than getting a local vegetable to feature on a school menu once a month. Besides, fresh produce presents a tremendous challenge for many school food service facilities that lack the labor, the facility, the time or the know-how to prepare fruits and vegetables properly or in a desirable way. Just this morning I was assisting in a school kitchen, laying frozen burgers that barely resembled beef out on trays, and filling bags with pepperoni, which had few traces of actual meat content.  I was then asked to cut up several dozen zucchini and squash which I was later horrified to watch being steamed to mush and served in such an undesirable fashion that even I did not care to try them. They didn't stand a chance on pizza day. (Need I mention that the pepperoni pizza sold out first?)

This evening I came across a post on Mark Bittman's website that shared a letter from a chef to his colleagues in the restaurant world offering the reasons they should strongly consider sourcing their meat from reputable, ethical, healthier farms. Beyond the health concerns of hormone and antibiotic use, of animal cruelty and corporate monopolization that the letter cites, the EPA lists "enteric fermentation" (ie. gas emitted from animals related to digestion) as the second highest contributors to U.S. methane gas emissions (climate change, anyone?). Number five on the list, "manure management" is an even greater problem because it also poses a food safety threat, as evidenced by the unusual (although increasingly usual) recent spate of produce cross-contaminated with e. coli.

Farm to school programs continue to grow, thanks in part to increased funding and grant opportunities (stipulated under the Healthy, Hunger-Free Kids Act) and to the birth of FoodCorps and that is exciting to behold.   Given the size and buying power of schools I hope that in the future, the programs expand to include considerations toward where they source their beef and dairy and move away from factory farms. While the supply does not currently exist for most schools to purchase all their animal products from non-factory farms, such efforts might, at the very least, put more pressure on the industry to create a healthier, more sustainable model. And it would certainly put a better product on the lunch line.

Minding my Peas and Q's

When I was in elementary school I begged my mother to take me off the school lunch program and pack my lunch at home. It was partly because I disliked school lunch, partly because I hated waiting in line but mostly because all of my friends brought lunch from home and I wanted to sit near them. I remember the feeling of relief when she finally sent me with a bagged lunch. I didn't care what it was and I don't know if I ever really ate it. So is eating school lunch as bad as I remembered?

Earlier this month I read about the release of Fed Up With Lunch, the expose written by a school teacher working in a Chicago public school who anonymously blogged about (and photographed) school lunch over the course of the school year under the pseudonym Mrs. Q.  I wondered how representative her experience was eating school lunch. But I didn't really have to wonder for very long. When I started this rotation is school food service my preceptor told me we would be eating lunch at the schools. As an insider on both ends of the lunch line I can now say this about school lunch: it's complicated! Oh, I've said that before? Well if I didn't convince you before, maybe I will now.


To start with I am certainly not the target demographic of the school lunch program. I don't eat meat, only eat kosher poultry and I avoid gluten and dairy among other things. Dairy is big in schools. HUGE. 'Got milk?' posters are ubiquitous and students are offered "white" milk and chocolate milk at all meals. So I was nervous about relying on school lunch given these restrictions so I packed myself a few snacks and figured my day is over at 3pm so worst case scenario I pick up some lunch on my way home. I was pleasantly surprised on the first day when I found Spanish (brown) rice, vegetarian beans, and a salad bar. Not the type of elaborate seasonal salad bar I'm used to - it included shredded (iceberg) lettuce, sliced tomatoes, pickled peppers, onions and cheese - but vegetables nonetheless. I ignored the sour cream, took some guacamole (which I later learned had yogurt in it to keep costs down and to add some nutritional value) and considered my lunch fairly healthy and satisfying.

Some days were better than others. One day the only remotely suitable options were brown rice, applesauce and lettuce. Yesterday I ate a baked potato, a bowl of mushy dark colored reduced-sodium peas, package of carrots and sunbutter. On those days I go home and eat leftovers as fast as I can. But other days I've been pleased to find treasures like quinoa, roasted vegetables and stuffed acorn squash. With Try-it Tuesdays and Why Not Wednesdays introducing new foods to the lunch line there more whole grains, vegetarian and vegan options available. Despite these healthy options I don't want to make this sound like some Midwestern miracle because here's the catch: most students don't choose these foods. They opt for the hot dogs, the burgers, the pizza, the french fries, the chicken nuggets and anything with cheese. Not all students, but most. And why are these foods sold in school cafeterias? Let's just say it has to do with dollars and cents.

Here's the breakdown from a typical school: Students pay $2.25 for a full-priced lunch. The government will reimburse $0.27 with an additional $0.26 in commodity values for total revenue of $2.73 per meal.

Now let's look at the costs:

1. Milk - $0.22
2. Fruit - $0.25
3. Grain - $0.30
4. Protein - $0.65
5. Vegetable - $0.25
6. Labor - $1.04
7. Indirect - $0.27

So while $2.73 is generated in revenue, the total cost for a lunch meal is $2.98. I'm no economist but I know that when costs exceed revenue you end up in the red. And that's what happens when the only food offered is the reimbursable meal, one which meets the USDA guidelines and offers at five food groups of which students must take at least three. Some cost can be saved if students choose less than the five items to which they are entitled, but that doesn't quite fix the hole. Interestingly, while the same imbalance exists in breakfast programs, many states reimburse the difference. So why not raise the price of lunch? Because when schools raise the price even 25 cents, students tend to opt out, parents send lunch from home and the only kids buying school lunch are those at free and reduced price. Instead, most school food service programs rely on other revenue generating means such as a la carte sale of chips and cookies and "healthier" snacks, vending machines, catering school events and providing box lunches for sports teams.

More and more schools have fruit and vegetables on the menu. Many schools are sourcing locally when possible. School food service and nutrition staff care about nutrition but they also care about feeding kids meals they will eat that will also qualify for reimbursement. They are forced to balance very tight budgets and provide items that meet the outdated government standards. They care about school lunch and they eat school lunch and they get very defensive when criticized for the role of school lunch in childhood obesity, citing shorter lunch periods and decreased activity as far worse offenders. They now find themselves at the center of a heated national debate. "They" are represented by giant organizations like the School Nutrition Association and the National Food Service Management Institute but they are individuals serving different communities and some have more leeway than others when making changes.

All of this might sound very discouraging. And there is definitely a lot of work to be done to change the current system. But the other day I went to a meeting with other school food service directors that was hosted by Gordon Food Service, a giant food distributor that many of the schools use. I asked those sitting around me if the field has changed since they started working in schools ten or twenty years ago. "Oh yes," they told me. "It has changed dramatically over the years. There was a time when we were behind the times by 10-15 years. Now with all the spotlight on school lunch we've had to catch up very quickly."  So while it's important to remember that the healthy school lunch pioneers (like Ann Cooper) have been at it for years, many of us have neglected to consider the state of school lunch until Jamie Oliver brought it to prime time and people like Mrs. Q started to blog about it. And with the spotlight on school gardens and cooking and celebrity chefs in the cafeteria and whole grains and physical activity, good things are happening.

Beyond the kitchen and lunch line, I can't say that I understand the social dynamics of the modern school cafeteria. Today I watched a girl from the lunch line as a girl sat alone at the end of her class's table in an area reserved as peanut-free and wondered how she felt. Do you think kids still judge the lunches their friends eat? I'm sure they do. As for me, I've had my fill of school lunch for a while. And I can't wait to bring my own lunch from home again.

To Serve and Defend: School Lunch in the U.S.

This week I started my rotation in food service, working with some local school districts.  Before my rotation started my preceptor told me she likes to have interns read about the history of the National School Lunch Program, so she loaned me a book called School Lunch Politics: The Surprising History of America's Favorite Welfare Program. As it turns out, not only was the school lunch program a welfare program providing many students with perhaps their only meal of the day, it was also a matter of national security. While early versions of the program date back to the pre-war era, when America entered world wars I and II it became clear that malnourished children grew up to become malnourished soldiers. Feeding the nation's youth was the best defense. There were concurrent concerns among American farmers about the fluctuating prices of their crops. In a brilliantly flawed move that created a giant conflict of interest and decades of debate, the National School Lunch Program was passed in 1946, and the program was designated under the auspices of the USDA. The Department of Agriculture would use surplus crops and commodities to feed the nation's youth, keeping prices steady and bellies full.  From the onset, the program also had a strong connection to the War Food Administration (and later to the Department of Defense, which it currently relies upon for much of its fresh produce).

Image from The Food Museum's online exhibit  on School Lunch

"What has been will be again, what has been done will be done again; there is nothing new under the sun."  While reading about the history of the school lunch program I couldn't help but think of the words of Ecclesiastes. Every major issue confronting the program today has been their since its very inception... the surplus commodities, the lack of proper equipment or trained food service workers to prepare nutritious meals, the tensions between running school food service as a business vs. as a public health program. And yet, what is most amazing is how this welfare program has endured despite these deep-rooted flaws.

What once constituted a "good" lunch -
not so different from the current USDA requirements

I would be remiss if I did not also mention the important role of the school lunch program in legitimizing the field of nutrition. Many of the earliest pioneers of the program were women who wanted to seriously pursue science but could not gain access to any advanced programs. Home economics was a "safe" way for women to study and apply the science of nutrition and also provided women with a point of entry into government jobs. The program also contributed to the standardization of the American diet - for better or worse.

The National School Lunch Program is "arguably the most regulated, thought-about, fought-over and highly planned meal in America."  There are so many competing interests and considerations, from cost to labor to reimbursement requirements to dietary guidelines to picky eaters, not to mention the regulations at the federal and state level and from the Department of Health as well. Furthermore, I find this ongoing connection to the DoD, with nutrition and war somehow becoming inextricably linked at once fascinating and troubling. I don't know if a month's time is enough for me to learn the ins and outs of this absurdly complicated program but it's an exciting time to be working in the field and to gain greater insight into the challenges of school lunch.

Big Fish

I didn't know what real salmon was until I moved to the Northwest. When I ordered grilled salmon for my first dinner in Seattle I was shocked to see the bright pink fish that arrived on my plate. During my three years living there I ate wild Alaskan salmon raw, grilled and poached, but mostly I enjoyed eating it smoked. This was especially surprising to me, raised Jewish in New York City where I had mistakenly believed that thinly sliced salty lox was the only smoked salmon out there. The salmon I discovered in the NW was thick and flavorful and widely available. I didn't eat it with cream cheese and a bagel. I preferred eating it with my hands. So when I visited Seattle last weekend to celebrate the Jewish New Year with my fiance and friends,  I had the perfect excuse to visit the Ballard Farmer's Market where I was handed heavenly samples of wild Alaskan king salmon smoked in brown sugar and garlic or maple and wine. I bought a piece and saved it for my last dinner before heading back to the Midwest, recognizing that it's one of the local foods I'd sacrifice by moving this long distance.

But somehow Seattle fish followed me back to Michigan. Yesterday I attended a school district meeting in a small town outside of Ann Arbor where someone referred to the "World Famous" Pike Place Market and it's "fish" philosophy. It wasn't the first time I'd heard about this. Back in July when I began my rotation in long term care I started each morning by attending the daily management meetings. I learned that the head administrator had started only a month or so earlier and was eager to bring some energy and enthusiasm to what was a pretty drab place. On my first day he asked me to select the winning "fish." He laid out a bunch of folded notes on the table and I selected one. I had no idea what these "fish" were for. He explained that they were complimentary notes that residents and staff could fill out, commending a staff member's performance or positive attitude. "You're from Seattle, you must know the Pike Place Fish Market." I nodded. I thought of the busy tourist attraction where the fishmongers would toss the purchased fish to one another in a call and response manner, every so often throwing a fake fish at an unsuspecting person in the crowd. It was a cute shtick but I had no idea what this had to do with anything. Apparently there was some greater philosophical underpinning, but I wondered if anyone present at the meeting had actually been there. 

After yesterday's meeting I was in my preceptor's office and noticed the Fish! book on her shelf, so I borrowed it and read it last night. It's one of those Who Moved My Cheese? types of self-help for the workplace books that is annoyingly oversimplified, perhaps a total lie but ultimately well-intentioned and a good motivational device that asserts four main ideas: Choose your attitude, Play (have fun while you work), Make their day (engage with those you work with and work for), and Be present. These concepts are all based upon the Pike Place Fish Market, and I think they're pretty good principles to incorporate into the workday.

When it comes to actually buying fish, I'll take Ballard over the Pike Place Market any day. But while I'm living 2500 miles away, turning my nose up at the ubiquitous farmed Atlantic pathetic excuse for salmon, counting down the weeks until I'm back in the NW (8!), these small references to Seattle make my day. Until then I certainly can work on being present, taking time to play and choosing a positive attitude - all good skills to develop when working in schools.

On Indigestion

Last week I wrapped up my time in the clinical setting. I conducted assessments of patients, most of them presenting with IBD (inflammatory bowel disease) flares. These conditions cause inflammation of the GI tract that can lead to abdominal pain, diarrhea, ulcers, bleeding and weight loss. As a result, many patients have nutrition-related concerns and are at risk for malnutrition and malabsorption. Going on rounds with the team gave me insight into how doctors think, how they assess, diagnose and treat these conditions. Endoscopies, colonoscopies, flex-sigmoidoscopies, double balloon enteroscopies were daily rituals in the unit. Sometimes surgery was discussed and many patients already had various -ectomies and -ostomies and had this -itis and that -itis. Allergies to steroids and antibiotics, bacterial infections, narcotic addictions, MRSA and C.diff were all part of the daily discussions. These were very complicated cases.

But the way doctors think is not the way dietitians think. After rounds with doctors I would later meet with patients to gather the bits of information that were rarely, if ever, discussed. I wanted to learn what they typically eat, what foods they avoid, what foods are triggers, and how their condition impacts their energy and level of function. I would observed their physical appearance to see if they showed signs of wasting, weight loss and malnutrition using a host of indicators under what is called a "subjective global assessment." I would keep an eye on how many days they were NPO (nothing by mouth). I would lament the Skittles, Rice Krispie treats, Goldfish crackers and Coca-Cola on their trays, but didn't have the courage to suggest that after landing in the hospital with severe GI distress these were perhaps not the best choices for healing foods. I would provide ADA handouts on the types of foods recommended for Crohn's and ulcerative colitis, even though I disagreed with some of their suggestions. I realized that my thought process is much more outpatient-oriented, thinking along the lines of "what dietary recs can I provide this patient to help them maintain remission so they do not end up here again?" while an inpatient dietitian has to consider the patients' needs right here and now. In time I began to speak up and share more patients' nutrition concerns with the doctors, who freely admitted they did not usually take such things into account. And by the end of my rotation I hoped that maybe, just maybe, the two dietetic interns who followed these attendings, residents, interns and medical students around for several weeks made enough of an impression that they will consider consulting with a dietitian in the future to optimize patient care.

The experience certainly made me wonder when diet became so separated from medical care. During my time in the GI unit I also worked with several interns on an unrelated project, researching the history of popular beliefs about health and diet in the Janice Bluestein Longone Culinary Archives at the Clements Library at U of M. We put together a presentation to introduce a talk given by Harvard School of Public Health's Eric Rimm who served on the advisory committee for the 2010 U.S. Dietary Guidelines and came to speak about the process.

A short list of our discoveries:

1. We've known for a long time that eating too much can cause indigestion.

"If more than ordinary quantity of food be taken, a part of it will remain undissolved in the stomach, and produce the usual unpleasant symptoms of indigestion." The physiology of digestion considered with relation to the principles of dietetics (1836)

2. Whole grains are far superior to refined grains

"Flour of the entire wheat is without doubt the purest flour in the world, and makes the best bread now known to housekeeping or culinary science, because it contains...all the bone, mucle, brain and nerve feeding elements of the wheat kernel, so unfortunately lacking in white flour..."The Boston Cooking-School Magazine of Culinary Science and Domestic Economics (1898)
3. We eat too much meat.

"The spirit as well as the letter of this book is universally needed. Overeating of meat has had its day, and left us as a reminder much sickness and sorrow."  Mrs. Rorer's Vegetable Cookery and Meat Substitutes (1909)

There was a time when the connection between food and health was undisputed. Now it's often dismissed as lacking sufficient evidence. I've been wondering how we got here, and having just started my next rotation working with the National School Lunch Program I think I have some ideas. Stay tuned.

On Digestion

As expected, working in the GI unit of the hospital is very different than working on a farm. I was excited to finally see the ways medical nutrition therapy was implemented in clinical settings - the tube feedings, the TPN - all stuff I'd read about, studied and heard about in lecture but I'd never seen them, nor spoken to patients who were relying on tubes for sustenance and life. Different indeed.

Early in the week my fellow intern and I tailed the doctors on their morning rounds for a few days, listening to the medical students, interns, residents and attendings hash out their diagnoses, treatments and prescriptions, and tried our hardest to keep up with the jargon. We then chose patients to follow, ie. to conduct assessments and chart using nutrition practice guidelines. It was all very intellectual and I found myself philosophically drawn back to my time at Bastyr where much of the focus was placed on digestion as the foundation of health. The gastrointestinal tract is a path for foreign objects to move through our body. When we ingest foods they technically remain outside of our selves until we digest them, break them down, absorb them into our very being. Digestion allows us to process that which is outside of ourselves and internalize it in a healthy, discerning matter. Finally, it is transformed into matter that serves us, creating energy and enabling life affirming pathways. In theory, anyway.

A reminder of the major organs involved in digestion

I've been thinking about this process all week - digestion, absorption, transformation - as I hit the two month mark of my internship. Somehow it feels like a real change. Maybe it was beginning my fourth rotation, transitioning from cold to hot cereal for breakfast, switching from running shorts to pants or leaving my house early enough in the morning to catch the moon still shining that it feels like summer is really gone and fall is here to stay. And while I look forward to the spectacular Michigan foliage I've heard so much about, to the abundance of honey crisps, winter squash, root vegetables, to wearing jeans and sweaters, I still find myself struggling with the start of the fall season as I do each year. I dread the inevitable extra curves on my body and roundness in my face, the result of less activity with the shorter, colder days and an increased appetite for warming, grounding foods. If summer is about expansion and openness, then fall brings contraction and retreat, a turn inward in preparation for the winter months. I'm finding it all a bit hard to digest.

Catching sunrise on my walk to work

And yet. Eventually I will make my peace with this transition, as I always do, with this new energy and space, this opportunity to reflect and re-evaluate my life course, a process facilitated by the onset of the High Holidays, the Jewish New Year and Day of Atonement that demand introspection and contemplation. Some years the holidays, based on the lunar cycle, fall earlier in September when the weather has not yet turned and they seem to appear suddenly, catching me off guard, unprepared to admit to my weaknesses and areas in need of improvement, to examine my relationship with the divine and with my fellow man and set an intention for the year ahead. But with another week and a half until the holidays begin, I find the change in weather, the change in my diet, the change in my mood appropriate for the start of a new year.

So what am I thinking about for this coming year? Most immediately I have career concerns. Re-entering the workforce this winter during this uncertain economic state is daunting and more and more I think about the importance of non-traditional entrepreneurial ventures. I've read, heard and been involved with many formal and informal debates lately about the relationship between education and employment. While a college degree may still vital be to getting a job, having one no longer guarantees security. Nor does a graduate degree or even two. Furthermore, tonight I was listening to a report on bankruptcy and in the past five years there has been a 20% increase in college grads filing for chapter 11, which honestly, came as no surprise.  Still, it is also an opportunity for incredible creating ways to (professionally) enact your beliefs in the world suggested by Peter Sellars who taught at UC Berkeley's Edible Education course (streamed here on YouTube). He posed this question to the audience: "What does it mean to put your belief system into your body? And actually live based on what you believe most deeply? Not at some future time, but now."

So for now, I try to focus on the task at hand: helping those with compromised digestive health achieve optimal nutrition status. And in doing so there is a reminder for me to measure my own digestive health. How well am I processing the information that is all around me? Am I integrating it into my mind and my body in a constructive way, or am I getting bogged down by the all the change, frustrated by the challenges and the dread of winter and all it brings? How can I optimize my spiritual and emotional digestion so that I can have a strong foundation in the year ahead? These may not be competencies I need to complete for my internship, but they are worth devoting some time toward nonetheless.

A Farewell to the Farm

After four weeks, I have completed my time on The Farm @ St. Joe's, my third rotation to date. Last week I posted on the farm's blog about why I felt it was an important component of the dietetic internship experience. But beyond some of the basic lessons in agriculture policy and practice and food growing 101, there were many more subtle messages that I learned in the process.

1. Free food will attract people's attention...even if it's kale.

After getting into the rhythm the first two weeks at the farmer's market, we decided to provide free samples and recipes utilizing some of the produce. The third week we featured red peppers with three different ways to prepare them and the fourth week we featured kale. Many people stopped by the farm cart who had never tasted kale before. They were curious, reluctant, excited, skeptical. But nearly everyone tried it. I consider that a success.

2. Find an ally in a position of power who will champion your cause.


According to the sources I spoke with, the idea for launching a farm on hospital property could not have happened without the support of the hospital's CEO. While it was a clinical dietitian and physician team who came up with the proposal, the fact that it fell on the right ears was critical to its success. The CEO is not only a supporter of health and healthy food in name and in print but he actually showed up to both the farm and the farmer's market during my time there and was clearly very proud of the project. He was simultaneously working on the hospital's new cafe, which opened during my last week there - sans deep fryers and fatty cuts of meat. It even has an elaborate system at the very entrance to help guide customers (70% of whom are apparently hospital staff) toward healthier options.

3. Acting local can still draw national headlines.

Since I started at the farm there has been at least one article a week published about the farm and its relationship with the hospital - and not all on annarbor.com. From the LA Times to Today's Dietitian, the media is taking notice of the work being done in this relatively small town. Not insignificantly, it is is also mentioned in Oran Hesterman's book, Fair Food, which was published this year and is making waves beyond just the food, health and agriculture networks. The lesson here is that you don't necessarily need to be working in a major city, on a large scale project, program or policy to catch the attention of people who matter. Acting within your own community, where you have relationships and opportunities (and possibly less red tape) can enable amazing things to unfold that can have ripple effects thousands of miles away.

4. It's never too late to learn.

My impression of farmers is that they've always been that way. Maybe they were raised on a farm, or at least with a garden, growing things, playing in the dirt, knowing that's what they wanted to do with their lives. Not so. Farmer Dan who runs the farm knows a tremendous amount about it, about organic practices, soil and growing methods but is relatively new to farming. He openly admits to us interns when he is experimenting with something new - a new crop, a new way of growing. He is teaching us and also learning as he goes. His approach to small scale farming makes it a lot less scary and a lot more fun. Through Dan I also had the opportunity to meet and volunteer with Diana Dyer, a dietitian who now runs a garlic farm full-time (actually, more than full-time). She and her husband had impressive careers before deciding to grow 42 varieties of garlic, which they sell at farmer's markets. They teach people about the power of growing and loving the food they eat.

Diana Dyer showing us how to clean garlic.

5. Calories in are not always equal to calories out.

The amount of calories one expends on a small farm is not insignificant. The work is hard and tiring and physical. To grow these low calorie foods required a tremendous amount of work and I couldn't help but think that if we were all growing our own food, this whole obesity thing would be non-existent.

6. Once you grow your own food it's hard to go back.

It you know anyone who grows their own tomatoes, you've probably heard them utter something like, "I could never eat a supermarket tomato again." This might sound snobby, but in fact it's a perfectly legitimate statement. Because after eating your own vine ripened tomatoes, the ones in the store are simply not tomatoes. They look like tomatoes, are labeled and sold as tomatoes, but they are not the same. Leaving the farm I will certainly frequent the farmer's market more, but I truly feel a loss at not being able to go out into the fields to see where my food grows and enjoy eating it, knowing exactly where it comes from.

7. Farming is not a fair weather activity.

During my month on the farm I saw the weather change from hot and sunny to gray and rainy. And I learned that while I loved being on the farm in the summer, the wet season was a whole other beast. Thankfully there was lots of work to be done indoors in the hoophouses because I hate wet socks.

8. Dietitians are uniquely positioned to connect the healthcare system and the food system. 

The fact that the farm was spawned by a dietitian and linked with nutrition and healthcare is not to be overlooked. While I may not be a farmer in the future (or I may! who can tell these things?) I certainly know that anywhere I go I will have the opportunity to build relationships between institutions and farms, communities and farms, schools and farms, all under the rubric of nutrition and health, which helps the cause more than one might imagine. During this rotation I met two very impressive dietitians who are using farming for improving nutrition and health status and, more importantly, as the best form of prevention.

I'm sure there there are countless other lessons to extract from this past month, but these are the ones that stick out the most. As a dietetic intern floating from one site to the next it's important to contribute as well as take what you can from each setting and then shift gears and move on to the next. In that vein and in yet another test of flexibility I will begin rounds in the GI unit at the hospital starting on Monday. After spending a month working on a hospital farm, I'm looking forward to working on the inside, with my clipboard, a team of physicians and, most of all, my lab coat.

Reap and Sow

There are certain signs that indicate the end of summer. The days grow shorter with each sunset. The cooler night air lingers longer in the morning as the sun takes its time making its way up into the sky. Kids are everywhere as camp programs end and the mad rush to enjoy the last days of freedom coincides with back to school signs and sales. And while this is the first year of many that I will not be returning to class in September, I have new indicators of the impending fall now that I am working on a farm: the harvest of summer produce and planting of fall and winter crops.

In these first two weeks on the farm I have already been a part of this segue to the fall. During my first few days at St. Joe's I harvested the last of the cucumbers in the hoophouse before tearing out the bed and preparing it for greens. Each day we frantically pick the ripest tomatoes, which have only a few more weeks. Just yesterday we tore out the remaining basil - some of it already damaged by the early morning frost, and prepared the bed with a broadfork, claw and hefty amount of compost. Though I still spend my days out in the warm summer sun, our latest farm work provides a good reminder that fall is just around the corner.

This week we directly seeds carrots and transplanted scallions, chard and lettuce into the hoophouse. The harvest included different varieties of tomatoes (read my guest blog post about Sun Gold tomatoes here), peppers, eggplant, chard, kale, basil, beets and carrots. 

The physical demands of the farm are certainly new to me.  But the cycle of crops, the forecasting of what to harvest next, seems somehow intuitive, and I wonder how much of it is related to my Jewish roots. Although I was grew up in a city, I was raised in the Jewish tradition, whose calendar maintains a strong agricultural tie so that the year has always held a close relationship with the land and the major pilgrimage holidays throughout the year are all connected to the harvest cycle. As this synagogue's website nicely explains, Passover marks the barley harvest in early spring, Shavuot marks the wheat harvest in early summer and the final harvest of the season is celebrated on the holiday of Succot in the fall. With the month of Elul beginning this week, it is hard not to anticipate the Jewish New Year and Succot after that.

Each day I appreciate how lucky I am to spend my time on The Farm, around a bounty of beautiful produce and a healthy eco-system filled with life (also filled with mosquitoes!). I eat better, sleep better and am inspired by the work of so many professionals and volunteers I've met so far. And the work itself is hard. On a small farm where almost everything is done by hand, patience and determination are good skills to have. But there's something very satisfying about planting and harvesting in the same day, experiencing two ends of the farm cycle at once. Planting is the start of something new, an act of faith and anticipation while harvesting is the result, the yield and fosters a sense of gratitude. I am grateful to experience both.

Money Matters

Nutrition has a new spokesperson in the form of Bill Clinton. Yesterday CNN posted clips from an interview with Dr. Sanjay Gutpa, in which the former president discussed how changing to a plant-based diet has saved his life and transformed his health. And my first thought was how in those two minutes Clinton may have done more for nutrition, for making the connection between food and health than the ADA has done in years.

To be clear, I am referring to the American Dietetic Association and not the American Diabetic Association (ADA) nor the American Dental Association (also, ADA) and definitely not the Americans with Disabilities Act (again, ADA). But the confusion over their acronym is only the beginning. Even more confusing is their message: "If consumed in moderation with appropriate portion size and combined with regular physical activity, all foods can fit into a healthful diet."

Founded during World War I, ADA initially sought to help the government preserve food and improve the public's health and nutrition. Over time its purpose and mission have evolved and currently it is "committed to improving the nation's health and advancing the profession of dietetics through research, education and advocacy." It is a professional organization, primarily of registered dietitians (RDs), the certification that is bestowed by the ADA upon an individual who has completed a CADE-accredited dietetics program (at either the bachelor's or master's level), an accredited dietetic internship program and then passed an exam.  Much of the organization's advocacy work is spent educating the public and the government about RDs, and establishing them as the authorities on food and nutrition. There are so many people posing as nutritionists these days that some qualifications and credibility are called for and I appreciate that there is a group committed to this task. But ADA receives significant funding from companies like Mars, ARAMARK, Hershey, Coca Cola and the National Dairy Council.  Isn't it a bit problematic when the organization trying to position itself as the unbiased expert on food and nutrition is sponsored by major food corporations built on selling the public on calories and food-like items they don't need and can potentially harm them? 

This appeared at the bottom of ADA's Knowledge Center email on 8/18/11

One day perhaps I could write an entire dissertation on the complexity of these relationships between health organizations and companies that generate most of their profits by saturating the market with high-sugar, high-calories, chemical-laiden, nutrient-poor products that contribute to the rise in nutrition-related chronic diseases.  Despite their "wellness" divisions, their corporate philanthropy and commitments to "healthy living" these ADA sponsors are best known for soda and chocolate bars (and not the high-cocoa content, fair trade varieties). Coca-Cola, for example, doesn't even pretend that its raison d'etre is to feed or nourish people. It's mission statement is simple: "To refresh the world...To inspire moments of optimism and happiness...to create and make a difference." Remember those joyous ads? 

I'm actually more moderate than I sound. Last year I started working with an organization called Cooking Matters (formerly known as Operation Frontline), a nationwide program that provides cooking and nutrition classes to low-income populations. While the program and its curriculum are sponsored by ConAgra and Walmart, the classes are taught by volunteers chefs and nutritionists and as a volunteer I was free to take some liberties with the program. (During the week that focused on calcium, for example, I provided lists of non-dairy dietary sources.) True the funding came from major corporations, but the program was very effective - in some cases truly transformative - without supporting any corporate agenda. We live in a time when corporations have money - let's use their money for good. 

My gripe with ADA's sponsorship is not really that they take money from these companies, it's that they do not address it or demand accountability. ADA constantly comes under attack for their ties to big industry and has never issued a statement explaining their position. In fact, back in May the president sent an email to ADA members stating:

Levelheaded criticism is different from deliberate misinformation, which ADA and many other credible organizations are occasionally subjected to. Blogs and other communications that contain falsehoods about our Association are easily written and – with a click on a keyboard – posted and re-posted the world over. I want to assure members that ADA will not be distracted by engaging in point-by-point rebuttals of disparaging untruths and insults every time they appear on the Internet.  ADA will not issue formal responses to ill-informed attacks or outright lies. Such responses would only lend credibility to erroneous arguments and baseless charges and elevate their authors. This is the intent of our detractors.

First of all, I'm not sure which "falsehoods" they are referring to, since their ties to the food industry are posted on their website. Secondly, to disparage blogs and communications that are "easily written...posted and re-posted" makes them sound as dated and out of touch as their detractors claim. Finally, to defend a position that has come into question does not lend credibility to the argument, it allows an organization to reiterate, clarify and hone its stance. As a card-carrying member of the ADA, I would appreciate a position paper of ADA sponsorship policies. Their website does say:

ADA’s procedures and formal agreements with external organizations are designed to prevent any undue corporate influence particularly where there is a possibility that corporate self-interest might tend to conflict with sound science or ADA positions, policies and philosophies.

Personally I would feel more comfortable if I understood how they get around the "possibility" of corporate self-interest with their current sponsors (for amusement, see the page on "What Our Corporate Sponsors Think").  Additionally, I would like to see more statements calling upon these companies to employ more responsible and honest marketing practices, including the elimination of advertising to children. I don't feel ADA needs to refuse their money, but should use their relationship with Big Food to push an agenda of their own, namely one that promotes public health nutrition, education, greater transparency and increased access to healthy foods. 

It may sounds optimistic, but I do believe the ADA has the potential to be a more potent and effective change leader in national nutrition discourse. Maybe I'm just rationalizing how I could accept scholarship money from the ADA Foundation toward my internship while I criticize ADA for accepting money from corporations with dubious intentions. Can the ends justify the means if the money is going toward quality nutrition programming, toward the training of future nutrition professionals, toward the education of groups that would not otherwise be reached?  I considered this for a moment when I received notification of the award but quickly realized it did not for a moment change my beliefs about nutrition practices, science or politics. If anything, it encourages me to cling to my position, continue doing what I'm doing and work toward changing the field of dietetics from within so that Bill Clinton is not the only harbinger of dietary changes in this country.

Market Day

Some people think of Wednesday as hump day. For the next month Wednesday is also Market Day - the day I arrive at the farm early to harvest greens, pack tomatoes into pints, arrange the beets and carrots and peppers in an old fashioned wooden wagon in the main hall of the hospital where I am working on the next rotation of my internship. The hospital is one of the first in the country to start its own farm that now boasts two hoophouses for year-round growing.  Just last week the ADA posted a link to a Food Sleuth podcast interviewing the RD who developed the project that turned 15 acres of hospital property back into farmland last April (a great podcast!). Then in July the farm began to sell its produce at a farmer's market in the hospital. The hours correspond with the hours during which most patients are discharged (11am) and also during staff lunch breaks. The idea is not only to sell fresh, local (!) produce, but send a message, linking farm and hospital, food and health.

Tomatoberry variety of cherry tomatoes

Working at the farmer's market earlier today made me feel like a local celebrity. People's faces lit up when they saw the cart. Shoppers commented on the fragrance of the basil, the colors of the chard stems, the perfection of the tomatoes, and they began to swap ideas on how to use the produce, recommending recipes, sharing what they grow in their own yards and asking me for suggestions as well. Some customers were bold enough to try something new, some were returning to buy the Sungold tomatoes after trying them last week (my favorites!). 

A bunch of Bright Lights rainbow chard

I'll be spending the next month on the farm and I'm sure I'll have plenty to share. It's the most exhausting work I've ever done but it's exciting to be onboard with a hospital that is committed to investing in preventative care through food and nutrition. 

Lessons from LTC

I was not looking forward to my rotation in long-term care. And when I started, I was relieved that it would only last for two weeks. But by the end I had gotten so comfortable there, so used to the smells, the sights, the residents that had scared me at first and I was sad to leave behind the routine, the meetings, the familiar faces to start all over again at a new site.

My time in long-term care (LTC) was mostly spent on my feet. While the dietitian I worked with had an office, she was hardly ever there unless it was to update residents' meal preferences or enter quarterly and annual assessments. Otherwise I tried to keep up as she breezed through the halls, whipping in and out of patients' rooms, checking up on them, tracking their weights, seeing how they were eating - did they need a speech or an OT consult? Were they have swallowing problems or difficulty holding their utensils? Were they able to meet their nutritional needs through oral intake or did they need liquid supplements? Were they getting their meals as they ordered it, and if so, was the temperature appropriate by the time it arrived from the kitchen? These were just some of the dietary concerns at the facility where I was working. Through these daily tasks I got to know the residents and their mannerisms, the ones who liked puzzles and the ones who ordered takeout food, the ones who spoke inappropriately to women and the ones who would grab your hand and not let go if you got too close. I learned who had their own set of teeth, who wore dentures and who preferred not to wear their dentures. I learned who was 105 and who was 85 and who was 55 and who must always always always get two cartons of chocolate milk at every meal or else. Then there were the harder parts.  I sat in on meetings with families of residents who were recommended for hospice care. During my two weeks there two residents died. I observed wound care on a patient whose foot had bad gangrene and pressure ulcers but refused amputation despite doctor recommendations.

During my first week I was focused on the sad parts, the decaying people, the empty shells of what were once vibrant lives - or were they? Many of the residents were homeless or alcoholics or, as my supervisor said, "had made poor life choices." A number of them had mental disorders and acted out and threw their trays and had temper tantrums. But there were lighter times too, and by the second week I grew to appreciate these even more, adapting in the ways people do who work in this environment for extended periods of time without losing their minds or their faith in humanity.  I joked around with the staff before the morning meetings and worked the tray line in the kitchen, hairnet and all, and laughed with the head of medical records and helped out with the Hawaiian staff bbq. I smiled at every person I made eye contact with and tried to learn the residents names to say hello to them every day. I learned that treating people with respect and dignity is paramount. I realized that everything can change in the span of two weeks.